The root causes of health inequities are to be found in weaknesses in political domains at the supranational level. These include: democratic deficit, weak accountability, institutional stickiness, missing institutions and restricted policy space for health. Achieving health equity is not just a matter of coming up with technical solutions and providing the means to finance them. We have to consider the political landscape and rectify the dysfunctions in global governance that undermine health
The Political Determinants of Health
by Ole Petter Ottersen*
and Desmond McNeill**
University of Oslo
The Millennium Development Goals report 2014 was launched in early July. The report shows that in the course of 22 years, annual number of under 5 deaths fell from 12 to 6.6 million while the global maternal mortality ratio was nearly halved, from 380 to 210 maternal deaths per 100 000 livebirths. Causes of progress are manifold, but setting clear goals has inspired, so much so that many talk of removing health inequities in a generation. Bill Gates, for one, articulates ambitions of this scale, as does the WHO Commission on the Social Determinants of Health.
It is tempting to make the assumption that the positive development will continue unabated, provided that due efforts are made to sustain or even increase funding of targeted initiatives such as those embedded in the Millennium Development Goals. However, in a changing world, extrapolations are fraught with difficulties. We have seen it in Syria, where polio was near eradication but now develops into a major health emergency. We have seen it in Greece, where health suffers in the wake of the austerity measures. And we saw it in the many countries that experienced a wave of hunger and malnutrition due to the food price volatility in 2008-2009. Recent history is replete with setbacks, and we need to pause and reflect on why.
Such an exercise reveals that root causes of health inequities are to be found in political domains outside of the health sector. We are talking about dysfunctions in global governance that negatively impact health. These dysfunctions were put under scrutiny by the Lancet-University of Oslo Commission that released its report in February this year. Based on the analysis of a number of cases the commission concludes that health is impacted by five major dysfunctions in governance at the supranational level: democratic deficit, weak accountability, institutional stickiness, missing institutions and restricted policy space for health. These weaknesses hamper or undermine the efforts of the global health system and constitute what we call the political origins of health inequity.
Let’s take the last point as an example: restricted policy space for health. An increasing number of decisions are taken at the supranational level, and many of these decisions constrain the policy space of nations. A primary obligation of a nation state is to safeguard the health of their population, but its ability to do so is easily thwarted when health is subordinated to other goals, primarily economic ones. Austerity measures have been mentioned. But trade agreements may similarly diminish policy space for health if they are put together without due consideration of the short or long term consequences for the health sector. Once signed, a trade agreement proves difficult if not impossible to change, even when inadvertent health effects come to the fore. The Commission used the TRIPS agreement (Agreement on Trade-Related Aspects of Intellectual Property Rights) as a case in point and as an example of “institutional stickiness”.
Trade agreements and foreign investment treaties also serve to illustrate other major dysfunctions of global governance that negatively impact health. Agreements and treaties that will ultimately affect large populations are often drafted without due transparency. There is a democratic deficit and weak accountability. Further, the Commission points out that institutions that could hold transnational corporations responsible for activities that interfere with health, are nascent or missing. There are powerful forces beyond the health sector that determine health, and there are substantial voids in global governance that leave these forces unchecked.
It is this political dimension of health that the Lancet-University of Oslo commission brings to the fore.
The commission argues that for ambitions to be realized, we have to ensure that there is global governance for health - i.e., that we have a global governance system that is conducive to the efforts of the health sector and of the numerous private-public initiatives that target specific health challenges. Achieving health equity is not just a matter of coming up with technical solutions and providing the means to finance them. We have to consider the political landscape and rectify the dysfunctions that undermine health.
To trace the political origins of health inequities the commission identified and discussed seven different cases, derived from political arenas outside of the health sector: foreign investment treaties, transnational corporate activity, immigration policies, violent conflict, food security and agriculture, intellectual property rights, economic crises and responses. When each arena is considered individually, it comes as no surprise that decisions taken therein significantly influence health. It is when these seven arenas are seen in context that a pattern emerges and an awareness is instilled about the cross-sectoral nature of the global governance dysfunctions impacting health. Only by taking a broad view across sectors was it possible for the Commission to recognize the five dysfunctions referred to above. These are dysfunctions that cut through the global governance system at large.
The value of narrowing down common denominators is obvious: we should be better able to find appropriate remedies in order to rectify what now stands as a defective global governance system for health. For the next move, timing is of the essence. The preparations for the post-2015 Sustainable Development Goals (SDG) are well under way, and it is of paramount importance that these goals are formulated with due attention to the shortcomings of global governance. For improvements to occur, there will be a need for concrete and quantifiable milestones. We will need to identify parameters and indicators by which we can measure progress when it comes to democratic involvement, accountability, institutional flexibility and policy space for health – i.e., across the dimensions identified above. This will not be an easy task. But it is a task from which we cannot shy away.
The Commission came up with a number of recommendations, the most essential of which is the establishment of an Academic Monitoring Panel. As we now see it, this panel should take responsibility for making the next move and help ensure that the political root causes of health inequities are duly taken into account when new policies are being worked out.
The panel should be mandated with the following tasks:
1. Revisit the political arenas analyzed by the commission, with the aim of providing concrete and proactive measures to safeguard health;
2. Carry out, solicit, or inspire high quality research, so as to deepen our understanding of the scale and nature of the global governance dysfunctions that impact health;
3. In order to avoid repetition or overlap, these tasks should be based on a comprehensive review of the efforts and initiatives that are currently being made to coordinate governance for health across political arenas outside of the health sector.
Point #1 acknowledges the complexity of the issues at hand and the need for much more research to truly understand how decision making at the supranational level affects health. Point #2 is based on the belief that high quality research should inform political choices. Point #3 is important, as the Panel should seek to fill a void rather than be seen as a body competing with existing initiatives or with WHO or other institutions in the health sector. Trade agreements and foreign investment treaties could be the first cases for the panel to revisit. By assessing health impacts of trade agreements in nascendi, the panel could help decision makers strike a balance between narrow economic goals and the need to safeguard and provide policy space for health.
It is important to note that the Panel should be truly independent and genuinely academic. As such, it should not be normative and assume an activist role, but rather inspire to action through high quality research and analyses. When confronted with hard evidence of health impact, it will prove difficult for decision makers to solely pursue restricted economic goals. And when confronted with hard evidence of the cross-sectoral nature of health, it will prove difficult for the architects of the SDG to avoid bringing global governance in as an important element. Health is biology, and technology has much to contribute to its improvement, but health is also inextricably coupled to politics on the grand scale. These are two views of health that today stand as utterly disconnected. The post-2015 agenda must be where the twain should meet and productively interact.
*Ole Petter Ottersen, Professor MD, PhD, President of the University of Oslo and Chair of the Lancet-University of Oslo Commission on Global Governance for Health
**Desmond McNeill, Professor PhD, Centre for Development and the Environment, University of Oslo, Commissioner, University of Oslo Commission on Global Governance for Health