News Link 104

The news links are part of the research project GESPAM (Geopolitica, Salute Pubblica e Accesso alle Medicine/Geopolitics, Public Health and Access to Medicines), which aims to focus on the best options for the use of trade and government rules related to public health by resource-limited countries

News Link 104

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The BRICS move forward

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The E15 Initiative Strengthening the Global Trade System

Competition Analyses of Licensing Agreements. Considerations for Developing Countries under TRIPS

Rapporto sullâattuazione della Piattaforma dâAzione di Pechino Rilevazione quinquennale: 2009-2014. Cosa veramente Ã¨ stato fatto in Italia

AIDS 2014: Financing the new global HIV treatment vision â advocacy and economics

Economic interventions for HIV prevention

Building social capital to improve health and reduce HIV risk

Systematically excluded: young womenâs experiences of accessing child support grants

New Medicines Patent Pool-Gilead Agreement For New HIV Drug In 112 Countries

GSK seeks approval for world’s first malaria vaccine

Health Policy Briefs Update

The Political Determinants of Health

The root causes of health inequities are to be found in weaknesses in political domains at the supranational level. These include: democratic deficit, weak accountability, institutional stickiness, missing institutions and restricted policy space for health. Achieving health equity is not just a matter of coming up with technical solutions and providing the means to finance them.  We have to consider the political landscape and rectify the dysfunctions in global governance that undermine health

The Political Determinants of Health

by Ole Petter Ottersen*

and Desmond McNeill**

University of Oslo

The Millennium Development Goals report 2014 was launched in early July. The report shows that in the course of 22 years, annual number of under 5 deaths fell from 12 to 6.6 million while the global maternal mortality ratio was nearly halved, from 380 to 210 maternal deaths per 100 000 livebirths. Causes of progress are manifold, but setting clear goals has inspired, so much so that many talk of removing health inequities in a generation. Bill Gates, for one, articulates ambitions of this scale, as does the WHO Commission on the Social Determinants of Health.

It is tempting to make the assumption that the positive development will continue unabated, provided that due efforts are made to sustain or even increase funding of targeted initiatives such as those embedded in the Millennium Development Goals. However, in a changing world, extrapolations are fraught with difficulties. We have seen it in Syria, where polio was near eradication but now develops into a major health emergency. We have seen it in Greece, where health suffers in the wake of the austerity measures. And we saw it in the many countries that experienced a wave of hunger and malnutrition due to the food price volatility in 2008-2009. Recent history is replete with setbacks, and we need to pause and reflect on why.

Such an exercise reveals that root causes of health inequities are to be found in political domains outside of the health sector. We are talking about dysfunctions in global governance that negatively impact health. These dysfunctions were put under scrutiny by the Lancet-University of Oslo Commission that released its report in February this year. Based on the analysis of a number of cases the commission concludes that health is impacted by five major dysfunctions in governance at the supranational level: democratic deficit, weak accountability, institutional stickiness, missing institutions and restricted policy space for health. These weaknesses hamper or undermine the efforts of the global health system and constitute what we call the political origins of health inequity.

Let’s take the last point as an example: restricted policy space for health. An increasing number of decisions are taken at the supranational level, and many of these decisions constrain the policy space of nations. A primary obligation of a nation state is to safeguard the health of their population, but its ability to do so is easily thwarted when health is subordinated to other goals, primarily economic ones. Austerity measures have been mentioned. But trade agreements may similarly diminish policy space for health if they are put together without due consideration of the short or long term consequences for the health sector. Once signed, a trade agreement proves difficult if not impossible to change, even when inadvertent health effects come to the fore. The Commission used the TRIPS agreement (Agreement on Trade-Related Aspects of Intellectual Property Rights) as a case in point and as an example of “institutional stickiness”.

