p u b l i c h e a l t h x x x ( 2 0 1 5 ) 1 e5
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Governance for Health Special Issue Paper
Global Governance for Health: how to motivate political change? D. McNeill*, O.P. Ottersen University of Oslo, Norway
article info
abstract
Article history:
In this article, we address a central theme that was discussed at the Durham Health
Received 12 February 2015
Summit: how can politics be brought back into global health governance and figure much
Received in revised form
more prominently in discussions around policy? We begin by briefly summarizing the
5 May 2015
report of the Lancet e University of Oslo Commission on Global Governance for Health:
Accepted 11 May 2015
‘The Political Origins of Health Inequity’ Ottersen et al. In order to provide compelling
Available online xxx
evidence of the central argument, the Commission selected seven case studies relating to, inter alia, economic and fiscal policy, food security, and foreign trade and investment
Keywords:
agreements. Based on an analysis of these studies, the report concludes that the problems
Global governance
identified are often due to political choices: an unwillingness to change the global system
Health
of governance. This raises the question: what is the most effective way that a report of this
Politics
kind can be used to motivate policy-makers, and the public at large, to demand change?
Inequity
What kind of moral or rational argument is most likely to lead to action? In this paper we
Justice
assess the merits of various alternative perspectives: health as an investment; health as a global public good; health and human security; health and human development; health as a human right; health and global justice. We conclude that what is required in order to motivate change is a more explicitly political and moral perspective e favouring the later rather than the earlier alternatives just listed. © 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
The Lancet-University of Oslo Commission on Global Governance for Healtha In this article, we address a central theme that was discussed at the Durham Health Summit: how can politics be brought back into governance and figure much more prominently in discussions around policy? This issue has concerned us e both during and after the preparation of the report of the
Lancet e University of Oslo Commission on Global Governance for Health: ‘The Political Origins of Health Inequity’:1 what combination of rigorous academic argument and moral outrage is required in order to motivate change? The challenge e as explicitly discussed at the Durham Summit e may be stated thus: ‘Leaders need to be value-based but also evidence-informed. They need to avoid being blown off course by academics ‘killing’ the evidence by overcomplicating it.’
* Corresponding author. E-mail address: [email protected] (D. McNeill). a In addition to members of the Commission, we especially acknowledge the assistance of Sidsel Roalkvam and Ann Louise Lie, Centre for Development and the Environment, University of Oslo. http://dx.doi.org/10.1016/j.puhe.2015.05.001 0033-3506/© 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: McNeill D, Ottersen OP, Global Governance for Health: how to motivate political change?, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.05.001
2
p u b l i c h e a l t h x x x ( 2 0 1 5 ) 1 e5
We will begin by briefly summarizing the Commission's report which formed the basis for much of the discussion at the Summit. The Commission was motivated by a shared conviction among its members that the current system of global governance fails to adequately protect public health, and that the failures strike unevenly, being particularly disastrous for the world's most vulnerable, marginalized, or poorest populations. There can be little doubt about the overriding significance of health as a global concern. But, to quote the report: ‘Despite large gains in health over the past decades, the distribution of health risks worldwide remains extremely and unacceptably uneven. While the health sector plays a crucial role in addressing health inequalities, its efforts often come into conflict with powerful global actors pursuing other interests such as protecting national security, safeguarding sovereignty, or pursuing economic goals.’ The report benefited from, and in part built upon, that of the WHO Commission on the Social Determinants of Health.22 The latter report made creative and very effective use of health indicators to demonstrate how extreme are the health inequities that we face today: at global, national and local levels. For example: ‘the lifetime risk of maternal death is one in eight in Afghanistan, but only one in 17,400 in Sweden;18 maternal mortality is three to four times higher among the poor compared to the rich in Indonesia’.5,18(p30) As that report clearly expresses it: ‘Justice is a matter of life and death. It affects the way people live, their consequent chance of illness, and their risk of premature death. We watch in wonder as life expectancy and good health continue to increase in parts of the world and in alarm as they fail to improve in others’.18(pi) The Lancet-University of Oslo Commission on Global Governance for Health focused not so much on the national as on the global level e the complex and varying ways in which the current system of global governance has failed to protect people's health. In order to provide compelling empirical evidence of the central argument, the Commission selected seven case studies relating to: irregular migration; patterns of armed violence; knowledge, health and intellectual property; austerity measures; investment treaties; food; and the conduct of transnational corporations. In each case, the aim was to reveal the causal chains linking the rules and practices of global governance to impacts e very frequently negative e on people's health. Some of the case studies may be briefly summarized to give a flavour of the content. In the case of food, nutritional status is affected by political and economic factors at the global level: agricultural trade agreements, price volatility and financial speculation, replacement of domestic crops with export crops, and marketing of unhealthy food by multinational corporations. Powerful actors, such as financial traders and multinational food and beverage corporations, make decisions with major implications for food and nutrition security; but they are not accountable for the health related effects of their decisions and there is little or no global regulation governing their actions in the interest of health.1 The effect of the recent financial crisis has been particularly disastrous for the people in Southern Europe, such as Greece and Spain, that had to accept bailout packages from
