Global Health Watch: Challenging entrenched ideas in global healthBMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k956 (Published 02 March 2018) Cite this as: BMJ 2018;360:k956
- Anuj Kapilashrami, lecturer in global health policy1,
- Ted Schrecker, professor of global health policy2
- Correspondence to: A Kapilashrami
The discursive and policy realms now identified as global health sometimes seem to unfold in parallel universes. In one universe, a Lancet Commission argues the possibility of worldwide convergence on health outcomes by 2035, while devoting just one paragraph to social determinants of health.1 The lead authors are former senior staff of the World Bank, an institution often associated with a destructive preoccupation with cost effectiveness in “resource poor settings” and promotion of socially devastating requirements for structural adjustment.23
In the other universe, less occupationally secure researchers focus on questions such as why some settings are resource poor and others are not,4 and on the “power asymmetries” that characterise the proliferating mechanisms of global governance that affect health.56
Since 2005 a transnational network of researchers and campaigners broadly sharing this second view, operating on a shoestring budget, has periodically produced Global Health Watch as an alternative to the better known (and better funded) annual outputs of the World Health Organization and the World Bank. In 2014, the fourth report7 began with an overview of how four decades of neoliberal globalisation increased inequality and undermined access to healthcare and opportunities for healthy life for many of the world’s people, in countries rich and poor. Global Health Watch 5,8 published in December 2017, continues the critique of neoliberalism but shifts the focus to more specific issues of governance and development policy, starting with the demanding political and institutional changes that will be needed if the sustainable development goals (SDGs) are to have any chance of being realised.
With five distinct sections—on global political and economic architecture; health systems; social and environmental determinants of health; the role of global institutions and private capital in health; and resistance from social movements—the report covers a large canvas. Across these sections, it offers a trenchant critique of privatisation of health systems, exemplified by public-private partnerships. This is, of course, directly relevant to the UK because of the fiscally disastrous private finance initiatives (PFI) in the NHS.9 While profit margins for investors in PFI schemes are 40-70%, paying private sector consortiums costs 2% of the NHS budget each year.10
Internationally, the role of the private sector, especially private insurance, is also central to ongoing controversies about universal health coverage. This is a key target of the sustainable development goals, and one now supported by both the World Bank and the World Health Organization,11 although they may not mean the same thing by it. Other dimensions of the role of money in health systems and health governance are dealt with in an admirably clear exposition of the changing financial picture of WHO and what that means for the organisation’s priorities, and an intriguing discussion of the expanding role of private philanthropic foundations and management consultancies in health policy and systems.
The two are often intertwined; between 2006 and 2014 the Bill and Melinda Gates Foundation spent more than $270m (£195m; €200m) on the services of Boston Consulting Group and McKinsey, leading global consultants. Thus, the familiar trope of the post-Westphalian landscape of global health governance—in which multiple “non-state” actors interact with, compete with, and occasionally supersede national governments12—is more politically fraught than sometimes acknowledged, and non-state actors are most certainly not all alike in terms of their resources or influence.
Unpacking and challenging neoliberal dominance in health has been a constant endeavour of the Global Health Watch series. Besides showing the effects of neoliberalism on health systems, social determinants, and inequities, the report’s strongest contribution to knowledge lies in making visible the ability of neoliberalism to structure debates, constrain policy spaces, and limit “what is sayable, doable, and even thinkable in global health.”13
In continuing that trend, Global Health Watch 5 offers both a critique and a compelling counternarrative to dominant discourses on some of the intractable problems in global health today. The report warns of the widespread euphoria surrounding SDGs by revealing fundamental contradictions and policy incoherence within the SDG agenda and the reductionist view of universal health coverage that is gaining momentum. It also highlights the “blind spot” in debates on migration, bringing to the fore structural factors (wars, climate disasters, rising global inequalities) that drive population movements and reminding us of the implications of framing global health problems as issues of security for resource allocation and policy priorities.
To conclude, the new edition of Global Health Watch offers a critical and compelling resource for alternative analysis on global health, and is a helpful reminder of the imperative for radical social change.
Competing interests: We have read and understood BMJ policy on declaration of interests and declare that AK is a member of the UK People’s Health Movement but has made no contribution to the Global Health Watch 5 report.
Provenance and peer review: Commissioned; not externally peer reviewed.