p u b l i c h e a l t h 1 2 9 ( 2 0 1 5 ) 8 6 6 e8 6 7
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Governance for Health: Special Issue Commentary P. Goldblatt UCL Institute of Health Equity, UK
It is over ten years since the WHO set up the Commission on the Social Determinants of Health (CSDH). In 2008, the Commission reported that the fundamental reasons, the causes of the causes, of health differences are ‘the conditions in which people are born, grow, live, work and age and the inequities in power, money and resources that give rise to them’.1 Since then there has been much discussion of how best to address the social injustices which underpin health inequalities within and between countries, development of specific programmes and initiatives to do this, and international statements of intent. This has included resolutions at the World Health Assembly, a European Commission Communication, the WHO European Strategy ‘Health 2020’2 and the recommendations of the Lancet-University of Oslo Commission on Global Governance for Health.3 Nonetheless, there have been considerable countervailing pressures during that ten year period e the increased concentration of resources and control over the production of in the hands of fewer individuals and global corporations, the global financial crisis which was then followed by austerity measures in many countries that disproportionately affected those with greatest needs. In consequence, while there have continued to be improvements in average levels of health in most countries, inequalities in health have persisted both within and between countries.1,3,4 The Durham Health Summit, Governance for Health in a Changing World, considered how politics can be brought back into governance and figure much more prominently in discussions around policy. The papers based on this meeting, set out to find solutions to this question. But it is a complex question and, like all such questions, has no single solution. Each paper inevitably offers different solutions, not contradictory but largely complementary. Together they cover some of the highest priorities e but in the process of prioritising, may have underplayed some important issues. The WHO review of social determinants and the health divide in the European Region, identified four broad areas for action - through the life course of individuals, in the wider
society in which they live, at the broad macro-level that includes trade, economics and international agreements, and in the systems in place to deliver in each area.4 The politics that need to be brought to bear in each of these areas are quite distinct e in that they operate at very different levels (the individual, the community, local, regional, national and transnational) e but they all require a change, or refocusing, of some basic principles, as identified by the WHO and Lancet Commissions. These include the moral cases for social justice and human rights, from which stem universality and proportionality of access as well as addressing discrimination and exclusionary processes. Changing politics and the international order in this direction is challenging. Harry Burns is therefore correct in prioritising action on early years development of children.5 This derives from a basic governance principle e the right of a child to have a healthy life. But it also recognises that the children of today are the parents (and voters) of tomorrow and so provides the long-term key to breaking the cycle of intergenerational transmission of inequalities and attitudes. However, while this is essential, it is not sufficient. Action on the systems that ensure health throughout life are paramount. Both Ilona Kickbusch and Larry Gostin analyse the failures of WHO, representing the international health system, to fully realise the political potential of its constitution and deliver on the promise set out in its holistic definition of health.6,7 These they identify as resulting from a lack of commitment of its Member States and the shortfalls in infrastructure and governance that largely follow from this. The recognition that ‘health in all policies’ cannot be achieved by the health sector alone is central to an organisation that largely works through its relations with health ministries. This requires a sea-change in the governance, organisation and influence of WHO to achieve effective alliances. The summit took place during the Ebola epidemic in West Africa. This provided a case study of failure in an activity
E-mail address: [email protected]. http://dx.doi.org/10.1016/j.puhe.2015.06.007 0033-3506/© 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
p u b l i c h e a l t h 1 2 9 ( 2 0 1 5 ) 8 6 6 e8 6 7
traditionally seen as at the core of WHO's competences. As Ilona Kickbusch points out, this is because it highlighted the need to deal with the complexity of the ‘social, political and ecological pathologies of the Ebola crisis’.6,8 Ted Schrecker goes further in identifying some particularly difficult areas of international organisation e trade policies and agreements.9 He argues that trade policy limits the ‘policy space’ available to governments to protect health, but that governments make these policy commitments because, to do otherwise, requires confronting not only powerful transnational corporations but also domestic consumer interests. These are all spheres areas outside WHO's remit. It must rely on better alliances with organisations that have the competence to argue for social justice in these areas. This, as Larry Gostin points out, will only be achieved by effectively engaging civil society, the private sector, governments and individuals.7
Author statements Ethical approval None sought.
Funding None declared.
Competing interests None declared.
867
references
1. Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health. Geneva: World Health Organization, http://www.who.int/social_determinants/thecommission/ finalreport/en/index.html; 2008 [accessed 15.07.13]. 2. Health 2020: a European policy framework supporting actions across government and society for health and well-being. Copenhagen: WHO Regional Office for Europe, http://www.euro.who.int/en/ what-we-do/health-topics/health-policy/health-2020-theeuropean-policy-for-health-and-well-being; 2012 [accessed 15.07.13]. 3. 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. 4. Review of social determinants and the health divide in the WHO European Region: final report. Copenhagen: WHO Regional Office for Europe, http://www.euro.who.int/__data/assets/pdf_file/ 0004/251878/Review-of-social-determinants-and-the-healthdivide-in-the-WHO-European-Region-FINAL-REPORT.pdf; 2013 [accessed 11.06.15]. 5. Burns H. Health inequalities e why so little progress? Public Health 2015;129(7). 6. Kickbusch I, Reddy S. Global health governance e the next political revolution. 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. McCoy D. The social, political and ecological pathologies of the Ebola Crisis cannot be ignore. Available from: http://blogs.bmj. com/bmj/2014/11/03/david-mccoy-the-social-politicalandecological-pathologies-of-the-ebola-crisis-cannot-beignored/. 9. Schrecker T. Bringing (domestic) politics back in: global and local influences on health equity. Public Health 2015;129(7).
