Correspondence
The Lancet—University of Oslo Commission on Global Governance for Health (Feb 15, p 630)1 articulates the various global non-health sector influences on health—namely, the global political determinants of health. The recognition of these effects is not new, but articulating a compelling way to refer to them is a useful contribution and will help to shape the future research agenda. The Commission highlights the way in which some actors are able to exert disproportionate levels of influence to serve their interests. We commend the Commission for identifying these serious power disparities in global governance, and illustrating their profound implications for health. The Commission has provoked attention to these political realities and created an important discussion. Yet the Commission’s recommendations, as the companion Youth Commission2 noted, “are likely to be influenced by the same diverging interests and power asymmetries described by the Commission”. We would like to propose a possible path forward. To tackle the global political determinants of health, there is first a need for more rigorous analysis of how national, international, and institutional actors shape and influence the global political determinants of health. The Commission refers to power, but it does not consider the need to better understand empirically how power is expressed in global health governance. The fields of international relations, sociology, and philosophy, however, do apply power as a conceptual lens for understanding how actors behave. While global health scholars led by Gill Walt3 have explored how power is expressed and exercised, power could be particularly useful to understand the global political determinants of health. www.thelancet.com Vol 383 June 28, 2014
There are a number of analytical frames to better understand or investigate power. Robert Dahl 4 proposed power as decision making (ie, A forcing B to do A’s choice against B’s will). Peter Bachrach and Morton Baratz5 argued for the importance of non-decision making (A confines B’s spectrum of possible choices); this has also been called the mobilisation of bias. Steven Lukes6 considered power as thought control (ie, A makes B want A’s choice). Together these three approaches to assess power, be it overt, covert, or latent, present one possible framework. Michael Barnett and Raymond Duvall7 presented another frame based on four approaches to power—namely, compulsory, institutional, structural, and productive forms. These frameworks, or a mix of them, could be a useful place to begin. A greater and more explicit focus on power as a tool for analysis of global political determinants of health can help to illuminate how actors create and exploit disparities to serve their interests. Crucially, a better understanding of power, which is especially important with the rise of non-health and non-state bodies’ influence over the global policy environment within which health systems must navigate, will allow for the design of policies and processes to redress disparities. We declare no competing interests.
*Robert Marten, Johanna Hanefeld, Richard Smith [email protected] The Rockefeller Foundation, New York, NY 10018, USA (RM); and Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK (RM, JH, RS) 1
2
3 4
Ottersen OP, Dasgupta J, Blouin C, et al. The political origins of health inequity: prospects for change. Lancet 2014; 383: 630–67. Gopinathan U, Cuadrado C, Watts N, et al. The political origins of health inequity: the perspective of the Youth Commission on Global Governance for Health. Lancet 2014; 383: e12–e13. Walt G. Health policy: an introduction to process and power. London: Zed Books, 1994. Dahl R. The concept of power. Behav Sci 1957; 2: 201–15.
5 6 7
Bachrach P, Baratz M. Two faces of power. Am Pol Sci Rev 1962; 56: 947–52. Lukes S. Power: a radical view, 2nd edn. Houndmills: Palgrave MacMillan, 2005. Barnett M, Duvall R. Power in global governance. Cambridge: Cambridge University Press, 2005.
The University of Oslo
Commission on Global Governance for Health: what about power?
A platform for a Framework Convention on Global Health The right to health provides the foundation to accelerate recent global health gains, extend them to the most excluded populations, and fortify them against threats beyond the health sector. Yet states often fail to meet their obligations. And the national focus can diminish effectiveness because solutions require global cooperation, from shared financing and capacity building to global norms and accountability.1 An innovative global health treaty—a Framework Convention on Global Health—could establish a right to health for the 21st century. The binding power of law would enhance the ability of civil society advocates to hold governments accountable through courts, parliaments, and the media, while creative incentives and sanctions would encourage compliance. Through international law, the Framework Convention on Global Health would ensure respect for the right to health within other legal regimes, such as trade, investment, and intellectual property—aspects of which might otherwise undermine this right. A treaty could establish the legal framework to achieve the grand convergence in global health envisioned by the Lancet Commission on Investing in Health.2 A Framework Convention on Global Health could chart the path towards true global health convergence, both among countries and within them, demanding the full gamut of actions to close domestic and international health inequalities that leave poorer and marginalised populations dying earlier than the well-off.
