15 June 2010

On 10-11 June 2010, the EU for the very first time organized a two day high-level event on global health. The central office of the European Commission, the Berlaymont building, was decorated for all to see, with a poster for the conference running down nearly the full height of its 18 floors in the heart of Brussels' EU quarter. Never has the EU's commitment to its global health responsibilities been so boldly displayed. The EU's commitment to global health was reinforced in the conference opening by EU Commissioner for Public Health John Dalli, presence of European Commission director generals for public health, development and research, and again in speeches from Margaret Chan, Director General of the World Health Organization, Bience Gawanas, African Union Commissioner for Social Affairs, and David Chiriboga, Minister for Health, Ecuador.

The event marks the culmination of the first phase in the creation of a comprehensive European strategy for global health. A year in the making, the EU now has a comprehensive policy framework on global health in the form of the European Commission's Communication on the EU Role in Global Health along with 19 priorities for its implementation found in the subsequent EU Council Conclusions on the Communication. The objective of the meeting was to present the European Commission Communication on global health and to discuss key challenges, goals, policy instruments and partnerships with stakeholders and global partners to see how the EU can most effectively engage with all actors to improve health at global level.

The EU was commended, even called courageous by Chan for tackling global health in all its complexity. "This world will not become a fair place for health all by itself" said Chan, "International trade agreements by themselves will not guarantee food security, or job security, or health security, or access to affordable medicines-equity happens only when equity is a specific policy objective," said Chan in her opening speech, and it was exactly these issues that participants at the meeting regularly challenged the EU to implement. Commissioner Gawanas also congratulated the European Commission for taking the bold step to involve so many stakeholders in creating a global health agenda but challenged the EU to put its words to action, "Africa and its partners in development by now know what the issues are, where the challenges lie, how to address them, why and when to intervene, now is the time for us to do what we know we can do," said Gawanas "people always ask me what are Africa's priorities and I wonder whether people do not listen, because Africa has said it loud and clear through the many declarations, decisions and commitments that have been taken by our leaders. I hope this conference will have the ability to listen and to build a global agenda that will take into account what Africa has said, what Africa has prioritized."

Ecuadorian Minister for Health David Chiriboga commended the consensus the EU had built around its priorities for a global health agenda, namely equity, access to universal coverage, human resources for health, social determinants of health, access to drugs, innovation and research, and the need for democratic and inclusive governance. However, the Minister questioned whether commercial and trade interests would win out in the end and called on the EU to challenge the dominant world view on development. "Global health is everyone's business, but are we really playing as equal partners in the global health field? What is really at stake here? Global public health or global health market strategies?" said Chiriboga. In addition to the long-established burdens of malnutrition and infectious diseases developing countries now also face diseases acquired through changing lifestyles, like in Ecuador where diabetes has already become the leading cause of death. "Developing countries face the bi-products of a path to development that gives rise to drawbacks in terms of quality of life and health," said Chiriboga. "There are many social determinants of health related to poverty, but it might be worth contemplating and researching social determinants related to the Western development model."

Stakeholders from a variety of disciplines, organizations and regions gathered first for a series of workshops to discuss key challenges, goals, policy instruments and partnerships. Issues covered in depth ranged from access to quality health care, coherence in response to globalization challenges, and access to new innovation in health sciences, to workshops on health as a human right, the future of global health governance, and the bridging of local and global challenges to health research.

A broader understanding global health

Each workshop produced recommendations which were further discussed in a plenary session on day two. The plenary discussion highlighted the lack of a common understanding of global health. Despite vehement pleas from many participants to change the way we discuss and understand global health discussions kept coming back to development aid and donor-recipient relationships. "How we actually talk about global health is crucial because that defines what we actually want to tackle with global health governance" said Ilona Kickbusch, Chair of the Global Health Europe Task Force. "Global health is not just about disease based initiatives, it's about strengthening systems and institutions for delivering health - not just strengthening health systems. It's about norms and standards, it's about whole of government approaches and partnerships, it's far beyond the ‘North-South' mind-frame, and even the infectious/non-infectious disease agenda needs to be framed quite differently. Global health governance means taking responsibility for the determinants of health in new ways, and there is no organization in the world that could do this more systematically than the European Union, if it wished to do so in relation to its trade policy, its agricultural policy, and its environmental policy."

