Tuesday, May 18, 2021

Global Health in Public Policy: Finding the Right Frame

It is very important to note that contrary to many believes and perceptions that exists one of health promotion’s major contributions has been its discursive challenge to biomedical and even behavioural models of health and illness. The concept of social determinants of health is now widely accepted by health authorities in many parts of the world. When health promoters focus on these determinants, however, it is often at local or national scales. Contemporary globalisation demands a more critical appraisal of how many health problems have become inherently global in cause and consequence. In making such an appraisal, it is helpful to consider how global health is presently being framed to determine which arguments are most likely to be health-promoting for the greatest number 

In 2005 the Bangkok Charter for Health Promotion stated that health promotion must become central to the global development agenda. The Charter emphasised the health promotion impact of increased trade in health-damaging products and services, an important but limited view of the role played by contemporary globalisation in influencing health. None the less, the need to extend the environmental aphorism ÔÇô think globally, act locally ÔÇô to transnational health activism has begun to move from the periphery of social movements. In doing so, multiple discourses around the issue of global health have emerged, each framing differing assumptions about the risks or opportunities for achieving greater health equity. Several are readily identifiable ÔÇô health as security, development, global public good and human right ÔÇô which comprise the dominant rationales for how and why the foreign policy roles and responsibilities of national governments should change.

These global health discourses represent different ways in which governments and multilateral institutions are responding to the increasing health risks posed by globalisation. They also represent differing approaches to what many analysts consider globalisation’s most critical challenge: a deficit in democratic or accountable global governance alongside an increase in the power of global economic actors. Each discourse has its own extensive literature. my purpose is not to present detailed theoretical or empirical examination of these discourses so much as to assess briefly the potential of each to generate state actions towards health equity, and how they might be used by activist health promoters to that end as it has also been presented by other scholars such as Lee et al 2002, 2007 respectively. 

In this piece I assume the nation-state to be an important political actor in negotiating global policies or advancing international practices that improve health equity. This does not negate the role played by other actors at the global level, which are predominantly dependent upon nation-states for their existence. Nation states have none the less entered into trade and liberalisation treaties that directly or in path-dependent ways restrict their present and future policy power. To many analysts this portends a gradual decline in the political power of the nation-state and the eventual emergence of more forceful forms of global governance. Such governance, however, is still likely to be dominated by the interests of those nation states presently most powerful; and there is nothing inevitable about if and what form(s) future global governance might take, as has been argued by scholars such as Backer, 2006.


Health as Development

Health has long been viewed as a desired outcome of development, most recently expressed in the Millennium Development Goals (MDGs), agreed to by all the world’s nations in 2000. The MDG 8 goals and 18 targets represent the most concentrated and collective global statement of development intent in human history. Most are directly or indirectly health goals. The MDGs, while galvanising global attention on issues of health and disparity, are not without trenchant criticism. They lack equity stratifiers, meaning that countries can achieve them by improving the health of the better off while worsening that of the poor. (2) There are few reliable data available to track progress. (3) They are silent on the causes of the problems that they commit the global community’ to address and lastly they are remarkably unambitious. The poverty goal, for example, is based on the narrowly defined World Bank $1/day level, a measure critiqued on both methodological grounds (the relevance of the basket of goods on which it is based and the accuracy of reporting) just for example. 

The more recent health/development story posits that investing in health yields substantial economic returns (Commission on Macroeconomics and Health 2001, Global Forum for Health Research 2004). Health is no longer seen simply as a consequence of economic growth, but as one of its engines. Historically, aid has been a major form of capital transfer from rich to poor countries for health and development purposes. Aid levels plunged during the 1990s as neoliberal orthodoxy defeated older theories of endogenous development; this instrumental reasoning raises three concerns. The subsequent resurgence of global activism around the need for greater levels of aid spending has been accompanied by renewed critiques of aid as dependency-producing with little to show in terms of development returns. In an increasingly interdependent economic world, the transfers now called ‘aid’ should not be seen as ‘aid’ at all but as redistributive obligations. 


Health as global public good

The limitations of the development aid discourse have none the less given rise to health as global  Public good. Health promoters frequently invoke public or common good as shorthand to capture an ethic that places collective benefit above individual gain. A global public good is one whose benefits extend to all countries, people, and generations. None the less, there are two qualities of a global public good: its benefits are not confined to citizens of one nation; and, as with all public goods, it is under-provided in the market because its use by all engenders free riders ÔÇô those who enjoy the good but pay nothing for it. Global public goods in turn, are characteristically private or public decisions made in one country that have undesirable spill-over effects (‘externalities’) on people in other countries. 


Health as human right

One human right covenant gaining global health policy prominence is the right to health, technically known as ‘the right to highest attainable standard of physical and mental health’. This right is embodied in a number of international declarations, covenants (treaties) and plans of action. Covenants are legally binding on countries that ratify them (‘states parties’), but do not require states to guarantee that all people enjoy the same level of health. Rather, they obligate states to ensure that all people enjoy the same access to goods and services essential to enjoyment of this right. A key text on this right is Article 12 of the International Covenant on Economic, Social and Cultural Rights (ICESCR). It specifically obligates states parties to ensure provision of a number of health care and public health services, as well as equitable and affordable access to such key underlying health determinants as ‘safe and potable water and adequate sanitation, an adequate supply of safe food, nutrition and housing, healthy occupational and environmental conditions, and health-related education and information, including on sexual and reproductive health’ (United Nations Committee on Economic, Social and Cultural Rights 2000). 


Thabo Lucas Seleke, Researcher Global Health Policy & Health Systems strengthening


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