Ronald LabontéCanada Research Chair

Globalization and Health EquityInstitute of Population Health

University of Ottawarlabonte@uottawa.ca

Health more prominent on global policy agendas◦ Funding increased (USD 5.6bn 1990 to USD 21bn 2008)◦ MDGs (3 health specific, rest SDH)Several countries have passed policies on health/development andpolicy coherence◦ Sweden (2003) parliamentary report on development coherence◦ Norway (2006-2008) foreign policy coherence commission◦ Switzerland (2005) health foreign policy◦ UK (2008) health is global policy◦ Norway, France, Brazil, Indonesia, Senegal, South Africa and Thailand

(2007) Oslo Ministerial Declaration UN General Assembly Resolution (2008) health and foreign policy2009 Annual Ministerial Review held by the UN Economic and Social Policy Council is devoted to the issue of global public health2010 EU Presidency (Spain): global health equity, coherence and knowledge

Global Health Diplomacy (GHD): The processes by which government, multilateral and civil society actors attempt to position health in foreign policy negotiations and to create new forms of global governance for health.◦ Framework Convention on Tobacco Control◦ International Health Regulations◦ Intergovernmental Working Group on Intellectual Property Rights◦ Intergovernmental Working Group on Virus-Specimen and Benefit-

SharingWHO Working Group on GHDInternational Consortium on GHD

Health and securityHealth and developmentHealth and global public goodsHealth and tradeHealth and human rightsHealth and ethical/moral reasoning

Most frequently encountered policy frameThree major aspects: ◦ National (border protection)◦ Economic (growth and competitive advantage)◦ Human (capacities for human flourishing)National and economic security foreign policy ‘high politics,’ first priority of statesHuman security and humanitarian aid foreign policy ‘low politics,’ more evidence of rhetoric than action

Unchecked disease can lead to economic decline, failed states and domestic/regional conflict (‘high politics’)Response to disasters and conflicts should be based on scale/need (‘low politics’) National health security (framed as pandemic preparedness) requires global health securityLack of coherence? (arms trade vs. humanitarian aid)

Utilitarian, self-interest, triage by short-term ‘high politics’Strategic alignment with ‘high politics’ reverses historic international health intervention based on humanitarian and ethical motiveSecuritization of certain diseases (HIV/AIDS, pandemic influenza) leads to investments vastly disproportionate to burdens of disease (need)No reference in policy documents to human security

Development long a frame in foreign policy◦ Health improvements seen primarily as positive

externalities of development/growthHealth now seen as investment in development/growth◦ Essential health care, sanitation, water, educationHuman security provides a link between security and development frames

Global health security is premised on improving human security Foreign policy decisions should increase other country’s ability to meet or make towards the Millennium Development Goals◦ Shift from infectious (cross-border risk) to chronic

(domestic development risk)

Health development assistance can improve receiving countries’ economic performance creating positive trade-related economic externalities (benefits) to donor countriesHealth development assistance, to continue receiving public and political support, needs to show results

FDI flows (properly regulated and directed) can benefit a country’s economic development, growth and healthIncreasing migration of lesser-skilled workers from low-income countries can aid health and development through remittances while meeting high-income labour needs

Lack of ambition: MDGsDevelopment triageInadequacies of aid levels/need requirementsCritiques of aid dependency

Global public good (GPG) offers one of the strongest theoretical arguments for global health policy◦ Rarely encountered by name in actual policy

statementsPeace, prevention of pandemics, financial stability, human rights, free access to knowledge and a stable climate all have characteristics of GPGs

Prevention of pandemic preparedness demands international cooperationEvidence-informed arguments more successful in policy negotiations, yet ‘gold standard’ evidence (post hoc) for climate stability unavailableClimate stability requires disproportionate actions in emissions reduction, clean technology and demand reduction by HICs permitting increases, then caps, by LMICs

Global trade and investment in alcohol and unhealthy foods are associated with increased burdens of disease related to alcohol abuse and poor dietary environments and choices◦ There are public health arguments for

strengthening global efforts to reduce the health harms associated with these products through global health conventions◦ Such conventions remain ‘soft law’ though they

have persuasive force within countries (e.g. Framework Convention on Tobacco Control)

Negotiating timeGlobal funding not following GPG needIntellectual property rights (IPRs) impeding cooperationTrade treaty conflicts

◦ FCTC avoided any reference to trade

The most problematic frame in global health diplomacy◦ Rules-based global trading system is regarded as

another global public good, the definition and enforcement of those rules is dependent upon countries’ economic and political power and past development history