In its global health framework policy and with this event the Commission has made a first attempt to brng together all the diverse interests in global health. "Imbalances in the understanding of global health which prioritize the development cooperation discourse over the discourse of global interdependence persist. This is because development focused NGOs are much better organized than are those groups advocating for wider discussions that centre on the provision of public goods at the global level" explains Kickbusch. "The Commission has its work cut out for it if it is to shift the discussion on global health to extend beyond paradigms of development cooperation." Yet despite this imbalance this first attempt in policy has had its successes as distinct Commission directorates for development cooperation, public health and research have come together to write this shared policy.

A more unassuming understanding of partnership and cooperation in health research

"There are no secrets as to how to achieve the next stage of emancipation of developing countries," held Paulo Buss, Director of the Brazilian national institute of health (Fiocruz), speaking on nascent models of "South-South" and "North-South-South" international cooperation in public health and health research. Buss calls this new type of cooperation "structural cooperation". "Structural cooperation means focusing on building sustainable institutions and not isolated projects through North-South cooperation schemes," explains Buss. Complimentary to approaches put forward in the Paris Declaration and the 2009 ECOSOC Ministerial Declaration, Buss says that structural South-South cooperation "should focus on supporting developing countries in building their own governance institutions and in training national professionals to manage and staff them with the best new intelligence in health, in health planning and health governance as well as in health promotion and disease prevention." The structural cooperation in health stems from the realization that most developing countries have huge growing health needs and face limitations in social and health governance systems. "Cooperation does not mean assistance," stressed Buss in an appeal to workshop participants to shift their understanding of cooperation in global health, "it is not one size fits all, but a joint conception and developing of activities to be implemented. In this sense this cooperation is eminently democratic and participatory, built on the concepts of alignment and ownership which also give it its emancipating character." An example of this new cooperation can be seen in the work of UNASUR Salud, the health body of the Union of South American Nations. Buss called for a joint summit on health between the EU and UNASUR to discuss working together for structural cooperation in health.

Supporting calls for a new frame of mind in health cooperation were voiced as plenary discussions on cooperation in health research regressed into conventional donor-recipient rhetoric. "Global health is about equity, and also about equity in research capacity, but we are still talking as if global health is about the ‘North' helping the ‘South' and this is really a mindset we have to change," said Bruno Gryseels, Director of the Institute of Tropical Medicine Antwerp. "Our vision for the future of global health can only be one: that is that countries have their own capacity. There will be international research in the future, among equal partners, and of course if we do research on tropical diseases we will have to do it with partners, just as our arctic researchers have to go to polar areas, but I truly believe and I hope, that in 15 years the European institutes of tropical medicine's roles won't any longer be in development, but in international collaborative research-just as for any other research institute."

Accepting a global health mind frame at national level

Discussions on global health governance tended to focus on international organizations such as the WHO; however the role of nation states and regional organizations like the EU were also recognised crucial. "There is absolutely no use in talking about global health governance if you haven't got your act together at home-global health begins at home" assured Ilona Kickbusch in the workshop on global health governance, "and this means changing the ways we approach global health at the national level." The entire field of global health is changing and has in many ways arisen due to the realization that there is an increasing overlap between national health objectives and common challenges beyond national borders, such as demographic transition and climate change.

In the workshop on coherence panellists described the negative synergies experienced at national level when rises in infectious disease, chronic disease and health worker migration are driven to converge due to processes such as development and globalization. In addition to measures at global level addressing these challenges requires long-term strategic investments in the health a national level, but the perception governments have of the health sector is holding us back. "We have a very poor mounted approach to health" stated Mike Ryan, Director of Global Alert and Response at the World Health Organization, "the security and military sector fight wars, that's the acute part of what they do-but they also have long term strategic investments which they don't consider to be expenditure."

