p u b l i c h e a l t h 1 2 9 ( 2 0 1 5 ) 8 3 1 e8 3 2
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Editorial
Governance for health in a changing world: special issue
The papers selected for this special issue, and accompanying invited commentaries, originate in all but one case in a Health Summit organised by the Centre for Public Policy and Health and held at Durham University on 10e11th November 2014.1 The Summit took place against a backdrop of health threats, notably Ebola, an increasing burden of non-communicable disease, the contribution of austerity measures to widening health inequalities, and considerable ferment in global governance processes outside as well as inside the health sector. The purpose of the Summit was to focus on what actions and steps might be taken to address the many health challenges requiring multilateral approaches e approaches which seem harder than ever to secure when the key institutions are gridlocked, under-resourced, lack focus and/or are bypassed. While there is no shortage of description and analysis of the problems, there is less surety of direction when it comes to finding politically acceptable solutions to these. The authors of all the papers presented here, and those providing commentaries, endeavour to grapple with this challenge. With the exception of the paper by Gostin et al., the remaining papers take as their starting point The Lancet e University of Oslo Health Commission on Global Governance for Health published in February 2014 with the aim of putting politics back into global health.2 The political nature of global health and the need to appreciate the social, commercial and political determinants were highlighted in the Commission's report. The opening scene-setting paper is by Ottersen, who chaired the Commission, and McNeill3 summarises its report. It then considers how such a report can be deployed to advocate for and motivate policy-makers and the public to demand change. For this to happen, the authors conclude that a more explicitly political and moral perspective is needed. Evidence alone, however compelling or rigorous, will not suffice. Kickbusch and Reddy4 are similarly motivated by the need for political action and regard a critical incident, like the Ebola crisis, as a way of reopening the debate on global governance and the role of WHO. The gridlock now manifest in multilateral governance can only be broken, they allege, by a health crisis that becomes a political driver for change. The authors acknowledge the difficult balancing act WHO is required to
perform in order to deliver on its various functions and meet expectations which sometimes conflict and are themselves highly political in nature. Kickbusch and Reddy see an important future for WHO but believe it can only remain relevant and at the forefront of global health policy if it is true to its own Health in All Policies (HiAP) and whole of government thinking and does not seek change by operating exclusively through ministries of health. The challenge will be to shift the focus from ministries of health and engage other ministries. It is one the Regional Director of WHO Europe, Zsuzsanna Jakab, is keen to pursue at the Regional Committee in September 2015. Schrecker5 offers a more nuanced critique of global influences on health, noting the important interplay between globalisation and domestic politics. Starting from The Lancet e University of Oslo Commission's analysis of ‘power asymmetries’, he reminds us that political choices made on the domestic rather than global level are at least as important when it comes to the political preferences and policy choices that affect health and health inequalities. He cites the startling statistic that around 70 per cent of the world's poorest people no longer live in the world's poorest countries, not to deny the importance of poverty reduction as a global concern but to make the point that a ‘political science of health must consider the interplay between globalisation and domestic politics’. Sir Harry Burns6 provides a country case study of the interplay between these global and domestic forces. Reviewing the causes of inequalities in life expectancy in Scotland, he shows that premature mortality is due to causes that are strongly related to adverse social conditions, and in particular changes that took place in social structures in Scotland in the second half of the 20th century. The fact that Glasgow and Dundee were the two cities most affected by the large scale social turbulence resulting from the loss of employment in traditional industries lends weight to this thesis. Citing WHO's concept of HiAP, Burns shows how the Scottish Government has sought to address a complex problem by adopting new policy approaches rather than adhering to conventional ones, which for the most part have failed. Breaking out of a traditional silo approach and embracing all sectors of society and government lie at the heart of this approach to joined-up government.
832
p u b l i c h e a l t h 1 2 9 ( 2 0 1 5 ) 8 3 1 e8 3 2
The final paper in the special issue, by Gostin et al.,7 did not form part of the Durham Health Summit although it could have done. It addresses many of the themes discussed at the Summit especially those raised in Kickbusch and Reddy's paper, notably the future of WHO e has it one and, if so, what might it look like? Like Kickbusch and Reddy, Gostin et al. see the Ebola crisis as a potential turning point for WHO. While WHO's technical role in regard to managing global epidemics and their spread is clearly established, if not always well executed, its normative authority and ability to shape or influence global rules and norms are of greater interest to the authors. They argue that if WHO is to be empowered to address more systemic global health needs, politicians will need to ‘elevate health to a higher priority’. To this end, health must be viewed as a global issue rather than as a purely domestic matter. Meeting the challenge will not be easy but if WHO is to have a future it needs to rise to it. For it to succeed, paying attention to more prosaic matters concerning its dayto-day management is overdue. This has been criticised for being slow, ponderous, rule-ridden and bureaucratic.8 Changing such practices is entirely within WHO's grasp should it wish to seize the opportunity. The special issue, like the Health Summit that generated it, has not resulted in a clear set of policy prescriptions but rather has provided a space in which to reflect on a set of dynamic and complex issues that continue to vex policy-makers and those with an interest in the future direction and shape of governance for health at both global and domestic levels. Finding a way forward and creating a new political consensus at a time when neoliberal thinking remains dominant and the public sphere continues to be eroded will not be easy as the recent UK general election has amply demonstrated. As Judt wrote in 2007, ‘discounting of the public sector has become the default condition of policy discourse in much of the developed world’.9 Challenging it on both domestic and global levels is surely the priority for the political action called for by the authors of the papers and commentaries in this special issue.
