It is the existing global set-up and norms that ultimately limit our range of choices and constrain our actions in health at the local level.
The present system of global governance fails to adequately protect and cater to the needs of public health the world over.
1. Many institutions of global governance –set up in the immediate post-World War IIera– have come under scrutiny as being outdated and anachronistic, having undergone almost no formal institutional reform to make them more relevant to the 21st century. As a result, rules that govern us are heavily biased in favor of the status-quo. The anachronistic structure of the international financial institutions (IFIs)*, the UN Security Council, as well as, the reluctance to open the governance of WHO to a wider range of claim holders are but three examples. Changes in the existing rules will be tough, but are a must –with those who de-facto control global governance simply having to cede power.
*: International decision-making processes often do not operate on the principle of ‘one nation state, one vote’. In the IMF andthe World Bank, the wealthiest countries have far greater influence over policy making than do less wealthy countries –and in the Security Council, veto power is vested on just a couple states.
2. Global governance processes outside the health sector are also not working and must be made to work better for health. Is this important? Indeed! It is global governance processes outside the health sector that must work more pointedly towards fairer and more just health systems that are in compliance with the fulfillment of the human right to health. For this to happen, it is primarily global health activists empowering claim holders that will have to more decisively push for the needed and unpostponable reforms.
3. In the current set-up, the main missing factors for a fairer global health governance** are: (i) political empowerment, (ii) non-discriminatory inclusion in social and political interactions, and (iii) the conditions for legitimate claim holders to stake claims.
**: A point of clarification: Global health governance (GHG) refers to governance of the global health system –defined as “the actors and institutions with the primary purpose of health”. Global governance for health (GGH) refers to “all governance areas that can and do affect health”.
4. The implications of applying fairer rules in global health governancecan and will be controversial and unwelcome to some, simply because it requires a candid assessment and a rebalancing of power structures.
5. Expressed as disfunctions,five systemic dysfunctions hinder the realization of a better global health governance:
• First, democratic deficit: Participation and representation of claim holdersin decision-making processes, is insufficient. (We are talking about claim holders in civil society, in social movements and in expert health bodies).
• Second, weak accountability mechanisms: The means by which power can be constrained and made responsive to the people that it affects are weak or inexistent and are insufficiently supported by transparent governance processes.
• Third, institutional stickiness: Norms, rules, and decision-making procedures are inflexible and difficult to reform (especially when they maintain entrenched interests);they therefore reinforce harmful health effects and inequalities.
• Fourth, inadequate policy space across sectors: The means by which public health can be protected and promoted both nationally and globally are inadequate, meaning that in global policy-making arenas outside of the health sector (GGH), health can be and often is subordinated to other objectives, such as economic or security interests.
• Fifth and finally, missing or only nascent and weak institutions: International institutions to protect and promote public health are either totally absent or still grossly ineffective (e.g., treaties, funds, courts, and softer forms of regulation such as norms and binding guidelines monitored by public interest civil society and human rights (HR) commissions).***
***: In apparent contradiction of this is the fact that the number of international bodies, conferences, and multilateral treaties grew from about 2900 in 1981 to 4900 in 2003. This trend has produced a system of overlapping, conflicting and nested sets of rules (sometimes called regime complexity) that blurs obligations and responsibilities and complicates accountability.(A hidden intention in this…?). [Note, however, that States can preserve their policy space for health by renegotiating, withdrawing from, or refusing to sign-up to international rules that will undermine the human right to health in their territory –but do they?].
6. To the above five dysfunctions, we can add some more found in the overall global governance system, namely: (i) the paucity of rules and codes of conduct that go beyond the realm of voluntary guidelines that do not work; (ii) weak or inexistent mechanisms for accountability of transnational corporations particularly to the people whose lives and health are most directly affected by their actions; (iii) weak institutions for enforcing international norms, laws, and standards when they are violated by transnational corporations; and (iv) the absence of institutions to ensure that competition for foreign direct investment between states does not lead to outcomes contrary to public health interests.
7. Bottom line here: It is the political determinants of health that basically ought to shape global health governance in order to frame the types of solutions that are proposed–solutions thatmore often than not currently exclude the consideration of alternative bottom-centered options.****
****: One way to get at the political determinants is to mandate international organizations and donors to carry out health equity or right to health impact assessments –a measure that should also be included as an explicit goal in the post-2015 agenda. Why? Because inequalities in health are not, in any sense whatsoever, a ‘natural’ phenomenon, but the result of a toxic combination of poor social policies and programs, unfair economic arrangements, and bad politics all skewing the distribution of health benefits. Another way to get at them is to demand that trade and investment agreements never again be negotiated between governments behind closed doors. The same is true for the adjudication of investment disputes between states and corporations that are shrouded in secrecy, even when major questions of public interest (such as tobacco control legislation or drugs patents) are at stake.
In principle, states are political equals in the global system. In reality, power disparities remain vast.
It is the politics of it all that generates and distributesthe power and resources at local, national and global levels and that ultimately shapes how people live, what they eat, and, ultimately, their health.