To drive his message home Ryan used an illustrative comparison between the ways governments view health spending to how they view investments in national security and defence. "If you take a carrier group in the US Navy, it costs roughly 30 billion dollars to build, it has to be ordered 15 years before it's used, and it has to be designed and adapted for the theatre of use. They are thinking 15-20 years ahead, and we fear doing this because we don't want to bring more expenditure into the health system. We don't consider health as an investment; we don't consider health as a contingency investment: we consider it as expenditure." What this leads to, explains Ryan, is that "in most European states the Minister of Health is seen as the biggest ‘spender' in the cabinet, not the biggest producer. He or she is not producing healthy people who contribute, but rather they are seen as using up our tax payer's money and causing our deficit to grow." This is juxtaposed with the fact that while governments try to cut what should be seen as investments for health, real expenditures from chronic diseases in Europe are on the rise. "The health sector needs to make much better arguments for the strategic nature of an investment in health, and the length of that investment," says Ryan, "we can't fight chronic diseases doing what we're doing now investing for the next 1 to 2 years, we need to be looking at planning for 10 -15 years ahead.

Creating coherence

The Brussels event marks a turning point from discussions on what should the EU be doing concerning global health challenges, to starting discussions on how can it be done. "Policy coherence is mainly about how we can address global health challenges, how we can work together" said Gaudenz Silberschmidt, head of the International Affairs Division of the Swiss Federal Office of Public Health, "Often we take the easier but problematic approach of seeing coherence as a one way process." If the health sector is to successfully influence other policy fields to contribute to the delivery of better health and to do no harm to health and well-being, this mindset on coherence is one that needs to change says Silberschmidt, "In the health sector, with Health in All Policies, we wanted to see how the other sectors could work for us. I heard this morning ‘policy coherence for development', ‘policy coherence for health,' for me there can be no ‘policy coherence for what,' there is only just policy coherence, which is a two way process."

This more comprehensive understanding of policy coherence should facilitate a more constructive dialogue between the health sector and other policy fields which influence the determinants of health. But as in other aspects of global health governance, coherence too must begin at home, in the health sector. In the words of Andrew Green, Professor of International Health Planning at the University of Leeds what we need now is "policy coherence in global health." Coherence between the diverse agendas and between the discourses of development and global interdependence is a prerequisite to coherence with other policy areas. As coherence with other policy sectors is a major aim of the new EU policy, achieving this coherence in global health should be a Commission priority.

The role of the WHO

The WHO featured prominently as a topic of discussion throughout the event; its roles at global, regional and country level being considered in detail. On the one hand participants tended to support and call for a strengthening of the WHO, but on the other hand it was also noted that reform is needed in the work plan, financing and governance of the WHO.

Speaking on his own behalf, Liu Peilong, Senior Advisor to the Chinese Ministry of health, explained that "global health governance should have five essential functions: reaching consensus on shared values upon which the various roles and responsibilities of actors are based; to engage all stakeholders and to ensure coherence, alignment and harmonization; to establish regulatory frameworks that include treaties, regulations, norms, standards and guidelines; and to mobilize sufficient resources to meet agreed priorities and to distribute them appropriately. There is no shortage of suggestions on how to achieve these essential functions, but for me," said Liu, "the most important way is to strengthen WHO's leadership role rather than move away from it."

Liu stated that the WHO should free itself from the implementation of development projects as this is a field where there are so many capable actors. Instead the WHO should be more proactive in its normative power to enhance the global health legal framework. "In the area of health development and global health inequity so far there are no legally binding instruments," said Liu, "I believe if the good will or voluntary assistance is turned into legal responsibility and obligations and if there is an effective mechanism for monitoring and enforcing these mechanisms, great progress will be achieved."

It was also felt that the WHO needs to be more creative in exploring mechanisms to engage non state actors within the framework of its constitution, "for example the proposal on a Committee C deserves our serious consideration" said Liu. Paulo Buss also explained that the traditional model of representative democracy in the UN system, namely one country, one vote, has become outdated and needs to be complimented with mechanisms for participatory democratic governance in order to preserve its legitimacy.

