Tackling the political determinants of global healthBMJ 2005; 331 doi: http://dx.doi.org/10.1136/bmj.331.7511.246 (Published 28 July 2005) Cite this as: BMJ 2005;331:246
This month sees the launch of an “alternative world health report,” a document that will from now on appear every two years.1 For the first time the institutions charged with improving global health are held accountable by the collective view of a coalition of civil society organisations reporting a clear message: the crisis in global health is not a crisis of disease, it is a crisis of governance.2
In tune with other citizens' movements for global social justice, this report argues that we have reached a stage in the history of public health where we can no longer accept profound inequities in access to health and treatment around the world. The report concludes that poverty and the lack of resources for the health of the poor are the key factors that hinder progress in global health, but it does not restrict itself to call for more charity. Instead the world needs a new policy model based on entitlement, in which good health is an integral part of social, economic, and cultural rights and citizenship and is ensured as a global public good. Achieving this will depend on an accountable mechanism for global governance and a strengthened public sector at all levels.
The alternative world health report scrutinises the conduct of global organisations—such as the World Health Organization, the United Nations Children's Fund (UNICEF), and the World Bank, global trade regimes, transnational corporations, and the rich nations—and their approaches to aid and debt relief. It underlines that the global regimes that support the international system of finance and trade need to be balanced by a global social contract that benefits people. It analyses how international organisations and donors have contributed to the current crisis and that many national governments have not prioritised population health. Critical processes are the redirection of global health functions from interstate mechanisms to a fragmented group of actors; the discussion of major health issues in forums (trade, agriculture, intellectual property, security) to which the public health community has little access; a commercialisation and privatisation of global health, which introduces a biomedical and technological bias and often stands in the way of building sustainable health systems.
The alternative world health report proposes that the current crisis of governance is provoked by the rich nations wanting to shape the international world order to their image—such a view lets some developing nations, particularly those that have become global players in their own right, get away too lightly. Also the report presupposes too easily that a more “equal” distribution of power in the international system would lead to a greater adherence to human rights and a greater commitment to equity—the ideological divergence in the current global system is too large and too fluid to be sure of such an outcome.3 These are issues that must be dealt with in future reports—as must the accountability of other players, such as foundations and non-governmental organisations.
The global health governance system needs a strong core that develops and monitors norms and standards including international health treaties, tackles key health issues of the poor, and ensures global health security through international regulations, surveillance, and rapid outbreak response. With this in mind, the chapter analysing WHO and the leadership and governance problems it faces is one of the most worrying in this report. The report makes specific proposals for a stronger WHO, for better funding and organisation of global health, and for cooperation between civil society movements committed to global public goods such as water, education, and health. It also proposes a global campaign for a tax to finance global public goods. How difficult such a shift will be could be seen at the recent G8 summit.4 Even so, when public health experts suggested a tax on airline tickets for global public health several years ago,5 6 they were considered dreamers; now this issue is part of the deliberation of heads of state, and airlines would do well in spearheading a movement for global health security on which their business depends.
I would hesitate to put most of the reason for failure down to the all encompassing concepts of neoliberalism and globalisation, as the alternative world health report is prone to doing, but health is deeply political. We need to tackle the political determinants of health. National public health associations and medical associations should be at the forefront of explaining and exploring the interface of national and global public health, maybe through the mechanism of national global health summits.7 They should commit to this unique historical opportunity, which is like the 19th century golden age of public health. Then as now: if we want “to make poverty history,” we need to tackle health.
Competing interests IK was requested to give and gave some months ago a positive commendation for the alternative world health report.
Log in using your username and password
Log in through your institution
Register for a free trial to thebmj.com to receive unlimited access to all content on thebmj.com for 14 days.
Sign up for a free trial