the International Monetary Fund, the European Central Bank and the EU Commission. The conditions attached to the bailout packages involved large cuts in social sectors, which negatively affected people's health. In Greece, for example, the health budget was cut by 40%, leading to reduced access to medicines and health care e especially among already vulnerable groups.17,b To take the case study of investment treaties: there are now more than 3000 investment agreements e bilateral, regional and multilateral;12 and such treaties have recently been used by firms to challenge national health regulations. Tobacco use is estimated to have killed 100 million people in the 20th century, and will cause the premature death of one billion more in the 21st century unless consumption is reduced; and today, 80% of all smokers live in developing countries.21 In 2010, the tobacco company Philip Morris sued the government of Uruguay, seeking to reject a new regulation that required graphic warning labels on cigarette packs. Rather than taking the case to the national court of Uruguay, the company has brought it to an international trade tribunal at the World Bank in Washington DC established to adjudicate conflicts between private firms and states that have signed investment treaties.c This is not an isolated case; there has been a sharp rise over the past two decades in the number of legal disputes brought by companies against states for violations of investment agreements, showing how public health concerns can be subordinated to the interests of private firms. Actors that benefit from the power disparities described here shape how the rules of the game are written and interpreted; and the decisions, policies and actions of such actors are in turn founded on global social norms. Their actions are not designed to harm health, but they can have negative side-effects that create health inequities and jeopardize the substantial achievements that have been made in global health in recent decades. All too often the health effects are not given due priority. The Commission concluded that the unacceptable health inequities within and between countries cannot simply be addressed within the health sector, by technical measures. And action at the national level alone is often insufficient; what is required is global political solutions. But, as the report made clear, based on an analysis of the seven case studies, there are substantial weaknesses in the current global governance system which hinder solutions being implemented. The report emphasised that these failures are often due to political choices: an unwillingness by powerful actors to change the global system of governance. This raises the question: what is the most effective way that a report can be used to motivate policymakers, and the public at large, to demand change? What kind of moral or rational argument is most likely to lead to action?
b
The case for austerity measures is, of course, much debated; what is in little doubt is that the most vulnerable people suffered disproportionately. c The outcome is still pending, but such legal actions have substantial effects even if, as may ultimately be the case here, they are unsuccessful.
Please cite this article in press as: McNeill D, Ottersen OP, Global Governance for Health: how to motivate political change?, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.05.001
p u b l i c h e a l t h x x x ( 2 0 1 5 ) 1 e5
Motivating change: the value base To repeat the conclusion from the Durham Health Summit: ‘Leaders need to be value-based but also evidence-informed’. What, then, is the appropriate value base that will effectively combine with academically rigorous evidence to convince leaders, and indeed the general public, since it is necessary to have broad political support? The Commission discussed this question at some length: assessing the merits of various different perspectives. In the remainder of this paper we will briefly assess these, which we summarize in the following terms.d Health as an investment Health as a global public good Health and human security Health and human development Health as a human right Health and global justice
Health as an investment This approach has been popular in recent years, often used in reports commissioned by the UN, for example the WHO Report of the Commission on Macroeconomics and Health chaired by Jeffrey D. Sachs,23 which states: ‘The importance of the MDGs in health is, in one sense, self-evident. Improving the health and longevity of the poor is an end in itself, a fundamental goal of economic development. But it is also a means to achieving the other development goals relating to poverty reduction. The linkages of health to poverty reduction and to long-term economic growth are powerful, much stronger than is generally understood’.23(p1) A similar argument has been used in the recent Lancet Commission on Investing in Health.6 ‘The returns on investing in health are impressive. Reductions in mortality account for about 11% of recent economic growth in lowincome and middle-income countries as measured in their national income accounts … This more comprehensive understanding of the economic value of health improvements provides a strong rationale for improved resource allocation across sectors.’ It is claimed that such arguments are effective for convincing national Ministries of Finance, and powerful international organisations such as the World Bank. While this may well be true, it is not, we suggest, an approach that is likely to inspire and motivate the man or woman in the street. And it tends to conceal more than reveal the political origins of health inequity.
Health as a global public good This is a variant of the rational economic argument, but being applied on a global scale it has more explicit implications for global governance. When something is classified, in economic d
These alternatives were to varying extents discussed by the Commission, but the analysis that follows should be interpreted as our own, not as a consensus or summary view of the Commission members.
3
terminology, as a public good this necessarily implies that it is under-supplied by the market and that intervention by a public body is required; a prescription necessarily follows from what appears to be a purely descriptive account. Historically, the concept was applied at the national level where the appropriate public body is the state. Following the work of Kaul et al.7 the concept has been extended to the global level. The problem with global public goods is, of course, that no equivalent supranational body exists. The logic of the argument is just as strong, but the feasibility of following the logic is heavily constrained. Indeed, this is precisely the challenge of global governance. The book by Kaul et al.7 contains two chapters on health as a global public good. Both argue primarily in relation to infectious disease surveillance, indicating that the global public good argument is often a sort of economic version of ‘health and security’ to which we now turn.
