"The world is in a mess, and much of this mess is of our own making... Collectively, we have failed to give the systems that govern international relations a moral dimension...[However] There is hope. I personally believe that health deserves careful consideration for a leading role. Our policies are guided by scientific evidence, and not by vested interests. We have the power and the objectivity of the scientific method on our side. The health sector has humanity's best interests at heart, a strong moral dimension, and a strong set of social values among its many stars. Let us all continue to provide the hope this world so badly needs at a time of severe crises - and transformation." Margaret Chan, Address at the 23rd Forum on Global Issues, Berlin, Germany, 18 March 2009.
UN Secretary-General Ban Ki-Moon recently asked UK Prime Minister David Cameron to chair a UN committee charged with putting together a new set of development goals once the MDGs expire in 2015. Commentators have noted that Cameron is likely to focus on economic growth and infrastructure at the expense of social sectors such as health and education. This would be a major missed opportunity.
Within the global health system, there are key structural failings that hinder our ability to "buy the most health for each dollar we spend." For example, the past 15 years have witnessed a constant deluge of initiatives focusing on specific diseases or issues. It has been estimated that there are more than 40 bilateral donors, 26 UN agencies, 20 global and regional funds and 90 global health initiatives active at the moment. This landscape is characterized by fragmentation, lack of coordination and even confusion as a diverse array of well-funded and well-meaning initiatives descend with good intentions on countries in the developing world. Many of the initiatives lack mechanisms of accountability, transparency and evaluation in the way they operate within countries and tend to focus on short-term results. As 'fashions' come and go, donors keep shifting attention from one disease to the next without working to build long-term national capacity. Many of these initiatives are narrowly focused on specific diseases (big three), are 'top-down' in nature and are largely driven by donor agendas rather than the country's own needs and priorities.
To address these inefficiencies, a global network of civil society and academics has united to form the Joint Action and Learning Initiative on National and Global Responsibilities for Healt
(JALI) (1). JALI's goal is a post-MDG global health agreement grounded in the human right to health and aimed at resolving today's vast health inequities between and within countries. In particular, the coalition is exploring the potential for and content of a Framework Convention on Global Health (FCGH). Such a treaty would work to health services that governments ought to provide; identify who would be obliged to provide what; and examine how this could be achieved through reform of global health governance. This kind of global agreement would support Ministries of Health within countries and institutionalize the norms, structures, and processes required to enable all people to enjoy the right to health.
The health goods and services guaranteed to everyone - an expansive version of universal health coverage, one that goes beyond health care alone -could focus on three areas:
(1) Health Systems and Services
-medical products, vaccines, and technologies
-a financing system that raises sufficient funds for health and assures access
-leadership and governance.
(2) Essential Drugs, Vaccines and Technologies.
(3) Fundamental Human Needs, which includes sanitation and sewage, pest control, clean air, potable water, diet and nutrition (neither under- nor over-nutrition), and tobacco and alcohol reduction.
While it might sound vague at first look, a Framework Convention on Global Health would be tightly focused and
- include ambitious yet achievable global targets, with processes to adapt them to local circumstances and ensure national and community ownership;
- require comprehensive public health strategies addressing both health services and social determinants of health;
- move towards clarifying what are the "key" health services that universal coverage should encompass and all people should enjoy, while still enabling adaptation to local circumstances and priorities;
- develop a financing framework with clear funding benchmarks for governments' domestic health spending (including non-health sectors central to the underlying determinants of health) and for international health funding commitments;
- establish targets on and develop mechanisms to dramatically reduce domestic health inequities and ensure the accountability of health services to the communities they serve;
- support civil society and community participation in planning, implementing, and evaluating local, national, and international-partner supported health plans, policies, and programs;
- establish commitments and monitoring mechanisms to ensure that health plans, policies, and programs emphasize the health needs of traditionally discriminated against and underserved populations, including women, people who are poor, and marginalized groups, and;
- offer specific measures that countries should take in trade, environment, finance, and other realms to protect and promote health, including mechanisms to evaluate the adoption and effective implementation of these measures. (2)
Cynics allege that this type of agreement is unrealistic, idealistic and politically impossible. But before dismissing this proposal, it is important to note that there is precedent for the use of international law in health, including the International Health Regulations and the Framework Convention on Tobacco Control. Unlike any other body in global health, the World Health Organization can create legally-binding conventions; and they only require a two-thirds majority vote to do so.
To naysayers I would ask, how else can we move forward? Ultimately improving health comes down to a social contract within countries, between the rich and the poor, and among countries, between higher and lower income governments. To be realized and actually mean something in practice, this social contract needs to be institutionalized and adequately financed. This is why we have (in most high income countries) universal health insurance and social welfare schemes with government playing a major role. In the tradition of the UK National Health System which ensures universal health coverage, pushing forward such an agreement would cement the UK government's place as a leader in international solidarity. References
(1)I would like to acknowledge insights gained from memership on the JALI Steering Committee and the following individuals: Eric Friedman, Larry Gostin, Gorik Ooms, Harald Siem, and Attiya Waris
(2) See http://www.med.uio.no/helsam/english/research/global-governance-health/submissions/documents/JALIsubmission12-7-11.pdf