Trade agreements and foreign investment treaties also serve to illustrate other major dysfunctions of global governance that negatively impact health. Agreements and treaties that will ultimately affect large populations are often drafted without due transparency. There is a democratic deficit and weak accountability. Further, the Commission points out that institutions that could hold transnational corporations responsible for activities that interfere with health, are nascent or missing. There are powerful forces beyond the health sector that determine health, and there are substantial voids in global governance that leave these forces unchecked.

It is this political dimension of health that the Lancet-University of Oslo commission brings to the fore.

The commission argues that for ambitions to be realized, we have to ensure that there is global governance for health - i.e., that we have a global governance system that is conducive to the efforts of the health sector and of the numerous private-public initiatives that target specific health challenges. Achieving health equity is not just a matter of coming up with technical solutions and providing the means to finance them. We have to consider the political landscape and rectify the dysfunctions that undermine health.

To trace the political origins of health inequities the commission identified and discussed seven different cases, derived from political arenas outside of the health sector: foreign investment treaties, transnational corporate activity, immigration policies, violent conflict, food security and agriculture, intellectual property rights, economic crises and responses. When each arena is considered individually, it comes as no surprise that decisions taken therein significantly influence health. It is when these seven arenas are seen in context that a pattern emerges and an awareness is instilled about the cross-sectoral nature of the global governance dysfunctions impacting health. Only by taking a broad view across sectors was it possible for the Commission to recognize the five dysfunctions referred to above. These are dysfunctions that cut through the global governance system at large.

The value of narrowing down common denominators is obvious: we should be better able to find appropriate remedies in order to rectify what now stands as a defective global governance system for health. For the next move, timing is of the essence. The preparations for the post-2015 Sustainable Development Goals (SDG) are well under way, and it is of paramount importance that these goals are formulated with due attention to the shortcomings of global governance. For improvements to occur, there will be a need for concrete and quantifiable milestones. We will need to identify parameters and indicators by which we can measure progress when it comes to democratic involvement, accountability, institutional flexibility and policy space for health – i.e., across the dimensions identified above. This will not be an easy task. But it is a task from which we cannot shy away.

The Commission came up with a number of recommendations, the most essential of which is the establishment of an Academic Monitoring Panel. As we now see it, this panel should take responsibility for making the next move and help ensure that the political root causes of health inequities are duly taken into account when new policies are being worked out.

The panel should be mandated with the following tasks:

1. Revisit the political arenas analyzed by the commission, with the aim of providing concrete and proactive measures to safeguard health;

2. Carry out, solicit, or inspire high quality research, so as to deepen our understanding of the scale and nature of the global governance dysfunctions that impact health;

3. In order to avoid repetition or overlap, these tasks should be based on a comprehensive review of the efforts and initiatives that are currently being made to coordinate governance for health across political arenas outside of the health sector.

Point #1 acknowledges the complexity of the issues at hand and the need for much more research to truly understand how decision making at the supranational level affects health. Point #2 is based on the belief that high quality research should inform political choices. Point #3 is important, as the Panel should seek to fill a void rather than be seen as a body competing with existing initiatives or with WHO or other institutions in the health sector. Trade agreements and foreign investment treaties could be the first cases for the panel to revisit. By assessing health impacts of trade agreements in nascendi, the panel could help decision makers strike a balance between narrow economic goals and the need to safeguard and provide policy space for health.

It is important to note that the Panel should be truly independent and genuinely academic. As such, it should not be normative and assume an activist role, but rather inspire to action through high quality research and analyses. When confronted with hard evidence of health impact, it will prove difficult for decision makers to solely pursue restricted economic goals. And when confronted with hard evidence of the cross-sectoral nature of health, it will prove difficult for the architects of the SDG to avoid bringing global governance in as an important element. Health is biology, and technology has much to contribute to its improvement, but health is also inextricably coupled to politics on the grand scale. These are two views of health that today stand as utterly disconnected. The post-2015 agenda must be where the twain should meet and productively interact.