Health and human security Gasper3 argues at length and with considerable conviction in favour of human security as a motivating idea: ‘Combined with ‘human’, ‘security’ conveys a visceral, lived feel, connecting to people's fears and feelings or to an observer's fears and feelings about others' lives. ‘Human security’ thus evokes a sense of real lives and persons. Like ‘rights’, it touches something deep in our awareness’.3(p8) He rejects MacFarlane and Khong9 assertion that the broad UN approach to human security offers ‘no analytical traction’, citing, amongst others, the conclusion of Werthes & Bosold19 that it has some real impact. Gasper goes so far as to imply that human security discourse, that ‘synthesises ideas from the partner ‘human discourses’ of human needs, human rights and human development’, is somehow better than all three. But it is important to note that there is a second, very different version of the ‘human security’ argument, which is based on enlightened self-interest and draws on a fear of the foreign, alien, uncontrollable. Gasper does acknowledge this: ‘While the ‘human security’ label aims to re-orient security discourse, it carries risks of being taken over by the psychic insecurities and fears of the rich and the military instincts of those with large arsenals and the habit of using them’.19(p16) But he does not regard this as a substantive criticism (personal communication). Recent experience with the Ebola crisis in West Africa may, however, cause one to reconsider this view. There can be little doubt that the threat to ‘human security’ that was experienced in at least some rich countries was a self-interested concern, not one based on global solidarity. It is certainly problematic that two such diametrically different views go under the same name.
Health and human development This is an approach with a long history. The concept of ‘human development’ is associated especially with the United Nations Development Programme (UNDP) Human Development Report initiated by Mahbub el Haq, and the works of Amartya Sen and others, which proved quite an effective counter to the focus on GDP, and the then dominant neoliberal consensus. ‘Human development, as an approach, is concerned with what I take to be the basic development idea:
Please cite this article in press as: McNeill D, Ottersen OP, Global Governance for Health: how to motivate political change?, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.05.001
4
p u b l i c h e a l t h x x x ( 2 0 1 5 ) 1 e5
namely, advancing the richness of human life, rather than the richness of the economy in which human beings live, which is only a part of it.’16 It has the merit of enjoying widespread support; and according to Helen Clark, Administrator, United Nations Development Programme, ‘… the human development approach has profoundly affected an entire generation of policy-makers and development specialists around the worlddincluding thousands within UNDP itself and elsewhere in the UN system.’ The concept has been further developed conceptually and in policy and programming terms.’2 though some practitioners e while valuing the visionary power of the term e have expressed doubts about its practical application.11
Health as a human right Especially at the turn of the century, human rights became popular among international development organisations as a basis for motivating action against extreme poverty. This proved e at least for some international organisations e rather too challenging a perspective. Thus, for example, the World Bank argued for a human rights perspective based on the instrumental argument that it promotes economic growth; and UNESCO (United Nations Educational, Scientific and Cultural Organisation) found it politically risky to promote the idea that ‘extreme poverty is a violation of human rights’.10 A human rights approach can, in principle, be effective not only in moral but also legal terms, since all those countries (the vast majority) which have ratified the International Covenant on Economic, Social and Cultural Rights are thereby bound to article 12: ‘The right to the highest attainable standard of health’. In a recent book, Gostin compares this approach with two other ‘global health paradigms that have international recognition’:4(p21) ‘human security’ and ‘global public goods’. In each case, ‘The challenge is to pursue a fundamental objective e optimal health, equitably distributed e while navigating various crosscurrents; these include politics (domestic and global), power dynamics (in the global North and South), vested interests (e.g. the corporate profit motive), economic power (e.g. wealthy states, foundations), security (national and human), and international relations’.4(p72) Gostin favours the right to health, which he argues has the force of law; but he also makes clear that there are severe limitations to what law can achieve in practice. 4 (p71),e
Health and global justice A global justice approach has been applied in recent years by philosophers such as Thomas Pogge,14 who are critical of the classic work of John Rawls15 as being limited to the national level. As Director of the Global Justice Program he has sought to link academic argument to practical action, for example through the health impact fund. Although not focussing specifically on health, Iris Young's work on the ‘social connection model of responsibility’ is particularly relevant to the concerns of the Commission. She writes: ‘Political responsibility e
Some would regard these limitations as fatal, due to problems such as defining what is ‘highest attainable’
… is necessarily a shared responsibility both because the injustices that call for redress are the product of the mediated actions of many, and thus because they can only be rectified through collective action. For most such injustices, the goal is to change structural processes by reforming institutions or creating new ones that will better regulate the process to prevent harmful outcomes’.24(p387) By comparison with the human rights argument, this is more grounded in applied philosophy. And although expressed in academic terms, an argument based on global justice may have a certain common-sense appeal. It is important to note that these six concepts have to varying extents been developed, debated and in some cases debased. Academics have analysed, refined, and redefined each of them, resulting in a variety of interpretations and perspectives. Furthermore, practitioners and go-betweens have sought to develop them into implementable form, by producing guidelines, manuals and checklists; as