Increases in global trade through liberalization (removal of border barriers to foreign goods and capital) have long been argued as essential means to improve growth, development and subsequent health in low- and middle-income countries

‘Health tourism’ can promote economic growth and, potentially, reduce the migration of health workers in search of greater practice opportunityTechnology development in HICs and global diffusion through trade has benefited ‘free-riding’ LMICsExtended IPRs are essential to finance research and development for new drugs

Asymmetrical globalization: who gains, who loses?o ‘Successful’ completion of Doha Development

Round projects asymmetrical gains to already developed nations, with greater tariff losses to developing nations

Trade liberalization is associated with increased economic insecurity through competitive pressures and labour market changes, and decreased public revenues through loss in tariffs

Private health care provision to foreign consumers (‘health tourism’) can squeeze out providers in public systems to citizens, worsening access for national residents, especially poorer groups less able to afford private careIncreased foreign investment in health services via liberalization under GATS (General Agreement on Trade in Services) can create inequities in access to health resources

The rationale that extended IPRs are essential to finance research and development for new drugs is weakPressure on LMICs to increase IPRs by removing flexibilities agreed to under multilateral negotiations can increase costs and decrease access to essential medicines in poorer countries

Human rights treaties are widely regarded as having primacy over other international treaties when conflicts ariseThe preservation of human life and health are at the base of such treaties and their obligations on states parties◦ Key human rights treaty obligations framing global health

diplomacy are found in Article 12 and General Comment 14 of the International Covenant on Social, Economic and Cultural Rights – the ‘right to the highest attainable standard of physical and mental health’

Evidence suggests that the stronger the force of these rights in domestic legislation, the more persuasive they can be in foreign policy negotiations

Human rights treaties impose core obligations on states parties◦ States parties are also obliged to ensure that their

foreign policies, other international treaties into which they enter or negotiate, and non-state actors within their jurisdiction operating nationally or internationally do not infringe upon their own ability, or that of other states, to meet their obligations under human rights treaties◦ This implies the necessity of human rights impact

analyses of all such foreign policies and international treaty negotiations

Health is considered a basic right, since it is foundational to the enjoyment of most other human rights◦ The foundational quality of health is reinforced in

the normative prominence it receives in the Millennium Development Goals◦ At a minimum, states’ foreign policies should not

lead to other states reducing in any way the present level of the realization of the right to health

The right to health can be interpreted in legal decisions or national policy as an individual right onlyHuman rights always supported in words, less evidence of support in action◦ Naming and shaming only?

States, the institutions they create and the persons who function within them are moral actorsA key moral theme in Western societies, and possibly universal across societies, is human dignity◦ This moral axiom demands not only respect for the

autonomy of individual, but extends to the provision of core resources for the capabilities people require to live valued lives

Basic to dignity is the autonomy of individuals, not simply as isolated rational agents but as persons whose identities and capabilities are embedded in social relations with othersHealth is considered to have ‘special importance’ in peoples’ lives, and in their ability to enjoy both dignity and personal security

Social justice is the dominant ethical theory by which societal decisions about distributive and redistributive allocation of resources for health and other capabilities are made◦ Equity is at the core of social justice theory with two

differing but non-exclusive conceptions: equality of opportunity (an emphasis on horizontal equity and procedural justice) equality of outcome (an emphasis on vertical equity and substantive justice)

Thomas Pogge ‘relational justice’:◦ The radical inequalities observed between peoples and

nations today are partly an effect of a violent history in which some gained at the expense of others

◦ Not only does procedural justice by itself fail to account for these vast disparities in initial conditions; it is impossible to conceive of these disparities existing on the scale that they do without ‘an organized state of civilization’ to uphold them

◦ Economic institutions operating on an international scale (the ‘organized state of civilization’) have been complicit in upholding these injustices

Redistribution important regardless of emphasis on opportunity or outcomeWhat remains at issue is the extent of moral obligation for amelioration of gross inequalities in initial conditions that create ‘shortfall inequalities in central health capabilities’Is there an ethically defensible scale of rectification?

All six framings offer some rationalizations for increasing health presence in foreign policy negotiations, but contradictions (lack of coherence) remainSome evidence for most in policy statements and (to lesser degree) in policy practiceTrade and national security remain most problematic yet most prominent (notably national security) – GHD to this point is not real transformation but realpolitik re-packagedYet: health could constitute a ‘meso-political’ discourse linking traditional high and low politics of international relations, but up to ‘health diplomats’ to be relentless in pursuing this in a post-crisis re-globalization