references
1. Durham University. Governance for health in a changing world. Durham health Summit commentary. Durham: Durham University, https://www.dur.ac.uk/resources/public.health/ DurhamHealthSummitCommentaryfinal.pdf; 2014. 2. Ottersen OP, Dasgupta J, Blouin C, Buss P, Chongsuvivatwong V, Frenk J, et al. The political origins of health inequity: prospects for change. Lancet 2014;383:630e67. 3. Ottersen OP, McNeill D. Global governance for health: how to motivate political change? Public Health 2015;129(7). 4. Kickbusch I, Reddy S. Global health governance e the next political revolution. Public Health 2015;129(7). 5. Schrecker T. Bringing (domestic) politics back in: global and local influences on health equity. Public Health 2015;129(7). 6. Burns H. Health inequalities e why so little progress? Public Health 2015;129(7). 7. Gostin LO, Sridhar D, Hougendobler D. The normative authority of the World Health Organisation. Public Health 2015;129(7). 8. Hawkes N. ‘Irrelevant’ WHO outpaced by younger rivals. Br Med J 2011;343:d5012e3. http://dx.doi.org/10.1136/bmj.d5012. 9. Judt T. When the facts change: essays 1995e2010. London: Heinemann; 2015.
D.J. Hunter, Professor of Health Policy and Management T. Schrecker, Professor of Global Health Policy R. Alderslade, Honorary Fellow Durham University, UK E-mail address: [email protected] (D. J. Hunter) Available online 12 July 2015 http://dx.doi.org/10.1016/j.puhe.2015.06.008 0033-3506/© 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Editorial
Governance for health in a changing world: special issue
The papers selected for this special issue, and accompanying invited commentaries, originate in all but one case in a Health Summit organised by the Centre for Public Policy and Health and held at Durham University on 10e11th November 2014.1 The Summit took place against a backdrop of health threats, notably Ebola, an increasing burden of non-communicable disease, the contribution of austerity measures to widening health inequalities, and considerable ferment in global governance processes outside as well as inside the health sector. The purpose of the Summit was to focus on what actions and steps might be taken to address the many health challenges requiring multilateral approaches e approaches which seem harder than ever to secure when the key institutions are gridlocked, under-resourced, lack focus and/or are bypassed. While there is no shortage of description and analysis of the problems, there is less surety of direction when it comes to finding politically acceptable solutions to these. The authors of all the papers presented here, and those providing commentaries, endeavour to grapple with this challenge. With the exception of the paper by Gostin et al., the remaining papers take as their starting point The Lancet e University of Oslo Health Commission on Global Governance for Health published in February 2014 with the aim of putting politics back into global health.2 The political nature of global health and the need to appreciate the social, commercial and political determinants were highlighted in the Commission's report. The opening scene-setting paper is by Ottersen, who chaired the Commission, and McNeill3 summarises its report. It then considers how such a report can be deployed to advocate for and motivate policy-makers and the public to demand change. For this to happen, the authors conclude that a more explicitly political and moral perspective is needed. Evidence alone, however compelling or rigorous, will not suffice. Kickbusch and Reddy4 are similarly motivated by the need for political action and regard a critical incident, like the Ebola crisis, as a way of reopening the debate on global governance and the role of WHO. The gridlock now manifest in multilateral governance can only be broken, they allege, by a health crisis that becomes a political driver for change. The authors acknowledge the difficult balancing act WHO is required to
perform in order to deliver on its various functions and meet expectations which sometimes conflict and are themselves highly political in nature. Kickbusch and Reddy see an important future for WHO but believe it can only remain relevant and at the forefront of global health policy if it is true to its own Health in All Policies (HiAP) and whole of government thinking and does not seek change by operating exclusively through ministries of health. The challenge will be to shift the focus from ministries of health and engage other ministries. It is one the Regional Director of WHO Europe, Zsuzsanna Jakab, is keen to pursue at the Regional Committee in September 2015. Schrecker5 offers a more nuanced critique of global influences on health, noting the important interplay between globalisation and domestic politics. Starting from The Lancet e University of Oslo Commission's analysis of ‘power asymmetries’, he reminds us that political choices made on the domestic rather than global level are at least as important when it comes to the political preferences and policy choices that affect health and health inequalities. He cites the startling statistic that around 70 per cent of the world's poorest people no longer live in the world's poorest countries, not to deny the importance of poverty reduction as a global concern but to make the point that a ‘political science of health must consider the interplay between globalisation and domestic politics’. Sir Harry Burns6 provides a country case study of the interplay between these global and domestic forces. Reviewing the causes of inequalities in life expectancy in Scotland, he shows that premature mortality is due to causes that are strongly related to adverse social conditions, and in particular changes that took place in social structures in Scotland in the second half of the 20th century. The fact that Glasgow and Dundee were the two cities most affected by the large scale social turbulence resulting from the loss of employment in traditional industries lends weight to this thesis. Citing WHO's concept of HiAP, Burns shows how the Scottish Government has sought to address a complex problem by adopting new policy approaches rather than adhering to conventional ones, which for the most part have failed. Breaking out of a traditional silo approach and embracing all sectors of society and government lie at the heart of this approach to joined-up government.
