The Battle for Global Health & Movers and Shakers vs Inequality Warriors

Progress on global health is a contentious subject. While some celebrate progress in key health indicators, others warn that gross global inequalities are still responsible for 20 million deaths every year. A group of experts and civil society that holds the latter view has proposed a Framework Convention on Global Health to ensure health coverage for all. The proposal is both interesting in and of itself, because of the consultative process involved, and because of its potential implications for the discussions around a post-2015 successor to the Millennium Development Goals.

Last month I had the pleasure of meeting public health law Prof Lawrence Gostin of Georgetown and Johns Hopkins universities, sometime adviser to Presidents Clinton and Obama, and former director of Liberty in the UK (the National Council of Civil Liberties, as was). Prof Gostin had addressed an audience at the Department of Public Health, University of Oxford, to present the idea of a framework convention on global health which he originally proposed and has been instrumental in building a movement for.

Prof Gostin spoke of there being two ‘realities’ in global health. One, held by the ‘movers and shakers’ (i.e. USAID, Pepfar, Global Fund and so on) but perhaps somewhat less securely now than it once was, is the view (supported by e.g. stats on HIV) that there has been stunning progress, and that it makes real sense to be thinking about the ‘endgame’. USAID apparently has projections for various indicators for convergence to (close to) rich country rates over 10-20 years.

{To see how the evidence could support both convergence and non-convergence views, below is an adapted version of figure 6 from a really interesting recent paper from Anna-Maria Aksan and Shankha Chakraborty. The first scatterplot shows that countries with lower life expectancy at birth in 1970 saw greater improvements over the next twenty years (before the major impact of HIV), while the second scatterplot shows the complete absence of any convergence in adult mortality.}

global health

The other reality, seen by Gostin and many of the southern civil society groups with which he is working, is that while the goal would look something like a rough, global equalisation of key morbidity and premature mortality rates, these are currently characterised by massive inequalities. They have calculated, for example, that collectively, health inequalities between countries result in around 20 million lives lost each year (i.e. this is the size of the gap between outcomes in high-income and other countries), and that this has held over the last 20 years. This is roughly one third of all deaths over the period, and says nothing about the effect (known to be powerful) of inequalities within countries – where e.g. The Spirit Level presented evidence that the most unequal countries have systematically poorer health outcomes at the national level (and similarly for the most unequal states of the USA).

 

To challenge this, this growing movement proposes a framework convention that would seek to establish a set of principles to shift fundamentally the way that things develop. The umbrella group that is taking this thinking forward is JALI: the Joint Action and Learning Initiativeon National and Global Responsibilities for Health. JALI’s steering committee is comprised of Lawyers Collective from India, SECTION27 from South Africa and the O’Neill Institute for National and Global Health Law from the USA. The steering committee is broader, including among others tax justice’s own Attiya Waris from the University of Nairobi and Armando de Negri of the World Social Forum.

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The emphasis on learning is seriously meant: while the group has a powerful manifesto, to which they invite signatories, the approach is far from one of pursuing a settled path. The website is focused as much on research questions as on presenting the idea, with responses actively sought through international consultation to a set of important, wide-ranging questions. This diagram (click for full size) illustrates the ‘bottom-up, top-down continuum’ of research areas:

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Unsurprisingly, JALI see the post-2015 discussions as potentially providing the space in which to take this forward. While the full Framework remains to be developed, there is already an outline analysis of what supporters should advocate for in the post-2015 process. Broadly, it emphasises the progressive realisation of universal health coverage, with particular attention to systematic inequalities in coverage, to accountability and to inclusive participation in decision-making.

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What’s not to like, you may well ask. What perhaps remains to be developed as the next step is the type of specific proposal that could point the way to elements of content in the MDG successor framework. What indicators, for example, would best encourage accountability on, and progress towards, universal coverage?

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The fourth of ten points in the post-2015 document, in full, is this:

4. “Universal” as universal: “Universal” must be truly universal. No population should be
excluded because of legal or other status (e.g., undocumented immigrants, stateless people). Similarly, universal should entail 100% population coverage. Less than truly universal coverage as a goal may enable countries to forego the efforts required to ensure coverage for the most difficult-to-reach populations, who are often the most marginalized.

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Given the concerns that universal goals in the MDGs allowed some governments to pursue the ‘low-hanging fruit’ – i.e. in order to reach the targets that they had set for themselves, all too often they put in place interventions and policies that reached the easiest to reach, while leaving the most excluded behind – this raises important questions of approach. For example:

  • Should we propose targets that capture progress towards health coverage among the most excluded groups (whether, for example, by income, ethnicity, gender or disability) relative to the most empowered? Targets would reflect levels of convergence – e.g. reducing the differentials in India between high caste groups and Scheduled Castes, Scheduled Tribes and Muslims, or between Afrodescendant and white Brazilians, and so on.
  • Can we envisage inclusive, national processes that determine in each country the relevant dimensions of exclusion to be covered? Much of the problem of weak national ownership of the MDGs could perhaps be addressed through an initial stage in rolling out the post-2015 framework in which citizens contribute identify the key group inequalities in their societies, effectively mandating specific applications of a global outline.
  • Should every country in addition have some common targets, such as the relative progress of the poorest 10% (or 20%, or 40%) against the richest?
And notwithstanding the sense of conflicting views of global health that this post’s title refers to, USAID themselves have done some great work on the programme side in thinking about how to ensure they are challenging health inequalities at each step of their work – see, for example, this checklist.
Slavonski Brod transit camp in Croatia. Croatian Red Cross volunteers assist the arriving people who are then directed to busses heading for registration. After registration almost all refugees continue to Slovenia. Volunteers provide refugees food items and warm winter clothes.

JALI’s post-2015 outline document also shows an interesting breadth, consistent with the overall approach of seeing health outcomes as stemming from much wider causes – reflecting not only a social determinants analysis (in particular, as per the report of the Commission on the Social Determinants of Health) but also wider issues such as the damage done by illicit financial flows (e.g. to accountability and to tax revenues, undermining not only governments’ ability to finance health systems but also citizens’ ability to hold them to account for doing so).

As illicit flows are increasingly highlighted by civil society as a fundamental obstacle to progress towards internationally agreed development goals, both in broader analysis and in specific areas such as health, it’s tempting to wonder whether a post-2015 element to reflect this concern could emerge, and tap the increasing interest among policymakers also. One to think about, at least…