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Towards a global social contract on health
I believe that we are at a turning point for public health—and that our choices are stark: either we reorient and strengthen public health within both modern and developing societies and institute a resilient system of global governance for health or we will face dire consequences in terms of human, social, and economic development. At present, it is the poorest countries that are paying the price for this negligence—but we have mounting signals that a new health divide is in the making as a large global underclass spreads out around the globe and defies the old definitions of vulnerable groups.
Forceful action at nation state level will not be enough—we need nothing less than a new global social contract on health. I was delighted to see the use of that phrase also by Richard Smith, editor of the British Medical Journal in a recent excellent editorial.1 The drive for such a contract can only be established politically—developed through an ethical and political debate throughout society initiated by outspoken public health professionals, responsible politicians, and a concerned civil society at national and global levels of governance. And maybe this is the time for the respective journals to make this a joint wake up call to our professional community.
We have reached a point where we need to make a choice of what kind of model of global public health we want to promote. It was one of the characteristics of modernity to take health out of the confines of religion and charity and make it a key element of the action of the state and the rights of citizenship. This process, initially within the context of the constitution of the nation state, today needs to go global as a key dimension of global justice. The International Labour Organization with its recent report on globalisation has presented some first steps in this direction. With such a perspective we can see that the present global drive for access to AIDS medicines for developing nations is not just about health, it is the spearhead of a global citizenship movement that has recognised that global health needs to move out of the charity mode of bilateral aid and philanthropy into the realm of rights, citizenship, and a global contract. With this in mind I would like to propose five key action areas for a global public health:
1 DEFINE HEALTH AS A GLOBAL PUBLIC GOOD
This implies ensuring the value of health, understanding it as a key dimension of global citizenship, and keeping it high on the global political agenda. It implies defining common agendas, increasing the importance of global health treaties, and increasing pooling of sovereignty by nation states in the area of health. It also implies a new interface between foreign and domestic policies. Finally it means new forms of sharing of research and proprietary information to resolve common health challenges.
2 ACCEPT HEALTH AS A KEY COMPONENT OF GLOBAL SECURITY
This implies an extensive global health surveillance role and expanded international health regulations with interventionist power for the World Health Organisation and sanctions (through other bodies such as the World Trade Organisation of the International Court of Justice) for countries that do not comply—the reliable financing of a global surveillance infrastructure and a rapid health response force would be ensured through a new kind of global financing mechanism or a global public goods tax, for example on airline tickets and tourism.
3 STRENGTHEN GLOBAL HEALTH GOVERNANCE FOR INTERDEPENDENCE
This means strengthening the WHO and giving it a new and stronger mandate. It must have the constitutional capability to ensure agenda coherence in global health, it must be able to strengthen its convening capabilities, and it should be able to ensure transparency and accountability in global health governance through a new kind of reporting system that is requested of all international health actors. Indeed recognition of its coordination and leadership role should significantly reduce the transaction costs for countries and for donors and should include a brokering role in relation to the health impacts of policies of other agencies. It should also be the coordinator of health in crises by acting as the intermediate health authority. Furthermore, it should gain more coordinating power for the actions necessary to reach the Millennium Development Goals (MDGs) on health.
4 ACCEPT HEALTH AS A KEY FACTOR OF SOUND BUSINESS PRACTICE AND SOCIAL RESPONSIBILITY
This falls squarely into the realm of the Millennium Development Compact and the Global Compact as well as Goal 8 of the MDGs. There is an enormous scope for business involvement in development, not only in form of the public private partnerships around diseases but also—as the work on nutrition has shown—for producing and marketing healthy and safe products to the poor—such new business models could be part of the work of the World Economic Forum. The International Business Leaders Forum has produced an excellent guide how business can contribute to the achievement of the MDGs.
It also means increasing the capacity of the WHO to negotiate a new system of access to drugs based on a global public goods model for example in the area of pricing (for example, joint negotiations of 10 Latin American Countries and PAHO with global players on Anti Retro Viral drugs led to a 92% price reduction). Clearly legally binding Global Health Conventions such as the Framework Convention on Tobacco Control must be further developed and strengthened. But even more important is to work on new financing models, such as the International Finance Facility proposed by Gordon Brown the British Chancellor of the Exchequer or a model package of a global Bismarckian type of health insurance together with the insurance industry and the ILO and the World Bank. There is an urgent need to establish a system to ensure how contributions of the rich world ensure access to prevention, care, and treatment in developing countries. Clearly health and social protection cannot be separated.
5 ACCEPT THE ETHICAL PRINCIPLE OF HEALTH AS GLOBAL CITIZENSHIP
This means working to develop a common notion of social justice and a system of international law where human rights constitute a legal claim.
In the next wave of modernity that now sweeps the globe social protection becomes a global challenge. As many recent analyses2 have shown the global institutions have focused on the global public goods necessary to the expansion of trade and commerce but have severely neglected the expansion of social public goods. This is exactly where we are challenged as a public health community today. What we need are public health models that take radically different approaches and question the very premise of what at the global level is a public and what is a private good.
Towards a global social contract on health
These ideas were developed in more detail on occasion of the Leavell lectureship of the World Federation of Public Health Associations, Brighton, April 2004
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