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
2207
The Lancet—University of Oslo Commission on Global Governance for Health (Feb 15, p 630)1 articulates the various global non-health sector influences on health—namely, the global political determinants of health. The recognition of these effects is not new, but articulating a compelling way to refer to them is a useful contribution and will help to shape the future research agenda. The Commission highlights the way in which some actors are able to exert disproportionate levels of influence to serve their interests. We commend the Commission for identifying these serious power disparities in global governance, and illustrating their profound implications for health. The Commission has provoked attention to these political realities and created an important discussion. Yet the Commission’s recommendations, as the companion Youth Commission2 noted, “are likely to be influenced by the same diverging interests and power asymmetries described by the Commission”. We would like to propose a possible path forward. To tackle the global political determinants of health, there is first a need for more rigorous analysis of how national, international, and institutional actors shape and influence the global political determinants of health. The Commission refers to power, but it does not consider the need to better understand empirically how power is expressed in global health governance. The fields of international relations, sociology, and philosophy, however, do apply power as a conceptual lens for understanding how actors behave. While global health scholars led by Gill Walt3 have explored how power is expressed and exercised, power could be particularly useful to understand the global political determinants of health. www.thelancet.com Vol 383 June 28, 2014
There are a number of analytical frames to better understand or investigate power. Robert Dahl 4 proposed power as decision making (ie, A forcing B to do A’s choice against B’s will). Peter Bachrach and Morton Baratz5 argued for the importance of non-decision making (A confines B’s spectrum of possible choices); this has also been called the mobilisation of bias. Steven Lukes6 considered power as thought control (ie, A makes B want A’s choice). Together these three approaches to assess power, be it overt, covert, or latent, present one possible framework. Michael Barnett and Raymond Duvall7 presented another frame based on four approaches to power—namely, compulsory, institutional, structural, and productive forms. These frameworks, or a mix of them, could be a useful place to begin. A greater and more explicit focus on power as a tool for analysis of global political determinants of health can help to illuminate how actors create and exploit disparities to serve their interests. Crucially, a better understanding of power, which is especially important with the rise of non-health and non-state bodies’ influence over the global policy environment within which health systems must navigate, will allow for the design of policies and processes to redress disparities. We declare no competing interests.
*Robert Marten, Johanna Hanefeld, Richard Smith [email protected] The Rockefeller Foundation, New York, NY 10018, USA (RM); and Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK (RM, JH, RS) 1
2
3 4
Ottersen OP, Dasgupta J, Blouin C, et al. The political origins of health inequity: prospects for change. Lancet 2014; 383: 630–67. Gopinathan U, Cuadrado C, Watts N, et al. The political origins of health inequity: the perspective of the Youth Commission on Global Governance for Health. Lancet 2014; 383: e12–e13. Walt G. Health policy: an introduction to process and power. London: Zed Books, 1994. Dahl R. The concept of power. Behav Sci 1957; 2: 201–15.
5 6 7
Bachrach P, Baratz M. Two faces of power. Am Pol Sci Rev 1962; 56: 947–52. Lukes S. Power: a radical view, 2nd edn. Houndmills: Palgrave MacMillan, 2005. Barnett M, Duvall R. Power in global governance. Cambridge: Cambridge University Press, 2005.
The University of Oslo
Commission on Global Governance for Health: what about power?
A platform for a Framework Convention on Global Health The right to health provides the foundation to accelerate recent global health gains, extend them to the most excluded populations, and fortify them against threats beyond the health sector. Yet states often fail to meet their obligations. And the national focus can diminish effectiveness because solutions require global cooperation, from shared financing and capacity building to global norms and accountability.1 An innovative global health treaty—a Framework Convention on Global Health—could establish a right to health for the 21st century. The binding power of law would enhance the ability of civil society advocates to hold governments accountable through courts, parliaments, and the media, while creative incentives and sanctions would encourage compliance. Through international law, the Framework Convention on Global Health would ensure respect for the right to health within other legal regimes, such as trade, investment, and intellectual property—aspects of which might otherwise undermine this right. A treaty could establish the legal framework to achieve the grand convergence in global health envisioned by the Lancet Commission on Investing in Health.2 A Framework Convention on Global Health could chart the path towards true global health convergence, both among countries and within them, demanding the full gamut of actions to close domestic and international health inequalities that leave poorer and marginalised populations dying earlier than the well-off.
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
2207