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Governance for Health: Special Issue Commentary P. Goldblatt UCL Institute of Health Equity, UK
It is over ten years since the WHO set up the Commission on the Social Determinants of Health (CSDH). In 2008, the Commission reported that the fundamental reasons, the causes of the causes, of health differences are ‘the conditions in which people are born, grow, live, work and age and the inequities in power, money and resources that give rise to them’.1 Since then there has been much discussion of how best to address the social injustices which underpin health inequalities within and between countries, development of specific programmes and initiatives to do this, and international statements of intent. This has included resolutions at the World Health Assembly, a European Commission Communication, the WHO European Strategy ‘Health 2020’2 and the recommendations of the Lancet-University of Oslo Commission on Global Governance for Health.3 Nonetheless, there have been considerable countervailing pressures during that ten year period e the increased concentration of resources and control over the production of in the hands of fewer individuals and global corporations, the global financial crisis which was then followed by austerity measures in many countries that disproportionately affected those with greatest needs. In consequence, while there have continued to be improvements in average levels of health in most countries, inequalities in health have persisted both within and between countries.1,3,4 The Durham Health Summit, Governance for Health in a Changing World, considered how politics can be brought back into governance and figure much more prominently in discussions around policy. The papers based on this meeting, set out to find solutions to this question. But it is a complex question and, like all such questions, has no single solution. Each paper inevitably offers different solutions, not contradictory but largely complementary. Together they cover some of the highest priorities e but in the process of prioritising, may have underplayed some important issues. The WHO review of social determinants and the health divide in the European Region, identified four broad areas for action - through the life course of individuals, in the wider
society in which they live, at the broad macro-level that includes trade, economics and international agreements, and in the systems in place to deliver in each area.4 The politics that need to be brought to bear in each of these areas are quite distinct e in that they operate at very different levels (the individual, the community, local, regional, national and transnational) e but they all require a change, or refocusing, of some basic principles, as identified by the WHO and Lancet Commissions. These include the moral cases for social justice and human rights, from which stem universality and proportionality of access as well as addressing discrimination and exclusionary processes. Changing politics and the international order in this direction is challenging. Harry Burns is therefore correct in prioritising action on early years development of children.5 This derives from a basic governance principle e the right of a child to have a healthy life. But it also recognises that the children of today are the parents (and voters) of tomorrow and so provides the long-term key to breaking the cycle of intergenerational transmission of inequalities and attitudes. However, while this is essential, it is not sufficient. Action on the systems that ensure health throughout life are paramount. Both Ilona Kickbusch and Larry Gostin analyse the failures of WHO, representing the international health system, to fully realise the political potential of its constitution and deliver on the promise set out in its holistic definition of health.6,7 These they identify as resulting from a lack of commitment of its Member States and the shortfalls in infrastructure and governance that largely follow from this. The recognition that ‘health in all policies’ cannot be achieved by the health sector alone is central to an organisation that largely works through its relations with health ministries. This requires a sea-change in the governance, organisation and influence of WHO to achieve effective alliances. The summit took place during the Ebola epidemic in West Africa. This provided a case study of failure in an activity
E-mail address: [email protected]. http://dx.doi.org/10.1016/j.puhe.2015.06.007 0033-3506/© 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
p u b l i c h e a l t h 1 2 9 ( 2 0 1 5 ) 8 6 6 e8 6 7
traditionally seen as at the core of WHO's competences. As Ilona Kickbusch points out, this is because it highlighted the need to deal with the complexity of the ‘social, political and ecological pathologies of the Ebola crisis’.6,8 Ted Schrecker goes further in identifying some particularly difficult areas of international organisation e trade policies and agreements.9 He argues that trade policy limits the ‘policy space’ available to governments to protect health, but that governments make these policy commitments because, to do otherwise, requires confronting not only powerful transnational corporations but also domestic consumer interests. These are all spheres areas outside WHO's remit. It must rely on better alliances with organisations that have the competence to argue for social justice in these areas. This, as Larry Gostin points out, will only be achieved by effectively engaging civil society, the private sector, governments and individuals.7
Author statements Ethical approval None sought.
Funding None declared.
Competing interests None declared.
867
references
1. Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health. Geneva: World Health Organization, http://www.who.int/social_determinants/thecommission/ finalreport/en/index.html; 2008 [accessed 15.07.13]. 2. Health 2020: a European policy framework supporting actions across government and society for health and well-being. Copenhagen: WHO Regional Office for Europe, http://www.euro.who.int/en/ what-we-do/health-topics/health-policy/health-2020-theeuropean-policy-for-health-and-well-being; 2012 [accessed 15.07.13]. 3. 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. 4. Review of social determinants and the health divide in the WHO European Region: final report. Copenhagen: WHO Regional Office for Europe, http://www.euro.who.int/__data/assets/pdf_file/ 0004/251878/Review-of-social-determinants-and-the-healthdivide-in-the-WHO-European-Region-FINAL-REPORT.pdf; 2013 [accessed 11.06.15]. 5. Burns H. Health inequalities e why so little progress? Public Health 2015;129(7). 6. Kickbusch I, Reddy S. Global health governance e the next political revolution. 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. McCoy D. The social, political and ecological pathologies of the Ebola Crisis cannot be ignore. Available from: http://blogs.bmj. com/bmj/2014/11/03/david-mccoy-the-social-politicalandecological-pathologies-of-the-ebola-crisis-cannot-beignored/. 9. Schrecker T. Bringing (domestic) politics back in: global and local influences on health equity. Public Health 2015;129(7).