832
p u b l i c h e a l t h 1 2 9 ( 2 0 1 5 ) 8 3 1 e8 3 2
The final paper in the special issue, by Gostin et al.,7 did not form part of the Durham Health Summit although it could have done. It addresses many of the themes discussed at the Summit especially those raised in Kickbusch and Reddy's paper, notably the future of WHO e has it one and, if so, what might it look like? Like Kickbusch and Reddy, Gostin et al. see the Ebola crisis as a potential turning point for WHO. While WHO's technical role in regard to managing global epidemics and their spread is clearly established, if not always well executed, its normative authority and ability to shape or influence global rules and norms are of greater interest to the authors. They argue that if WHO is to be empowered to address more systemic global health needs, politicians will need to ‘elevate health to a higher priority’. To this end, health must be viewed as a global issue rather than as a purely domestic matter. Meeting the challenge will not be easy but if WHO is to have a future it needs to rise to it. For it to succeed, paying attention to more prosaic matters concerning its dayto-day management is overdue. This has been criticised for being slow, ponderous, rule-ridden and bureaucratic.8 Changing such practices is entirely within WHO's grasp should it wish to seize the opportunity. The special issue, like the Health Summit that generated it, has not resulted in a clear set of policy prescriptions but rather has provided a space in which to reflect on a set of dynamic and complex issues that continue to vex policy-makers and those with an interest in the future direction and shape of governance for health at both global and domestic levels. Finding a way forward and creating a new political consensus at a time when neoliberal thinking remains dominant and the public sphere continues to be eroded will not be easy as the recent UK general election has amply demonstrated. As Judt wrote in 2007, ‘discounting of the public sector has become the default condition of policy discourse in much of the developed world’.9 Challenging it on both domestic and global levels is surely the priority for the political action called for by the authors of the papers and commentaries in this special issue.
references
1. Durham University. Governance for health in a changing world. Durham health Summit commentary. Durham: Durham University, https://www.dur.ac.uk/resources/public.health/ DurhamHealthSummitCommentaryfinal.pdf; 2014. 2. Ottersen OP, Dasgupta J, Blouin C, Buss P, Chongsuvivatwong V, Frenk J, et al. The political origins of health inequity: prospects for change. Lancet 2014;383:630e67. 3. Ottersen OP, McNeill D. Global governance for health: how to motivate political change? Public Health 2015;129(7). 4. Kickbusch I, Reddy S. Global health governance e the next political revolution. Public Health 2015;129(7). 5. Schrecker T. Bringing (domestic) politics back in: global and local influences on health equity. Public Health 2015;129(7). 6. Burns H. Health inequalities e why so little progress? Public Health 2015;129(7). 7. Gostin LO, Sridhar D, Hougendobler D. The normative authority of the World Health Organisation. Public Health 2015;129(7). 8. Hawkes N. ‘Irrelevant’ WHO outpaced by younger rivals. Br Med J 2011;343:d5012e3. http://dx.doi.org/10.1136/bmj.d5012. 9. Judt T. When the facts change: essays 1995e2010. London: Heinemann; 2015.
D.J. Hunter, Professor of Health Policy and Management T. Schrecker, Professor of Global Health Policy R. Alderslade, Honorary Fellow Durham University, UK E-mail address: [email protected] (D. J. Hunter) Available online 12 July 2015 http://dx.doi.org/10.1016/j.puhe.2015.06.008 0033-3506/© 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