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*Ole Petter Ottersen, Professor MD, PhD, President of the University of Oslo and Chair of the Lancet-University of Oslo Commission on Global Governance for Health

**Desmond McNeill, Professor PhD, Centre for Development and the Environment, University of Oslo, Commissioner, University of Oslo Commission on Global Governance for Health

News Link 103

News Link 103

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Philippines: European Development Cooperation Should Not Support Commercialisation of Health Care Exacerbating Inequality

The current privatization policies of the Philippine government do not provide an answer to the enormous health needs. Despite the name of the Philippine "Universal Health Care" program that claims to "bring equity and access to critical health services to poor Philippinos", commercialisation of health services will do exactly the opposite. Unfortunately, the European Commission is supportive of these policies and formerly approved a contribution of  € 33 million in support of the Health Sector Reform Agenda of the Philippine government

Philippines: European Development Cooperation Should Not Support Commercialisation of Health Care Exacerbating Inequality

by Natalie Van Gijsel*

Campaign and Policy Officer at Medecine Pour le Tiers Monde (M3M)

Today, in the Philippines, 28 women out of 100 do not enjoy skilled attendance during delivery, a situation showing a glaring lack of access to healthcare. While in Belgium each year 8 mothers die of pregnancy-related causes, in the Philippines 8 mothers die every day. Every day 194 children under five years die in the Philippines, compared to one child per day in Belgium. Especially the poorest of the poor die without ever having seen a doctor.

Philippine civil society criticizes Public Private Partnership approach

The Aquino government claims that “public-private partnerships (PPP)”¹ are the only alternative to meet the health needs and the continuing population growth in the Philippines. By outsourcing public hospitals to the commercial sector², as announced by Health Minister Enrique Ona, one wants to save on government spending, while progressing in public health outcomes. All 72 public hospitals in the Philippines would be eligible for privatization.

However, according to local organisations – IBON, Gabriela, Council for Health and Development (CHD) and Advocates for Community Health - the current privatization policies of the Philippine government do not provide an answer to the enormous health needs. Despite the name of the Philippine “Universal Health Care” program that claims to “bring equity and access to critical health services to poor Philippinos”, commercialisation of health services will do exactly the opposite and leave the poor behind.

What is the role of the European Union?

The European Commission (EC), being a big donor in Overseas Development Assistance to the Philippines, is supportive of the current health sector reforms in the Philippines and formerly approved a contribution of € 33 million in support of the Health Sector Reform Agenda of the Philippine government. The latest published Philippine-EU Strategy Paper (2007-2013) stated that “further privatisation is critical and urgent” (p.18).

The “Agenda For Change“ of the European Union’s Development Cooperation (Directorate General Devco) -in line with the 1993 World Bank Report ‘Investing in Health’– is pushing for more involvement of the private sector. In the document it is written how “the EU should develop new ways of engaging with the private sector, notably with a view to leveraging private sector activity and resources for delivering public goods”, including health care provision. According to the Agenda For Change, the EU should “catalyse public-private partnerships and private investment”. References are made to imposing stricter conditionalities on the development aid provided, “through a range of aid instruments, notably ‘sector reform contracts'”. In a recent press release Andris Piebalgs, the European Commissioner for Development, confirmed the urge for “A Stronger Role of the Private Sector in Achieving Inclusive and Sustainable Growth in Developing Countries”, stating that “The private sector has a crucial role to play in helping people to lift themselves out of poverty (…), ensuring that businesses find an enabling environment to invest more, and more responsibly, in developing countries to help everyone enjoy the economic opportunities which the private sector can bring”.

Commercialization increases inequalities in access to health care

The most disadvantaged populations in the Philippines live in slums in the cities. People migrate to the city in search for work opportunities and a better life. But what they find is poverty, a life in unsanitary conditions and exposure to pollution. Although slum dwellers are the most vulnerable to diseases, they have the least access to health care.

