Panel: Good Governance Is Key To Achieving Global Health Goals

As the future United Nations development goals are being debated and decided, two important reports make the case for inclusion of a discussion on global governance and its impact on health.

Failures in governance can be detrimental to health efforts, according to speakers at a 7 May event in Geneva, and there is a need to look at good governance across many different policy areas, at both the country and international levels. The case for increased investment in health is also made.

The event organised by the Graduate Institute Geneva and the Permanent Mission of Norway, discussed, “Post 2015: The next era of global governance? Health as an indicator and outcome for all Post 2015 goals.”

Speakers introduced two recent reports in the UK journal The Lancet on the political determinants of and financial investment in health, followed by perspectives from the United Nations Development Programme (UNDP) and the intergovernmental South Centre.

Steffen Kongstad, Ambassador and Permanent Representative of Norway to the UN in Geneva, said global health “so often is about politics.” Governance is where the political and the technical meet, he said, “where resources and commitment of actors connect with technical experts.”

The “new era of global politics” and post 2015 development goals will have to address interactions between the fields of health, finance, industry, and environment, he said.

Ole Petter Ottersen, professor of medicine and president of the University of Oslo, presented a report by the Lancet-University of Oslo Commission on Global Governance for Health, which he chaired, on “the political origins of health inequity: prospects for change.”

The report, published on 11 February, looks at the “political determinants of health,” said event moderator Ilona Kickbusch, director of the Global Health Programme at the Graduate Institute. It is essential to discuss health in all policy areas at the international level to move forward into the new post-2015 era, she said.

The report concludes that achievements of health are sometimes undermined by failures in global governance.

“One illustrative example of how political arenas outside health can affect and undermine some of the efforts of the health,” said Ottersen, is UNITAID’s analysis of the negative impact that the Trans-Pacific Partnership will have on health (IPW, Bilateral/Regional Negotiations, 26 March 2014).

Global governance issues must be “duly taken into account in the development agenda debate,” he said. Unacceptable health inequities require political action across many different sectors and regions, he said, and many countries will require assistance to ensure the health sector a continued success.

The report analysed seven different policy areas that impede health equity: economic crisis and austerity, access to knowledge and intellectual property investment agreements, food security, transnational corporations, irregular migration and organised violence.

“It’s disheartening to realise that the deep routes of inequity in health that we find today are to be found in politics,” said Ottersen. But this gives rise to some optimism, he said, as politics leaves a choice: “We can act in order to remedy these dysfunctions.”

From these seven areas, the report identified five systematic political dysfunctions from which its recommendations are based: democratic deficit, weak accountability, institutional stickiness, missing institutions, and lack of policy space for health.

General suggestions include strengthening existing efforts for the removal of health inequities, and ensuring more civil society engagement in the issues.

A more concrete recommendation is for the “establishment of an independent scientific monitoring panel that will look across all policy areas to really identify those health impacts before we make irreversible decisions on it,” explained Ottersen.

Information from this panel would then feed into a multi-stakeholder platform for discussion, which will come up with actionable efforts to improve health, closely working with the World Health Organization.

The report concludes that “decisions in all political domains should be made with health at the core of thinking.” This is far from the norm today, said Ottersen, but a precondition for change is awareness about what impact policy decisions in the different arenas will have on health, and the proposed panel can ensure that “the awareness will lead to action.”

Investing in Health

David Evans, director of the WHO Department of Health Systems Financing presented a second report published in December 2013, on “Global health 2035: a world converging within a generation. The Lancet Commission on Investing in Health.”

The report analysed changes that have taken place in the past 20 years, putting forward strong arguments for continued and increased investment in health. Four major conclusions were made, said Evans. First is that “there is enormous payoff from investing in health” in the financial sense, as well as obviously in the health sense. Some 11 percent of economic growth in lower and middle income countries has been due to health improvements, said Evans, adding, “returns are very, very substantial.”

The second conclusion is that “grand convergence” between the level of health in lower income counties and best performing middle income countries “is achievable within our lifetimes”. Judicial and financial investment and external assistance can make convergence happen more rapidly, said Evans.

Third, “fiscal policies are a powerful and underused level for curbing of non-communicable diseases and injuries,” said the report. Prevention and promotion are very important alongside treatment, Evans said. For example, tobacco taxes are an effective and efficient way to raise health levels, as well as provide more money that governments can put back into health.

The final conclusion from the report is that “progressive pathways towards universal health coverage is an efficient way to achieve health and financial protection.” The poorest need to be covered and have access to the interventions they need, as well as be protected financially from the costs of paying out of pocket, said Evans.

The report identifies implications for governance at a country and global level. At country level, this will mean prioritising investment for health, committing increasing proportions of GDP to health as countries get richer, implementing fiscal tariffs to combat non-communicable diseases (NCDs) against pressure from “powerful interest groups”, and providing low cost, high impact interventions with a focus of the poorest populations, concluded Evans.

At the global scale, the report recommends doubling investment on new technology, and strengthening global surveillance of pandemics, to push forward convergence. Technical assistance for the implementation of fiscal policies and regulations, and international cooperation against tobacco, are among key recommendations for control of NCDs, as well as financial assistance for universal healthcare, summarised Evans.

Dudley Tarlton, programme specialist for HIV, Health and Development at UNDP, said exclusion and inequality are “fundamental obstacles to sustainable development.”

Many say that a goal for governance was missing in the UN Millennium Development Goals, he said, but it is likely to be built into the next agenda either as a stand alone goal, mainstreamed through other goals or as part of a goal on governance and peaceful societies. The outcome of recent working groups apparently favours the last option, he added.

Working groups at UNDP have identified key components of good governance including: effectiveness, responsiveness, openness and transparency, addressing corruption, justice and the rule of law, participation in decision making and combating transnational organised crime. In the context of health, Tarlton gave the examples of UNDP’s work on corruption in the health sector, health risks arising from urbanisation, and organised crime’s trafficking of illicit tobacco and counterfeit medicines.

Most discussions have focussed on national governance, he said. However, recognition of the importance of non-state actors, and the health sector as a leader in global policymaking, will be key at the global level. Compartmentalisation of issues poses a challenge when dealing with overarching global issues, and there will be a need to look at linkages across regions and institutions as well as different policy sectors, he said.

Martin Khor, director of the South Centre, said for developing countries, health is the most important topic, and it includes water, food and sanitation. The South Centre provides developing country governments with information, research and analysis to help them effectively participate in global decisions, as some of these countries don’t even have a mission in Geneva, he said.

Stronger global partnership is essential as “health problems are global,” said Khor. “If there is infection in one area, it spreads though tourism, trade, so many other ways.”

International rules on trade, finance, intellectual property and investment have a direct and indirect impact on health, he added. Khor made references to the IP debate in relation to access to medicines, and that countries are being sued for taking anti-tobacco and pollution measures under investment treaty law. An international committee should look into how to control corporate influence, he suggested.

However, developing countries should also be given the means to implement goals decided on for the post-2015 agenda, which includes the provision of money and technology, he said, adding, “Otherwise, we are asking countries to commit to goals that they cannot implement.”

Julia Fraser is an intern at Intellectual Property Watch. She is currently training to be a solicitor and will start work at an international law firm in London in 2015. She has a BSc Honours in Biology from Edinburgh University where she developed an interest in public health related intellectual property issues.