The Lancet-University of Oslo Commission on Global Governance for Health, involving several well-known names in the field, was set the ambitious task of analysing how policies and actions outside the health sector impinge on health and proposing recommendations accordingly. Its report, published today, provides much food for thought, but the analysis could have been briefer and its recommendations stronger.
The commission’s task was a daunting but important one. Health outcomes are determined as much by the circumstances in which people live as by their access to quality health services. There is therefore a need to consider what can be done in other sectors that impact on health.
The first part of the report ranges widely over the ‘political nature of global health’ drawing heavily on the 2008 World Health Organization (WHO) report of the Commission on the Social Determinants of Health which was chaired by Sir Michael Marmot, also a member of this commission. Although it is expressed at length and repetitively, the essential point is that globalization has promoted growth but exacerbated inequality. Inequalities in power and economic status drive poor health outcomes for those at the bottom of the pile. In the words of the report, there is an ‘unjust global economic system that favours a very small elite with great wealth at the price of environmental and social degradation that negatively affects health equity’.
The commission, through a ‘process of informed deliberation’, selected seven areas to look at: the financial crisis and austerity, intellectual property, investment treaties, food, transnational corporations, migration and armed conflict. What informed the deliberation is not made clear − for instance, why an obvious candidate such as climate change was omitted.
The middle portion of the report provides commentaries on the seven chosen areas. An inherent problem in addressing the relationship between health and other sectors is that those who know about health necessarily have a limited knowledge of other sectors, and vice versa. This is, for instance, a perennial problem in considering how the WHO, dominated by health professionals, should address the social, economic and environmental determinants of health.
Similarly, this commission composed mainly, but not entirely, of health specialists, runs a risk of being accused of straying outside its competence. For example, the discussion of the impact of austerity in Greece and elsewhere on social and health expenditures, attributed entirely to the conditions imposed by the International Monetary Fund (IMF) and the European Union, might be considered one-sided and naive even by those favourably disposed to their thesis.
The report identifies five ‘systemic dysfunctions that impede the realization of global governance for health’. The democratic deficit is a combination of the unequal voting power in the United Nations (‘one nation one vote’ rather than ‘one person one vote’) and the Bretton Woods institutions (‘one nation many votes’), inadequate access to decision-making by some non-state actors (e.g. NGOs) and too much access by others (e.g. industry lobbyists). There is weak accountability at the global level – for example in relation to governments that transgress internationally agreed rules and norms, transnational corporations or even the European Central Bank and the IMF. Institutional stickiness refers to the failure to reform institutions created in a different era, such as the UN Security Council. Inadequate policy space for health and missing or nascent institutions highlight unsatisfactory arrangements to protect health in decision making in other sectors.
The report contains two principal recommendations: establishing a UN Multistakeholder Platform on Global Governance for Health and an Independent Scientific Monitoring Panel on Global Social and Political Determinants of Health.
The Multistakeholder Platform should provide ‘space for diverse stakeholders to frame issues, set agendas, examine and debate policies in the making that would have an effect on health and health equity, and identify barriers and propose solutions for concrete policy processes’.
The report notes that many issues would need to be worked out in establishing such a panel ‘in a broad and open consultative process’. A puzzling feature, which is not explained, is the peripheral role assigned to the WHO, the obvious convenor of such an initiative.
The Monitoring Panel ‘will call for, receive, assess, analyse, debate, and communicate multiple lines of independent evidence − across disciplines − and provide independent and transparent strategic information to the UN and other actors that affect global governance for health’. The analogy is with the Intergovernmental Panel on Climate Change, which is controversial enough. Can an ‘independent’ panel be successfully formed in these even more highly contested areas?
These principal recommendations seem tame in a report that suggests the need for very radical change to address the fundamental global inequities that are harming health.
Apart from the question of whether it is in fact feasible or practicable to set up new bodies of such complexity, and what in reality they might achieve, it is notable that the companion Youth Commission suggests the proposals are likely to be undermined by the very same power asymmetries that the commission describes. The Youth Commission, whose report is yet to be published, says that ‘a more ambitious response’ is required and it will be interesting to see what proposals they make.
Based on its analysis, it might have made more sense for the commission to produce recommendations that focus on what changes it would like to see in the policies of national governments, and what policies it would like see them pursue to reform the key international bodies whose governance and policies are, often rightly, criticized and which they control. A talking shop and a monitoring mechanism seem inadequate to address the systemic problems identified.
This is the third 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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