a result a particular concept may become linked e for better or worse-to a specific policy; health as a human right to universal health coverage, for example. Before attempting to briefly summarize the strengths and weakness of these alternatives it is useful to clarify how they are to be used e in a report such as that of the Commission. They may, we suggest, serve one or more of three rather different purposes: as a vision of where one wishes to end up; guidance as to how to get there; or a spur to encourage people to set out on the journey. Problems can arise when a concept is expected to serve all three. And they are likely to appeal to different types of audience, depending on the extent to which each perspective offers moral, legal, political or technical/ economic grounds for action. The vision in this case is, for us at least, clear e it is health equity: the ideal that ‘everyone should have a fair opportunity to attain their full health potential and, more pragmatically, that no one should be disadvantaged from achieving this potential, if it can be avoided’.20,f If one accepts the Commission's findings then the route to be taken is also indicated, at least in broad terms: it involves identifying and challenging unfair rules and practices in global governance. (This is clearly not the only way of promoting global health, but it is the route favoured by the Commission). Viewed in this way, the first two approaches e ‘health as an investment’ and ‘health as a global public good’ e may be regarded as relatively weak, on two grounds. First, although promoting better health as a goal they do not explicitly emphasise health equity. Second, they are technical/economic rather than moral/political arguments. ‘Health and human security’, although potentially powerful in moral/political terms, does risk being misinterpreted, as discussed above. (Although under one interpretation it certainly does emphasise health equity). The remaining three e ‘health and human development’, ‘health as a human right’ and ‘health and global justice’ e all f The quotation continues: ‘The aim of policy for equity and health is not to eliminate all health differences so that everyone has the same level and quality of health, but rather to reduce or eliminate those which result from factors which are considered to be both avoidable and unfair.’20
Please cite this article in press as: McNeill D, Ottersen OP, Global Governance for Health: how to motivate political change?, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.05.001
p u b l i c h e a l t h x x x ( 2 0 1 5 ) 1 e5
have their merits, and need not be mutually exclusive.g They all imply a concern with health equity. The first provides, at least according to some, guidance as to the road to be taken. The second e if interpreted in legal rather than moral/political terms e offers a mechanism for securing action, albeit rather weak in practice. Global justice is perhaps the most explicitly moral/political of them all. If stated in simple terms as ‘it just isn't right’ this might have the greatest appeal to the public at large.h If change is to be achieved, if the current system of global governance is to be challenged, this will require an appeal to fundamental values. The choice of approach, or motivating concept, should, we argue, be guided primarily by what is most effective in order to motivate change e in addition to compelling evidence, rigorously analysed. We conclude that what is required in order to motivate change is an explicitly political and moral perspective e favouring the later rather than the earlier alternatives just listed.
Author statements Ethical approval None sought.
Funding None declared.
Competing interests None declared.
references
1. De Schutter O. International trade in agriculture and the right to food. Geneva: Friedrich Ebert Stifting; 2009. 2. Fukuda-Parr S. The human development paradigm: operationalizing sen's ideas on capabilities. Fem Econ 2003;9(2e3):301e17.
5
3. Gasper D. The idea of human security GARNET. Working paper: no 28/08. The Hague: Institute for Social Studies; 2008. 4. Gostin L. Global health law. Harvard University Press; 2014. 5. Graham H, Kelly M. Health inequalities: concepts, frameworks and policy. Health Development Agency; 2004. 6. Jamison Dean T, Summers Lawrence H, Alleyne George, Arrow Kenneth J, Berkley Seth, Binagwaho Agnes, et al. Global health 2035: a world converging within a generation. Lancet 2013;382:1895e955. 7. Kaul I, Grunberg I, Stern M. Global public goods: international cooperation in the 21st century. Oxford University Press; 1999. 9. MacFarlane N, Khong Y. Human security and the UN e a critical history. Bloomington, IN: University of Indiana Press; 2006. 10. McNeill D, Lera St. Clair A. Global poverty, ethics, and human rights: the role of multilateral organisations. Routledge; 2009192. 11. McNeill D. ‘Human development’: the power of the idea. J Hum Dev 2007;8(No. 1):5e22. 12. Mercurio B. International investment agreements and public health: neutralizing a threat through treaty drafting. Bull World Health Organ 2013;2014(92):520e5. http://dx.doi.org/ 10.2471/BLT.13.130955. 14. Pogge T. World poverty and human rights: cosmopolitan responsibilities and reform. London and Cambridge: Polity Press; 2002. 15. Rawls J. The law of peoples. Cambridge, MA: Harvard University Press; 1999. 16. Sen A. Interview. UNDP, http://hdr.undp.org/en/humandev; 1998. 17. Stuckler D, Basu S. The body economic: why austerity kills. Basic Books; 2013. 18. UNICEF. The state of the world's children 2008: child survival. New York: United Nations Children’s Fund; 2007. 19. Werthes S, Bosold D. Caught between pretension and substantiveness e ambiguities of human security as a political Leitmotif; 2006. Quoted in Gasper 2008. 20. Whitehead M. The concepts and principles of equity and health. Int J Health Serv Plan Adm Eval 1992;22(3):429e45. 21. WHO. Tobacco; 2013. Fact sheet no. 339. 22. WHO. Closing the gap in a generation: health equity through action on the social determinants of health. Geneva: World Health Organisation; 2008. 23. WHO. Macroeconomics and health: investing in health for economic development report of the commission on macroeconomics and health chaired by Jeffrey D. Sachs; 2001. 24. Young I. Responsibility and global labor justice. J Polit Philos 2004;12(4):365e88.
g
Perhaps none of the perspectives is mutually exclusive in logical terms. The problem is that to use more than one grounds for motivating action can risk both confusion and depoliticisation. h Just as it had considerable appeal to many of the Commissioners.
