Ilona Kickusch
Associate Fellow, Centre on Global Health Security
Taro Aso, Japan's deputy prime minister and finance minister and Jim Yong Kim, president of the World Bank Group, at the Global Conference on Universal Health Coverage for Inclusive and Sustainable Growth 6 December 2013 Tokyo, Japan. Photo by Tomohiro OhTaro Aso, Japan's deputy prime minister and finance minister and Jim Yong Kim, president of the World Bank Group, at the Global Conference on Universal Health Coverage for Inclusive and Sustainable Growth 6 December 2013 Tokyo, Japan. Photo by Tomohiro Ohsumi/Bloomberg/Getty Images.

As more and more money flows through the global health domain, and emerging economies and companies take a more influential role in it, new approaches are needed to help the agenda adapt. Creating a commission on the financial and commercial health environment, a funding mechanism for global public goods for health and a high-level independent panel on health impact would all help drive it forward.

Global governance is in a period of upheaval, and the health agenda has not been spared. As the processes of globalization have led to major power shifts between states and global market forces, the future of global governance for health will increasingly depend on positions taken by emerging economies and rising powers. For example, will they invite the tobacco industry in, like Indonesia, or will they tax products harmful to health, like Mexico?

It always helps to follow the money. The greater the financial resources flowing through the global health domain, the more pressure there will be on countries and on international organizations to choose between facilitating the further growth of the global health industry or strengthening global regulation.

To date, global health think tanks have mainly tracked how billions of development assistance dollars have been spent on specific disease challenges such as HIV/AIDS. To some extent they have also tracked the externalities of disease outbreaks and the health consequences of natural disasters, for example, the huge losses incurred in sectors such as agriculture, travel and tourism.

But what is required now is to systematically follow other financial flows and analyse what their consequences will be for health. Increasingly this means monitoring the global investment strategies of governments and the private sector as well as multilateral, regional and bilateral trade negotiations. Much of the future of global health is decided in boardrooms – not ministries of health.

The health industry – medicines, devices, technology, hospitals, insurance, human resources, to name but some of its components – has grown to be one of the largest industries worldwide. It will continue to grow exponentially as more countries aim to ensure universal health care and access to medicines. Meanwhile, huge profits are generated by industries producing tobacco, processed foods and sugary soft drinks, all of which ravage the health of populations.

The World Bank estimates that, if non-communicable diseases such as diabetes and cardiovascular problems are not contained, the cumulative economic losses to low- and middle-income countries will surpass an average of nearly $500 billion per year. This is equivalent to approximately four per cent of these countries’ current annual GDP. The proposals included in the Trans Pacific Partnership Agreement are set to weaken countries’ access to generic drugs through enhanced patent and data protection, and will weaken public-health safeguards in favour of commercial interests.

The World Health Organization (WHO) (possibly together with others such as the UN Economic and Social Council, the World Bank and the World Economic Forum) should take the work of the Global Health 2035 report a step further and establish a commission on the global financial and commercial environment as it relates to health. Such a commission would map the growth of the global health industry, the investment strategies of key industries detrimental to health and the role of trade agreements. Such data need to be reported as regularly as those on morbidity and mortality are now. They would provide a much-needed knowledge base for the next era of global health.

Towards Better Governance

Two major streams of action are beginning to emerge from the post-2015 development agenda. First, international solidarity through ‘global issue networks’ to help the poorest, like Medicines for Malaria or The Partnership for Maternal, Newborn and Child Health. Second, actions to tackle global issues through a global public goods approach. Both need money – the report by Global Health 2035 has calculated the amount to be $60 billion annually. The global health sector has been particularly successful on the first stream. It now needs to put as much effort into ensuring a well-financed governance system that is committed to the production of agreements that generate global public goods for health (GPGH).

While member states remain unwilling to increase their assessed contributions to the WHO, there is no reason that the work on GPGH should be financed by governments alone. The stability and the rule of law provided through a strong multilateral system benefit everyone − people, governments and industry – but right now mainly governments are paying.

Diversity of financing already applies to many global health initiatives. For instance, the UNITAID initiative is financed primarily via a levy on airline tickets in participating countries. In a similar vein there should be a funding mechanism for GPGH that requires other stakeholders to contribute. The present financing dialogue at the WHO provides an entry point for this.

GPGH include rules that apply across borders, institutions that supervise and enforce these rules, and benefits that accrue without distinction between countries. There is still a need for countries to better recognize under which conditions sovereignty is strengthened, not weakened, as they join up for health in the face of pressures from other states or from global companies.

A number of recent agreements by the WHO show the way. The Framework Convention on Tobacco Control showed that a global health treaty can be implemented for diseases that were not infectious pandemics, the Pandemic Influenza Preparedness Framework showed that the pharmaceutical industry can be brought on board, and the success of the International Health Regulations demonstrated that countries can be motivated to be more transparent in reporting outbreaks in the context of a rules-based system. Member states should provide more political support to the WHO to fully apply the powers enshrined in its constitution for the production of such GPGH – and civil society must advocate vehemently for this commitment.

Emerging economies that have highly attractive markets but often weak national institutions would benefit most from strong global agreements combined with resolute regional and national action. They could lead this new era of global health with domestic legislation, such as high taxes on tobacco, alcohol, and sugary foods and drinks. But transborder and multisectoral action for health also needs to be taken forward vigorously. This will require a willingness to establish new mechanisms linking the WHO agenda with those of the United Nations and other agencies.

To provide hard data, a high-level independent panel on global health impact should be established. It would analyse and oversee the implementation of the health and other international agreements adopted (such as in trade, the environment, and food) and report regularly to the UN General Assembly and World Health Assembly. At present these institutions have to rely on ad hoc commissions (such as Global Health 2035, initiated by the Lancet) or reports by foundations, think tanks and research groups. Once reliable data are available the potential for enforcement of GPGH should be examined – not just of government actions, but also those of the other global health stakeholders.

This is the second in a series of expert comments offering different views on global health governance, leading up to the publication of the Centre on Global Health Security's Working Group on Governance report in spring 2014.

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