Global Health Governance

Sophie Harman

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781136586514
• Edition: 1
• Topic: Politica e relazioni internazionali
• Subtopic: Politica

In the light of scares about potential pandemics such as swine fever and avian flu, the issue of global health and its governance is of increasing concern to scholars and practitioners of medicine, public health, social work, and international politics alike.

Providing a concise and informative introduction to how global health is governed, this book:

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• Explores the various ways in which we understand global health governance

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• Explains the "nuts and bolts" of the traditional institutions of global health governance, highlights key frameworks and treaties and their relative successes and failings

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• Examines the actors in global health governance, their purpose, influence and impact

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• Offers an in depth analysis of the effectiveness of global health interventions, focusing particularly on HIV/AIDS, tuberculosis and malaria.

Highlighting the wide variety of actors, issues and approaches involved, this work shows the complex nature of global health governance, forcing the reader to examine who or what really governs global health, to what outcome, and for whom.

1 Approaches to Global Health Governance

• Inequity, justice, and global public goods

• Right to health

• Multisectoralism

• Health as a security concern

• Health governance as biopolitics

• Conclusion

Central to the governance of global health and the institutional mechanisms organized within it are the conceptual approaches that direct how certain health issues are addressed, defined, and prioritized. Approaches to health governance have changed rapidly over the last fifty years. Typically biomedical models of health interventions have dominated the terrain of how we understand global health and how it is approached and practiced. However, the increasingly globalized nature of health has required a wider recognition of the socio-economic determinants of poor health and the need to balance biomedical approaches with that of human rights and wider participation in delivering health services beyond medical practitioners. Global health has come to constitute a development concern, a barometer of global inequality, and a security threat. Each of these framings of health has had an impact on global health policy: how it is addressed, how specific issues come on to the global agenda, levels of public and private sector involvement, and how institutions have positioned health and disease in global and local spaces.

This chapter builds on the shift from international to global health outlined in the Introduction. In so doing it considers the following approaches to global health governance: inequity and health as a public good, the right to health, multisectoralism, health as a security concern, and health as biopolitics. It outlines what is meant by each of these approaches, how they correspond to policy and practice, and what they mean for global health governance.

Inequity, Justice, and Global Public Goods

Health interventions have always been underpinned by debate over how to provide the best achievable healthcare for the largest number of the population whilst maintaining standards of care, the rights of the individual, and advances in medical research. The provision of health for all reflects rights and responsibilities basic to any social contract between those who deliver and receive care. This social contract can be seen in the Hippocratic Oath taken by medical practitioners to the modeling of how to run health systems effectively. As with recent changes in public health interventions, ethics and how to address inequalities within global health have come to the fore of our approach to public health. According to Tarantola et al., the new public health movement that associates health with development processes and change within the global political economy has put the notion of rights, access to public goods, and the need to address global inequalities at the heart of this agenda.¹ Central to that is the framing of health within wider commitments to reducing poverty. Health remains the ultimate barometer of poverty, well-being, and relative deprivation, and there remains an important rationale that economic growth, political peace, and stability will only occur within healthy populations. Health and life expectancy continue to be directly related to social class and wealth.² Hence approaches to global health interventions have become cognizant of inequalities and inequities and the need to address them.

A basic definition of health inequities can be those “differences (in health) which are unnecessary and unavoidable but, in addition, are also considered unfair and unjust.”³ Health inequity is often seen to be driven by risky behavior, healthcare provision, structural change, and the clustering of risk factors. In practice, for health this means tackling specific health issues and diseases in the form of vertical interventions, or more horizontal health system strengthening, and broadening the remit of public health out to include the structural determinants of inequity. In contrast, health equity refers to the absence of avoidable differences among populations defined socially, economically, demographically, or geographically. Hence, health (in)equity is based on a normative understanding of what is considered to be fair or just. Any intervention to combat health inequity is thus underpinned by wider debates on distributive justice and the contention over equality of opportunity and equality of outcome.

For Amartya Sen, distributive health justice rests on the “capabilities” argument that there are a number of capabilities essential to the health of individuals. Individuals should be provided with these basic capabilities: once provided, it becomes the individual’s responsibility or choice as to how they use or disregard these capabilities. According to Sen, “health is among the most important conditions of human life and a critically significant constituent of human capabilities which we have reason to value,”⁴ health becomes a central capability for an individual’s ability to function,⁵ and hence the provision of social justice. Inequalities may arise from individual choice, but inequities in health are centered upon unequal access to these capabilities. It thus becomes the responsibility of states to “level up” and provide these basic capabilities to address inequalities. Although he does not directly address health,⁶ distributive health justice and the capabilities argument has often been discussed in the context of John Rawls’ egalitarianism. In principle, provision of basic capabilities should give rise to what Rawls sees as “fair equality of opportunity.”⁷ As such, health as a capability becomes a right underpinned by a normative understanding of distributive justice, which for a just society to exist health is a basic function, capability, or a global public good. The problem is that when applying such a principle to practice, questions arise over which capabilities function as “basic” capabilities, who or what should provide for them and at what cost.