Please cite this article in press as: McNeill D, Ottersen OP, Global Governance for Health: how to motivate political change?, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.05.001
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Governance for Health Special Issue Paper
Global Governance for Health: how to motivate political change? D. McNeill*, O.P. Ottersen University of Oslo, Norway
article info
abstract
Article history:
In this article, we address a central theme that was discussed at the Durham Health
Received 12 February 2015
Summit: how can politics be brought back into global health governance and figure much
Received in revised form
more prominently in discussions around policy? We begin by briefly summarizing the
5 May 2015
report of the Lancet e University of Oslo Commission on Global Governance for Health:
Accepted 11 May 2015
‘The Political Origins of Health Inequity’ Ottersen et al. In order to provide compelling
Available online xxx
evidence of the central argument, the Commission selected seven case studies relating to, inter alia, economic and fiscal policy, food security, and foreign trade and investment
Keywords:
agreements. Based on an analysis of these studies, the report concludes that the problems
Global governance
identified are often due to political choices: an unwillingness to change the global system
Health
of governance. This raises the question: what is the most effective way that a report of this
Politics
kind can be used to motivate policy-makers, and the public at large, to demand change?
Inequity
What kind of moral or rational argument is most likely to lead to action? In this paper we
Justice
assess the merits of various alternative perspectives: health as an investment; health as a global public good; health and human security; health and human development; health as a human right; health and global justice. We conclude that what is required in order to motivate change is a more explicitly political and moral perspective e favouring the later rather than the earlier alternatives just listed. © 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
The Lancet-University of Oslo Commission on Global Governance for Healtha In this article, we address a central theme that was discussed at the Durham Health Summit: how can politics be brought back into governance and figure much more prominently in discussions around policy? This issue has concerned us e both during and after the preparation of the report of the
Lancet e University of Oslo Commission on Global Governance for Health: ‘The Political Origins of Health Inequity’:1 what combination of rigorous academic argument and moral outrage is required in order to motivate change? The challenge e as explicitly discussed at the Durham Summit e may be stated thus: ‘Leaders need to be value-based but also evidence-informed. They need to avoid being blown off course by academics ‘killing’ the evidence by overcomplicating it.’
* Corresponding author. E-mail address: [email protected] (D. McNeill). a In addition to members of the Commission, we especially acknowledge the assistance of Sidsel Roalkvam and Ann Louise Lie, Centre for Development and the Environment, University of Oslo. http://dx.doi.org/10.1016/j.puhe.2015.05.001 0033-3506/© 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: McNeill D, Ottersen OP, Global Governance for Health: how to motivate political change?, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.05.001
2
p u b l i c h e a l t h x x x ( 2 0 1 5 ) 1 e5
We will begin by briefly summarizing the Commission's report which formed the basis for much of the discussion at the Summit. The Commission was motivated by a shared conviction among its members that the current system of global governance fails to adequately protect public health, and that the failures strike unevenly, being particularly disastrous for the world's most vulnerable, marginalized, or poorest populations. There can be little doubt about the overriding significance of health as a global concern. But, to quote the report: ‘Despite large gains in health over the past decades, the distribution of health risks worldwide remains extremely and unacceptably uneven. While the health sector plays a crucial role in addressing health inequalities, its efforts often come into conflict with powerful global actors pursuing other interests such as protecting national security, safeguarding sovereignty, or pursuing economic goals.’ The report benefited from, and in part built upon, that of the WHO Commission on the Social Determinants of Health.22 The latter report made creative and very effective use of health indicators to demonstrate how extreme are the health inequities that we face today: at global, national and local levels. For example: ‘the lifetime risk of maternal death is one in eight in Afghanistan, but only one in 17,400 in Sweden;18 maternal mortality is three to four times higher among the poor compared to the rich in Indonesia’.5,18(p30) As that report clearly expresses it: ‘Justice is a matter of life and death. It affects the way people live, their consequent chance of illness, and their risk of premature death. We watch in wonder as life expectancy and good health continue to increase in parts of the world and in alarm as they fail to improve in others’.18(pi) The Lancet-University of Oslo Commission on Global Governance for Health focused not so much on the national as on the global level e the complex and varying ways in which the current system of global governance has failed to protect people's health. In order to provide compelling empirical evidence of the central argument, the Commission selected seven case studies relating to: irregular migration; patterns of armed violence; knowledge, health and intellectual property; austerity measures; investment treaties; food; and the conduct of transnational corporations. In each case, the aim was to reveal the causal chains linking the rules and practices of global governance to impacts e very frequently negative e on people's health. Some of the case studies may be briefly summarized to give a flavour of the content. In the case of food, nutritional status is affected by political and economic factors at the global level: agricultural trade agreements, price volatility and financial speculation, replacement of domestic crops with export crops, and marketing of unhealthy food by multinational corporations. Powerful actors, such as financial traders and multinational food and beverage corporations, make decisions with major implications for food and nutrition security; but they are not accountable for the health related effects of their decisions and there is little or no global regulation governing their actions in the interest of health.1 The effect of the recent financial crisis has been particularly disastrous for the people in Southern Europe, such as Greece and Spain, that had to accept bailout packages from