The commercial sector in the Philippines invests mostly in specialized hospitals in the cities. Rural areas, where the majority of the population lives, and preventive primary health care are being overlooked by the private-for-profit sector. In addition, one has to pay high fees for health care by private for-profit providers, while user fees have been proven to result in low utilisation of and exclusion from health care and further impoverishment. The rural and urban poor are then pushed to rely on the underfunded public health sector or poorly regulated informal providers.

The outsourcing of healthcare to commercial investors goes at the expense of the public sector; it is diverting resources away from the public sector. First of all, the private-for-profit sector entices health workers away from the public sector by offering better working conditions and higher salaries³.The Philippines also train health workers en masse for export. So there is a net surplus of health workers, but through the “brain drain” the poor in urban and rural areas are left behind with a shortage of doctors and nurses. Secondly, increasing commercial sector involvement replaces Philippine public expenditure for health care. For reasons of diversion of resources away from the public sector, public health care provision is often of poor quality. A two-tier health system with commercial facilities for the better off and underfunded public services for the poor raises concerns of equity and social justice in health care access. Considering that the health system, being an important social determinant of health equity, can increase or reduce inequities in health outcomes.

Does the private-for-profit sector provide better quality health care?

If assumed that “quality care” is understood as “offering the best treatment according to the diagnosis, based on evidence and international treatment guidelines”, then this is not necessarily the case. Indeed, research in developing countries shows that, more often than their public counterparts, doctors in the private-for-profit sector do not respect international treatment guidelines.

In Peru and Chile higher rates of potentially unnecessary procedures, particularly ceasarian sections, were reported in private-for-profit settings after privatization of obstetric services. Studies in Mexico suggested that fee-for-service payment structures (which are more heavily present in private than in public care delivery settings) incentivized increased C-sections, while ceasarian sections should only be performed on medical indication because they entail more health risks for the mother.

Recent studies also suggest that in several developing countries, private-for-profit practitioners had a significantly worse knowledge of correct diagnosis and treatment. In Sub-Saharan Africa doctors serving in the for-profit sector have shown to be more likely to prescribe unnecessary antibiotics to children with diarrhea, instead of the recommended oral rehydration salts. Irrational prescribing practices could lead to antibiotic resistance, which poses the world population at risk.

Is the private sector more efficient than the public sector?

We understand “efficiency” as “producing the best possible results with the available budget”. According to the 2009 Oxfam report “Blind optimism“, commercialization of health care increases public spending, while health outcomes deteriorate. Lebanon has one of the most privatized health systems in the developing world. The country spends two times more on health care than Sri Lanka, a country far lower on the development index of the United Nations. Despite the high public spending, the infant and maternal mortality rates are 2.5 and 3 times higher, respectively. Outsourcing healthcare to the commercial sector in China- still remembered for its former “barefoot doctors”- has led to a decline of less-profitable preventative health care; immunisation coverage dropped by half in the following five years. Likewise, following extensive privatization reforms in Colombia in 1993, population vaccine coverage declined and more cases of tuberculosis occurred.

EU should refrain from promoting privatization policies

Economic development is seen as the panacea in creating health and wealth. However, opening up the health sector for increased private-for-profit investments is creating inequalities in access to health care and thus inequities in health outcomes, which raises serious concerns of sociale justice. Therefore, the European Union should refrain from development policies that support or push privatization efforts in the health sector.

References

1-IBON Facts and Figures. PPP in Health. Vol. 34. N° 7 & 8, 15 & 30 April 2011

2- IBON Facts and Figures. Aquino’s Universal Health Care. Vol 34, N° 17, 15 september, 2012

3-Haddad, S., Baris, E., & Narayana, D. (2008). Safeguarding the health sector in times of macroeconomic instability: policy lessons for low- and middle-income countries. Ottawa: Africa World Press: International development research centre

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*Natalie Van Gijsel is Campaign and Policy Officer at Medecine pour le Tiers Monde in Belgium. Being a midwife she worked in Belgium and for some years in Sierra Leone. She is a master-student in Global Health Policy at the London School Of Hygiene and Tropical Medicine