Health inequity and renewed focus on the capabilities argument has led to the labeling of health as a global public good, in that it should be non-excludable—no one should be excluded from accessing good health—and non-rivalrous—in that one person’s health does not restrict another’s. Health is a global public good in that its benefits are, or should be, universal across sovereign borders, people, and generations.⁸ Increased interdependency between states and global issues has transposed health from a private good, that is, of which the individual is the prime beneficiary, to being public with multiple external effects on the global economy, environment, and society.⁹ According to Chen et al., it is these global “externalities” that see the shift of health from a private good to a global public good and the indivisibility of health as a positive sum game in which all must benefit, with one’s health not detracting from another’s.¹⁰

The non-rivalrous and non-excludable nature of public goods can make their supply and consumption problematic.¹¹ For Kaul et al., public goods tend to be under-provided and over-consumed.¹² Access to global public goods may depend on indirect cost, governance and control, change, and geography resulting in individuals being excluded.¹³ For example, health and knowledge are both considered global public goods, yet health knowledge is excludable through patent laws, product location, and the infrastructure delivering such knowledge.¹⁴ Such public goods depend on the distinction between the non-rivalrous and non-excludable nature of both production and consumption.¹⁵ Provision of global public goods by the free market generates problems and concerns of free-riding that in turn result in under-supply.¹⁶ Framing health as non-excludable or non-rivalrous in turn can lead to problems over who covers the cost and responsibility of their provision, what cost and to whom.¹⁷ Non-excludability can lead to the sidelining, or exclusion of health interventions that do not apply to the whole population, for example child health or women’s health, and moreover create a stalemate on any health interventions that undergo the existential question as to what impact they may or may not have on future generations. Thus, for Woodward and Smith, an alternative approach to health as a global public good would be to stress the degree to which goods exhibit “publicness across national boundaries” in which it is irrational to exclude individuals and, crucially, “irrespective of whether that nation contributes to its financing.”¹⁸

Approaches to health as a basic capability or a global public good act as normative guides as to how health should be considered and how inequalities within healthcare should be addressed. However, they are not only thought-exercises posing questions and ideas of justice, but translate into real policy outcomes through the emergence of multisectoral agendas for health and global commitments to health as a human right through recognition of the right to health. It is the problems, contradictions, and debates over social justice and fairness within these capabilities and public-goods-based arguments that make the terrain of global public health provision so problematic in terms of responsibilities, action, and who funds them.

Right to Health

The association between health, distributive justice, and global public goods has led to a broadening of the health agenda to include rights and multisectoral inclusion of non-health practitioners and approaches to combating health inequity. The first example of this has been the development of the United Nations “right to health.” The right to health refers to the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, established by the United Nations (UN) Commission of Human Rights resolutions 2002/31 and 2004/27 and extended by Human Rights Council 6/29.¹⁹ The right to health is an explicit recognition of the relationship between health and human rights, and their broader association with health inequity. As special rapporteur on the right to health 2002–8, Paul Hunt, argues, health is adversely affected by human rights abuses, specific health policies can be in violation of human rights, and in turn ill-health and vulnerability to ill-health can be reduced by greater awareness of human rights.²⁰

Rights-based interventions should enhance participation, empowerment, accountability, and crucially in regard to health equity, social justice.²¹ The right to health has the following main features. First, it is an inclusive right, based on non-discrimination and equal treatment of acceptable and good quality. It cannot be bought or sold. Nondiscrimination and equality are fundamental principles of human rights laws and are thus intrinsic to the right to health.²² Second, it contains freedoms and entitlements, in that individuals have the right to prevention, treatment, and control of disease, and should be free from non-consensual medical treatment or experimentation. Individuals should be free to control the health of their body and be active and informed participants in decision-making on their health. States must not directly violate an individual’s right to health, and must further monitor non-state and private actors to this end.²³ Hence, third, the right to health should be accountable and involve multiple forms of participation from individuals, states, and the international community. Fourth, the right to health is not the right to be healthy or an abstract ideal. It has short-term aims, resources, and guiding principles, and is progressive in character.²⁴ The right to health is not just an abstract concept but has systems and structures in which to operationalize its objectives.

The purpose of the right to health is to take a rights-based approach to health interventions, applied by human rights treaties and mechanisms. The right to health is implemented through a variety of international, national, and regional laws that clarify the role of different actors in terms of delivery and monitoring.²⁵ In terms of domestic law, the right to health is enshrined in 60 national constituencies, and 115 state constitutions, and multiple sources of regional law and regional human rights treaties.²⁶ States are also bound to multiple sources of international law, most notably the International Covenant on Economic, Social and Cultural Rights (ICESCR), article 12, which safeguards the right to health. Article 12 stipulates the need to take steps to reduce infant mortality and child development; improve environmental and industrial hygiene; prevent, treat, and control epidemic, endemic, occupational, and other diseases; create conditions that assure medical services and medical attention in the event of sickness. The broad range of health concerns and their inter-relationship with other human and labor rights and development issues means that the right to health is also enshrined in other international treaties²⁷ and public health policies.²⁸ Those states that recognize the right to health commit to core obligations: respect, protect, fulfill, and progression towards realization. In practice, this requires states to provide the essential bases of primary care, food, housing, sanitation, and the adoption and implementation of a national health plan.²⁹ Enshrining the right to health in domestic law gives individuals the right to pursue complaints or legal decisions within national courts, and hence affords them the opportunity to hold states to account.³⁰ Making the right to health work in practice thus rests on individual participation in regard to the ability of individuals to make decisions as well as how they hold states to account.

Accountability and the adherence to the international, regional, and state legislation show some of the flaws of the right to health approach. Whilst the approach takes broad steps to addressing health inequities and is keen to have a tangible basis, in many ways it is a dead-letter regime that has the appearance of political commitment and will but little practical realization of it. For example, a topical problem with the right to health has been its relationship with other forms of international law, most notably international trade law such as the trade-related intellectual property rights (TRIPs) (see Chapter 2 for further detail). Under TRIPs, states “can adopt measures necessary to protect public health” and restrict patents “if they pose a threat to human life.”³¹ However, in practice the realization of this has been problematic, and often patent laws supersede the rig...