the International Monetary Fund, the European Central Bank and the EU Commission. The conditions attached to the bailout packages involved large cuts in social sectors, which negatively affected people's health. In Greece, for example, the health budget was cut by 40%, leading to reduced access to medicines and health care e especially among already vulnerable groups.17,b To take the case study of investment treaties: there are now more than 3000 investment agreements e bilateral, regional and multilateral;12 and such treaties have recently been used by firms to challenge national health regulations. Tobacco use is estimated to have killed 100 million people in the 20th century, and will cause the premature death of one billion more in the 21st century unless consumption is reduced; and today, 80% of all smokers live in developing countries.21 In 2010, the tobacco company Philip Morris sued the government of Uruguay, seeking to reject a new regulation that required graphic warning labels on cigarette packs. Rather than taking the case to the national court of Uruguay, the company has brought it to an international trade tribunal at the World Bank in Washington DC established to adjudicate conflicts between private firms and states that have signed investment treaties.c This is not an isolated case; there has been a sharp rise over the past two decades in the number of legal disputes brought by companies against states for violations of investment agreements, showing how public health concerns can be subordinated to the interests of private firms. Actors that benefit from the power disparities described here shape how the rules of the game are written and interpreted; and the decisions, policies and actions of such actors are in turn founded on global social norms. Their actions are not designed to harm health, but they can have negative side-effects that create health inequities and jeopardize the substantial achievements that have been made in global health in recent decades. All too often the health effects are not given due priority. The Commission concluded that the unacceptable health inequities within and between countries cannot simply be addressed within the health sector, by technical measures. And action at the national level alone is often insufficient; what is required is global political solutions. But, as the report made clear, based on an analysis of the seven case studies, there are substantial weaknesses in the current global governance system which hinder solutions being implemented. The report emphasised that these failures are often due to political choices: an unwillingness by powerful actors to change the global system of governance. This raises the question: what is the most effective way that a report can be used to motivate policymakers, and the public at large, to demand change? What kind of moral or rational argument is most likely to lead to action?
b
The case for austerity measures is, of course, much debated; what is in little doubt is that the most vulnerable people suffered disproportionately. c The outcome is still pending, but such legal actions have substantial effects even if, as may ultimately be the case here, they are unsuccessful.
Please cite this article in press as: McNeill D, Ottersen OP, Global Governance for Health: how to motivate political change?, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.05.001
p u b l i c h e a l t h x x x ( 2 0 1 5 ) 1 e5
Motivating change: the value base To repeat the conclusion from the Durham Health Summit: ‘Leaders need to be value-based but also evidence-informed’. What, then, is the appropriate value base that will effectively combine with academically rigorous evidence to convince leaders, and indeed the general public, since it is necessary to have broad political support? The Commission discussed this question at some length: assessing the merits of various different perspectives. In the remainder of this paper we will briefly assess these, which we summarize in the following terms.d Health as an investment Health as a global public good Health and human security Health and human development Health as a human right Health and global justice
Health as an investment This approach has been popular in recent years, often used in reports commissioned by the UN, for example the WHO Report of the Commission on Macroeconomics and Health chaired by Jeffrey D. Sachs,23 which states: ‘The importance of the MDGs in health is, in one sense, self-evident. Improving the health and longevity of the poor is an end in itself, a fundamental goal of economic development. But it is also a means to achieving the other development goals relating to poverty reduction. The linkages of health to poverty reduction and to long-term economic growth are powerful, much stronger than is generally understood’.23(p1) A similar argument has been used in the recent Lancet Commission on Investing in Health.6 ‘The returns on investing in health are impressive. Reductions in mortality account for about 11% of recent economic growth in lowincome and middle-income countries as measured in their national income accounts … This more comprehensive understanding of the economic value of health improvements provides a strong rationale for improved resource allocation across sectors.’ It is claimed that such arguments are effective for convincing national Ministries of Finance, and powerful international organisations such as the World Bank. While this may well be true, it is not, we suggest, an approach that is likely to inspire and motivate the man or woman in the street. And it tends to conceal more than reveal the political origins of health inequity.
Health as a global public good This is a variant of the rational economic argument, but being applied on a global scale it has more explicit implications for global governance. When something is classified, in economic d
These alternatives were to varying extents discussed by the Commission, but the analysis that follows should be interpreted as our own, not as a consensus or summary view of the Commission members.
3
terminology, as a public good this necessarily implies that it is under-supplied by the market and that intervention by a public body is required; a prescription necessarily follows from what appears to be a purely descriptive account. Historically, the concept was applied at the national level where the appropriate public body is the state. Following the work of Kaul et al.7 the concept has been extended to the global level. The problem with global public goods is, of course, that no equivalent supranational body exists. The logic of the argument is just as strong, but the feasibility of following the logic is heavily constrained. Indeed, this is precisely the challenge of global governance. The book by Kaul et al.7 contains two chapters on health as a global public good. Both argue primarily in relation to infectious disease surveillance, indicating that the global public good argument is often a sort of economic version of ‘health and security’ to which we now turn.
