28 June 2010

In a presentation delivered at the June 2010 "Global Health: Together we can make it" conference in Brussels, Professor Ilona Kickbusch, Director of the Global Health Programme at the Graduate Institute, Geneva and Chair of the Global Health Europe Task Force, summarized the key challenges that have to be tackled in order to improve global governance for health.

"Our understanding of health" itself, its determinants, and how we address it as a policy issue has also changed. This is the result of changing lifestyles, and demographic and epidemiological transitions that are being experienced as populations age and countries advance in social and economic development. New global challenges resulting from industrial growth, globalization and increasing interdependence, such as climate change, food insecurity, epidemic levels of chronic diseases and pandemic disease impact on human health and wellbeing and must be addressed in public policy.

As the determinants of health increasingly stem from collective problems that cannot be adequately addressed by the Westphalian model of independent nation states, national governments must increasingly look to the multilateral system for solutions. It is this overlap between national objectives and common purpose that Kickbusch sees as the most significant driver of change in global health governance.

10 challenges

1. the focus of global health initiatives (content - approaches)
Kickbusch holds that how we think about global health is crucial, because that defines what we actually want to tackle with global health governance. "Global health is not just about disease based initiatives" says Kickbusch, "it's about strengthening systems and institutions for delivering health-and that doesn't just refer to 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-set-there are totally different networks at play-even the infectious/non-infectious disease agenda needs to be framed quite differently." This broader understanding of global health, demands that global health governance takes responsibility for the determinants of health.

The last few years have seen many debates in the global public health community over what are referred to as "vertical" approaches that focus on treating and preventing a single disease, and "horizontal" approaches that try to build health systems that can prevent disease and provide a range of services. Kickbusch is not simply arguing for more horizontal approaches, she is arguing for holistic approaches that incorporate vertical and horizontal projects, but which also look outward from the health sector to other policy fields such as trade, agriculture, transport, environment, rule of law and social justice where many of the determinants of health lie. This means that efforts much stretch beyond building institutions to deliver health care, to institutions and mechanism that can build coherence within health and between health and other sectors. Global health is therefore something larger than the global public health or health in developing countries which people usually think of when discussing global health.

2. accepting a global governance mind frame within ministries of health
Challenge two is that the health sector itself must change its own mind-set. Most people active in health still see health mainly as a national issue, and they see global health as a special niche of public health that is focused on addressing the diseases of poverty. In fact today domestic issues need to be seen in a regional and global context otherwise policies and actions to address these issues will be ineffective. "There is a tremendous work to be done," explained Kickbusch, "and again this is partly a challenge to the European Commission, now that it has its Council Conclusions on the EU Role in Global Health, to see how it can get that message into Ministries of Health and the people that represent them."

3. the distance between development and global public goods - two spheres
The third challenge is the distance between the systems and the financial streams that have been established between sphere of development cooperation and the sphere of the provision of global public goods. At country level practically all the money for international health is with development agencies. There is very little money available to other sectors to actually be active in relation to governing interdependence-in relation to creating laws, norms and standards, and to ensuring the implementation of international agreements. This, explains Kickbusch, creates an unworkable situation in governing interdependence.

Countries come together to accept binding international treaties for health protection of populations worldwide, such as the International Health Regulations, but there is no money to help poor countries to establish the infrastructures to actually fulfil their obligations. Kickbusch suggests that this is because the financial resources for investing in such infrastructures are with the development agencies whose interests are not in provision of public goods at the global level but rather on ameliorating the suffering of populations at the local level. While such action is undeniably necessary, it needs to be complimented by building institutions and mechanisms to fund and provide public goods at the global level; otherwise we are in many cases treating the disease while ignoring its causes.

4. national level: coherence between increased number of policy arenas
Challenge four is about managing the complexity of the modern social, economic and political determinants of health. "There is absolutely no use in talking about global health governance if you haven't got your act together at home" says Kickbusch, "Good global health governance begins at home, and that means you need strategies, policies and mechanisms to bring together various sectors and stakeholders." Just as the challenges countries faced can no longer be addressed from behind the nation-state's sovereign borders, the same is true for traditional policy fields.

Modern government has been set-up in a way in which issues are categorized and Ministries are created to address a single category of issues. The Department of Agriculture used to manage issues related to farming, the Ministry of Foreign Affairs to engage in diplomacy to protect national interests abroad, and the Ministry of Health to regulate or run the national health system. Today challenges cut-across traditional policy silos, but it isn't always the case that challenges are seen as "common", rather it seems more likely that the policies of one Ministry may be undermining the policies of another, but since responsibility and accountability to stakeholders is divided, there is little incentive for these Ministries to work together. Tobacco regulation provides several examples where Ministries are caught between public health interests and industry interests which both have legitimate claims over government action.