Representatives from the Obama Administration were also present to share US views on reforming global health governance. Further supporting stakeholder engagement initiatives such as Committee C, Nils Daulaire, Director of the Office of Global Health Affairs at the US Department for Health and Human Services, stated that "NGOs, as an existing part of the global health architecture, need to be represented in global health governance; we need to have greater access to their experience and relationships on the ground working in the health systems we want to support." The Obama administration's openness to working with the EU on global health is an opportunity in stark contrast with unilateral approaches of the Bush era and should be seen as a new opportunity. "EU-US cooperation is a cornerstone of US foreign policy and a vital function of the US global health strategy" said Daulaire. This was supported in a presentation by USAID Bureau for Global Health Deputy Assistant Administrator Susan Brems who said that we should expect extensive commonalities between the EU framework and the US strategy which is expected to be released at the end of the month.

However, Daulaire did not voice support for the WHO as strongly as Liu. "Given the complexity of the global public health architecture one comes to the discussion of who will coordinate all these actors, and how does WHO fit into this picture, and I don't see an easy answer to either question." said Daulaire, "In considering models of governance for the 21st century I think it is import to consider the modern discipline of complexity science and apply this to governance. Chaos theory teaches us that it is counterproductive in a complex adaptive system to try to micro-manage, over-structure, or preordain. Rather we need to establish joint principles, so-called boundary conditions, such as equity, safety, common norms, transparency and accountability; and make sure that looser structures of governance adhere to these principles." In his conclusion Daulaire call for a change in mindset about governance and signaled that the US was setting an example in changing the way it does business in global health as well, "surely governance cannot be about top-down control today anymore than it can be managed by acting unilaterally," said Daulaire, "Today harmony takes on new meaning."

In reply Ilona Kickbusch confirmed that in fact European thought leaders are on the same page with the US, "Some of us explicitly don't use the term architecture" said Kickbusch, " this is because it sounds like something solid, like a house, when what we're actually looking for is something much more fluid and network based. We want to maintain the dynamisms of the current system but without the fragmentation." Arun Nanda, Senior advisor to the WHO European Office Regional Director Zsuzsanna Jakab, provided a working example of the approach to new governance for health in a presentation delivered on Jakab's vision for the future of WHO's role in the European Region. The Regional Office in Copenahagen has just put forward reform proposals to the member states that would see the Copenhagen office become a networked organization which brings together the region's diverse assets in health knowledge and expertise while engaging Members States and civil society in inclusive and transparent decision making.

The EU's Role in Global Health

There was consensus among participants that the EU has made a historic step forward and now the real work can begin. Discussions showed that much still needs to be done to achieve coherence and coordination of ideas and actions amongst European actors. The EU's framework now joins a collection of influential initiatives, from the Paris Declaration and Accra Agenda, to the ECOSOC ministerial statement and UN General Assembly Resolution 63/33 on global health and foreign policy.

As a starting point we believe the EU should seek coherence between these policies. The EU should also take up the call for a joint health summit with UNASUR, and should also bring its dialogues on global public goods for health into the framework of the EU-US and EU-China summits, as was recently done with the case on antibiotic resistance. The challenges highlighted at the conference can be addressed successfully if the EU can sustain the truly historic momentum for global health governance reform that European Commission has been able to build. This will be crucial as preparations are made for September's UN Summit on the MDGs and WHO's meeting of the European Regional Committee, and into the new year at the January 2011 meeting of the WHO Executive Board.

On all levels the EU appears to be trailblazing with diverse new understandings of global health and global governance. Its policy framework has provided a benchmark for values based global health strategies around the world and within its own member states. "This conference has been unique in the breadth and diversity of the expertise of the participants" said EU Commissioner for Public Health, John Dalli, "health is a right, a right not enough realize. I believe in ‘all for health, health for all,' together we can make it happen."

All presentation slides and links to video from the event can be found at: http://onetec.be/global_health/index.html