Health and human security Gasper3 argues at length and with considerable conviction in favour of human security as a motivating idea: ‘Combined with ‘human’, ‘security’ conveys a visceral, lived feel, connecting to people's fears and feelings or to an observer's fears and feelings about others' lives. ‘Human security’ thus evokes a sense of real lives and persons. Like ‘rights’, it touches something deep in our awareness’.3(p8) He rejects MacFarlane and Khong9 assertion that the broad UN approach to human security offers ‘no analytical traction’, citing, amongst others, the conclusion of Werthes & Bosold19 that it has some real impact. Gasper goes so far as to imply that human security discourse, that ‘synthesises ideas from the partner ‘human discourses’ of human needs, human rights and human development’, is somehow better than all three. But it is important to note that there is a second, very different version of the ‘human security’ argument, which is based on enlightened self-interest and draws on a fear of the foreign, alien, uncontrollable. Gasper does acknowledge this: ‘While the ‘human security’ label aims to re-orient security discourse, it carries risks of being taken over by the psychic insecurities and fears of the rich and the military instincts of those with large arsenals and the habit of using them’.19(p16) But he does not regard this as a substantive criticism (personal communication). Recent experience with the Ebola crisis in West Africa may, however, cause one to reconsider this view. There can be little doubt that the threat to ‘human security’ that was experienced in at least some rich countries was a self-interested concern, not one based on global solidarity. It is certainly problematic that two such diametrically different views go under the same name.
Health and human development This is an approach with a long history. The concept of ‘human development’ is associated especially with the United Nations Development Programme (UNDP) Human Development Report initiated by Mahbub el Haq, and the works of Amartya Sen and others, which proved quite an effective counter to the focus on GDP, and the then dominant neoliberal consensus. ‘Human development, as an approach, is concerned with what I take to be the basic development idea:
Please cite this article in press as: McNeill D, Ottersen OP, Global Governance for Health: how to motivate political change?, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.05.001
4
p u b l i c h e a l t h x x x ( 2 0 1 5 ) 1 e5
namely, advancing the richness of human life, rather than the richness of the economy in which human beings live, which is only a part of it.’16 It has the merit of enjoying widespread support; and according to Helen Clark, Administrator, United Nations Development Programme, ‘… the human development approach has profoundly affected an entire generation of policy-makers and development specialists around the worlddincluding thousands within UNDP itself and elsewhere in the UN system.’ The concept has been further developed conceptually and in policy and programming terms.’2 though some practitioners e while valuing the visionary power of the term e have expressed doubts about its practical application.11
Health as a human right Especially at the turn of the century, human rights became popular among international development organisations as a basis for motivating action against extreme poverty. This proved e at least for some international organisations e rather too challenging a perspective. Thus, for example, the World Bank argued for a human rights perspective based on the instrumental argument that it promotes economic growth; and UNESCO (United Nations Educational, Scientific and Cultural Organisation) found it politically risky to promote the idea that ‘extreme poverty is a violation of human rights’.10 A human rights approach can, in principle, be effective not only in moral but also legal terms, since all those countries (the vast majority) which have ratified the International Covenant on Economic, Social and Cultural Rights are thereby bound to article 12: ‘The right to the highest attainable standard of health’. In a recent book, Gostin compares this approach with two other ‘global health paradigms that have international recognition’:4(p21) ‘human security’ and ‘global public goods’. In each case, ‘The challenge is to pursue a fundamental objective e optimal health, equitably distributed e while navigating various crosscurrents; these include politics (domestic and global), power dynamics (in the global North and South), vested interests (e.g. the corporate profit motive), economic power (e.g. wealthy states, foundations), security (national and human), and international relations’.4(p72) Gostin favours the right to health, which he argues has the force of law; but he also makes clear that there are severe limitations to what law can achieve in practice. 4 (p71),e
Health and global justice A global justice approach has been applied in recent years by philosophers such as Thomas Pogge,14 who are critical of the classic work of John Rawls15 as being limited to the national level. As Director of the Global Justice Program he has sought to link academic argument to practical action, for example through the health impact fund. Although not focussing specifically on health, Iris Young's work on the ‘social connection model of responsibility’ is particularly relevant to the concerns of the Commission. She writes: ‘Political responsibility e
Some would regard these limitations as fatal, due to problems such as defining what is ‘highest attainable’
… is necessarily a shared responsibility both because the injustices that call for redress are the product of the mediated actions of many, and thus because they can only be rectified through collective action. For most such injustices, the goal is to change structural processes by reforming institutions or creating new ones that will better regulate the process to prevent harmful outcomes’.24(p387) By comparison with the human rights argument, this is more grounded in applied philosophy. And although expressed in academic terms, an argument based on global justice may have a certain common-sense appeal. It is important to note that these six concepts have to varying extents been developed, debated and in some cases debased. Academics have analysed, refined, and redefined each of them, resulting in a variety of interpretations and perspectives. Furthermore, practitioners and go-betweens have sought to develop them into implementable form, by producing guidelines, manuals and checklists; as a result a particular concept may become linked e for better or worse-to a specific policy; health