8. Yes, power asymmetries and the norms and policies these bring about do limit the range of our choices and do constrain our actions in health. [But beware, this state of affairs also sometimes provides opportunities –if we succeed to mobilize the powerless to stake concrete claims against injustice]. The resulting disparities and discrimination pervade all aspects of life, e.g., relations between men and women, between old and young people, as well as relations between countries, corporations, and people’s organizations. But somehow the situationstill remainshostage to the above norms and policies clearly maintained by those actors with the most power.(Do not forget that the media also exert power–only seldomthough to outrage the public and to inspire political mobilization).
The power of the market consistently supersedes the power of human rights principles, including in the area of health.
The internalization stage of human rights principles and standards, including in the human right to health domain, remains weak and woefully incomplete.
9. No single global political authority exists to hold states accountable when they violate the human right to health or fail to comply with internationally agreed-upon HR rules, principles, and standards. Nor do adequate accountability mechanisms exist for transnational corporations that move between jurisdictions with relative ease and are more powerful and better resourced than the governments that should regulate them. TNCs thus end up de-facto exerting what is an illegitimate and undemocratic influence in global and national policy processes.
10. The problem called the ‘democratic deficit’ pertains to the lack of an equal rightparticipate in decision-making, i.e., of fair representation with voice and influence, of transparency, and of accountability. As said, public interest civil society organizations, social movements, marginalized groups, and health experts are inadequately included in international decision-making processes. By comparison, corporations have more privileged access to national delegates to UN agencies, who can bring the TNCs’self-interested proposals to the negotiating table. The democratic deficit thus remains a central feature of most global governance processes including health.
11. Much of the pressures of the corporate sector pertain to them pushing for privatization and/or market access. They do so really lacking the evidence to show that the market logic improves access to health or cuts costs. The arguments the ‘privatizers’ use read like this: “Public services provide poor health care”, and “the state does not have the means to invest in public health services”. Both arguments are flawed, are relative and respond to a neoliberal ideological interpretation of what a health system ought to be.
12. Moreover, as you may know, Intellectual Property Regimes are increasingly focused on protecting business and corporate interests and investments. (UN Committee on ESCR) These regimes have effectively demonstrated that they have the ability to block the optimal development of, and greater access to new appropriate technology solutions to essential human problems such as in primary health care, in the provision of adequate nutrition and of clean water, as well as in the attainment of higher levels ofquality of health care, of drug effectiveness and safety,ofchemical safety, and the achievement ofclimate change. (CETIM)
Private corporations have an unwarranted influential role in contemporary global and health governance.
When health is compromised by transnational corporations’ ulterior global pursuits, our response must simply be changing the inner workings of global governance.
13. Let us not be fooled: Large TNCs wield tremendous economic power that they can and do deploy to further their interests in global governance processes and global markets. But they are not alone. Other ‘non-state actors’ such as foundations also wield substantial economic power. You know the philathrocapitalistBill & Melinda Gates Foundation has become the most influential players in global health.
14. In the realm of nutrition, the speculative bubble, i.e., the increased trade in futures food commodity markets has been the main underlying cause of excessive food-price volatility. TNCs, mega family owned corporations and financial speculators are increasingly expanding their influence in these global decision-making processes, with no accountability whatsoever with respect to the international laws protecting the myriad populations being rendered vulnerable. Some firms exploit cross-country differences in regulations to maximize their profits.*****
*****: With their increasing power, a few powerful corporations dominate the ultraprocessedjunk food sector. This results in a globalized food market in which consumer welfare is measured by price rather than by nutritional value or health effects.
15. Deplorably, the existing multilateral global governance structures do not allow the Special UN Rapporteurs to impose the respect of HR beyond exerting a mere normative moral force. We must call for a strengthened use of HR instruments in health policy making, such as those the UN Special Rapporteur for Health has been calling for–among other, calling for stronger sanctions against a broader range of violations by corporate actors by more proactively using the national and international judicial systems.
How far are we from an era where health will be adopted as a universal value, as a human right and as a shared social and political objective for all?
16. Economic globalization has outpaced the political reaction to its negative effects, i.e., the development of institutions and the mobilization of forces that can more fairly govern the global market and protect societies against past market failures and those surely yet to come. Mechanisms to do exactly that remain pitifully isolated and thus weak. New and/or drastically retooled institutions and mechanisms, as well as strong regulations are needed when the operations and interests of some of the state and non-state actors seriously conflict with people’s health and wellbeing.
17. Furthermore, the UN Human Rights Council should expand the mandates of the Special Rapporteurs to include HR audits of the decision-making processes of global governance organizations.Moreover, having the Special Rapporteur for health report directly to the World Health Assembly would help as would strengthening the mechanisms for imposing sanctions and arranging for reparations in cases of demonstrated violations of the human right to health.
18. Getting there will require agents of change (us) and a determination for change, within social movements, inside the UN and among the political leaders of the world.
19. The sad truth is that we still do not have adequate means to ensure the accountability of states and of the private sector for the health consequences of their actions. Only weak institutions exist in the health sector itself, as well as in other sectors to protect health as a HR –especially in the politically powerful sectors of finance, trade and security. Major hurdles remain for a fairer and better global governance of health regime. So the era we yearn-for is still in the distance. Each of us can play a role in bringing it closer.
Claudio Schuftan, Ho Chi Minh City
cschuftan@phmovement.org