5. leadership - power - money - technical
Challenge number 5 is who actually takes leadership for global health? This is closely linked to challenge three and where financial resources for global health lie. "Having leadership for global health can be helpful, but it can also be difficult" explains Kickbusch, "the question is in the global health area who speaks for whom? Are countries speaking for themselves, who has taken the leadership? Who has the power the money or the technical knowledge?" One example Kickbusch used was where Ministries of Foreign Affairs have taken the leadership in the case of the Oslo Ministerial Declaration which lead to the adoption in December 2009 of UN General Assembly Resolution 63/33 on global health and foreign policy. In this case Ministers of Foreign Affairs from Norway, Brazil, France, Senegal, Thailand and South Africa called for countries to look at health in with totally different eyes. However, in many cases it is the development agencies that take the leadership. This Kickbusch says is because they have the money and the result is that often technical people in health are not involved or left behind because they have neither the power or the money, and this, says Kickbusch, has to be addressed at global governance level.

6. Increased number of actors: at national level in development
Challenge six and seven reflect two sides of the same coin. There has been an explosion of actors working in health and development in the last two decades, some actors are new and others are only newly engaging in heath. Challenge six refers to the implication of this at national level, and specifically in developing countries which are often on the receiving end of these actors. In fact, this is indeed a challenge general to the field of foreign affairs and development cooperation. "How can a country at national level create coherence among all these well-doers who come into your country and don't only give you money but also take up your time and create vertical programmes rather than help you build a health system?" asks Kickbusch. The reality is so absurd that it would be comical if it weren't true. Charts describing the organizations that come to work in developing countries and their linkages often look like spaghetti bowls of looping intersecting lines. The piloting of a "one UN" where all UN organization reside in a "UN House" has had positive results but still doesn't address a plethora of non-UN actors who organise projects and send delegations for country governments to receive.

7. Rapid increase of global health actors
This rapid increase is also a challenge at the global level. There have been initiatives to promote coherence, coordination and complimetarity at the global level, such at the International Health Partnership (IHP), the Health 8 (H8), "but again if you look at the examples they are mainly coordinating within the area of the vertical global health initiatives-they are not in the area of global public goods" says Kickbusch "Coordination for global public goods is also needed. We need to see how this can be done and in what ways these coordination mechanisms can also be accountable." Treaty processes are also a coherence mechanism, reminds Kickbusch, "We need to think in what ways existing treaty processes can be moved forward in new ways and many of us think that actually this coherence process should be linked again to the World Health Assembly, which is why we've suggested a mechanism called the Committee C."

There are already Committees A and B at the World Health Assembly. The former deals with technical and work programme related issues, while the latter is dealing with financial and administrative issues of the World Health Organization. A Committee C is envisages as an entry point for non state actors-actors from academia, business and civil society-to come together and to have a voice in the constitutional forum of the WHO.

8. Health in other institutions, in all policies, impact of health on other sectors
The eighth challenge is that "health institutions," says Kickbusch, "and even the World Health Organization are not really set-up, are not prepared, and do not have the staff and resources to really work in all those other sectors that produce or hinder health, be it the World Trade Organization, be it the FAO, you can list them all." The classical cooperation within the UN system used to be about agencies coming together around a common agenda, for example "you deal with women and children and I deal with women and children, and therefore we are together," But in issues that are described as hard policy, trade and security for example, WHO and other health agencies just plainly do not have the mechanisms and the resources to engage. As a result health gets lost in issues like environment, trade, food security, etc, as was seen most recently at the Climate Change summit in Copenhagen.

9. Resource imbalances - global public goods - separate health initiatives
The resource imbalance, Kickbusch says, is perhaps the greatest challenge in global health governance. Once again this is particularly notable in the imbalance between global public goods provision and the separate health initiatives for issues like AIDS or neglected tropical diseases. That leads us to discussing the financing of the WHO. "You have a situation now where 80% of its budget is earmarked, how can an organization like that fulfil its norms, standards and treaty making responsibilities with that kind of budget?" asks Kickbusch, "to finance global public goods you need money, and to coordinate money is also needed. One of the reasons why the European Commission can produce norms and standards like its new policy framework on global health is because it has a budget to do so and it doesn't have to go fund raising, competing with others for money. Unless we create that situation for the WHO we are stuck in global health governance and we will continue to be in the situation that we are in now."

10. A new commitment to the role of WHO
"If the goal is that global health governance should be delivering results, that it should have fair results and that it should address the distribution of power then we end up in my view with challenge 10" says Kickbusch, "we need a new commitment to the World Health Organization, and a clarification of its role, I personally believe it is entering a new decade of responsibilities, related to common global health security, and health as a global public good, and it needs to be based on a new financial basis, to move that forward. And only then can it perform its coordination function and engage the many new health actors that are necessary."

The way forward

To move ahead in global health governance we need long term perspectives and long term investments. The uncoordinated venture philanthropy of recent years has developed what some call market multilateralism. This basically means a sector which should also produce a global public good has been driven from a results based perspective from the private sector. Kickbusch concludes by saying we have to rethink the direction this has taken us in. To improve our situation today "we have to examine key elements of what it means to introduce those types of long term perspectives in global health governance, and then have a new kind of accountability-both of Member States of international organizations and of the other players.