as a human right to universal health coverage, for example. Before attempting to briefly summarize the strengths and weakness of these alternatives it is useful to clarify how they are to be used e in a report such as that of the Commission. They may, we suggest, serve one or more of three rather different purposes: as a vision of where one wishes to end up; guidance as to how to get there; or a spur to encourage people to set out on the journey. Problems can arise when a concept is expected to serve all three. And they are likely to appeal to different types of audience, depending on the extent to which each perspective offers moral, legal, political or technical/ economic grounds for action. The vision in this case is, for us at least, clear e it is health equity: the ideal that ‘everyone should have a fair opportunity to attain their full health potential and, more pragmatically, that no one should be disadvantaged from achieving this potential, if it can be avoided’.20,f If one accepts the Commission's findings then the route to be taken is also indicated, at least in broad terms: it involves identifying and challenging unfair rules and practices in global governance. (This is clearly not the only way of promoting global health, but it is the route favoured by the Commission). Viewed in this way, the first two approaches e ‘health as an investment’ and ‘health as a global public good’ e may be regarded as relatively weak, on two grounds. First, although promoting better health as a goal they do not explicitly emphasise health equity. Second, they are technical/economic rather than moral/political arguments. ‘Health and human security’, although potentially powerful in moral/political terms, does risk being misinterpreted, as discussed above. (Although under one interpretation it certainly does emphasise health equity). The remaining three e ‘health and human development’, ‘health as a human right’ and ‘health and global justice’ e all f The quotation continues: ‘The aim of policy for equity and health is not to eliminate all health differences so that everyone has the same level and quality of health, but rather to reduce or eliminate those which result from factors which are considered to be both avoidable and unfair.’20
Please cite this article in press as: McNeill D, Ottersen OP, Global Governance for Health: how to motivate political change?, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.05.001
p u b l i c h e a l t h x x x ( 2 0 1 5 ) 1 e5
have their merits, and need not be mutually exclusive.g They all imply a concern with health equity. The first provides, at least according to some, guidance as to the road to be taken. The second e if interpreted in legal rather than moral/political terms e offers a mechanism for securing action, albeit rather weak in practice. Global justice is perhaps the most explicitly moral/political of them all. If stated in simple terms as ‘it just isn't right’ this might have the greatest appeal to the public at large.h If change is to be achieved, if the current system of global governance is to be challenged, this will require an appeal to fundamental values. The choice of approach, or motivating concept, should, we argue, be guided primarily by what is most effective in order to motivate change e in addition to compelling evidence, rigorously analysed. We conclude that what is required in order to motivate change is an explicitly political and moral perspective e favouring the later rather than the earlier alternatives just listed.
Author statements Ethical approval None sought.
Funding None declared.
Competing interests None declared.
references
1. De Schutter O. International trade in agriculture and the right to food. Geneva: Friedrich Ebert Stifting; 2009. 2. Fukuda-Parr S. The human development paradigm: operationalizing sen's ideas on capabilities. Fem Econ 2003;9(2e3):301e17.
5
3. Gasper D. The idea of human security GARNET. Working paper: no 28/08. The Hague: Institute for Social Studies; 2008. 4. Gostin L. Global health law. Harvard University Press; 2014. 5. Graham H, Kelly M. Health inequalities: concepts, frameworks and policy. Health Development Agency; 2004. 6. Jamison Dean T, Summers Lawrence H, Alleyne George, Arrow Kenneth J, Berkley Seth, Binagwaho Agnes, et al. Global health 2035: a world converging within a generation. Lancet 2013;382:1895e955. 7. Kaul I, Grunberg I, Stern M. Global public goods: international cooperation in the 21st century. Oxford University Press; 1999. 9. MacFarlane N, Khong Y. Human security and the UN e a critical history. Bloomington, IN: University of Indiana Press; 2006. 10. McNeill D, Lera St. Clair A. Global poverty, ethics, and human rights: the role of multilateral organisations. Routledge; 2009192. 11. McNeill D. ‘Human development’: the power of the idea. J Hum Dev 2007;8(No. 1):5e22. 12. Mercurio B. International investment agreements and public health: neutralizing a threat through treaty drafting. Bull World Health Organ 2013;2014(92):520e5. http://dx.doi.org/ 10.2471/BLT.13.130955. 14. Pogge T. World poverty and human rights: cosmopolitan responsibilities and reform. London and Cambridge: Polity Press; 2002. 15. Rawls J. The law of peoples. Cambridge, MA: Harvard University Press; 1999. 16. Sen A. Interview. UNDP, http://hdr.undp.org/en/humandev; 1998. 17. Stuckler D, Basu S. The body economic: why austerity kills. Basic Books; 2013. 18. UNICEF. The state of the world's children 2008: child survival. New York: United Nations Children’s Fund; 2007. 19. Werthes S, Bosold D. Caught between pretension and substantiveness e ambiguities of human security as a political Leitmotif; 2006. Quoted in Gasper 2008. 20. Whitehead M. The concepts and principles of equity and health. Int J Health Serv Plan Adm Eval 1992;22(3):429e45. 21. WHO. Tobacco; 2013. Fact sheet no. 339. 22. WHO. Closing the gap in a generation: health equity through action on the social determinants of health. Geneva: World Health Organisation; 2008. 23. WHO. Macroeconomics and health: investing in health for economic development report of the commission on macroeconomics and health chaired by Jeffrey D. Sachs; 2001. 24. Young I. Responsibility and global labor justice. J Polit Philos 2004;12(4):365e88.
g
Perhaps none of the perspectives is mutually exclusive in logical terms. The problem is that to use more than one grounds for motivating action can risk both confusion and depoliticisation. h Just as it had considerable appeal to many of the Commissioners.
Please cite this article in press as: McNeill D, Ottersen OP, Global Governance for Health: how to motivate political change?, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.05.001
