The political origins of health inequity: prospects for change by The Lancet, University of Oslo Commission on Global Governance for Health 4:35pm 15th Feb, 2014   Feb 2014    Despite large gains in health over the past few decades, the distribution of health risks worldwide remains extremely and unacceptably uneven. Although the health sector has a crucial role in addressing health inequalities, its efforts often come into conflict with powerful global actors in pursuit of other interests such as protection of national security, safeguarding of sovereignty, or economic goals.    This is the starting point of The Lancet—University of Oslo Commission on Global Governance for Health. With globalisation, health inequity increasingly results from transnational activities that involve actors with different interests and degrees of power: states, transnational corporations, civil society, and others.    The decisions, policies, and actions of such actors are, in turn, founded on global social norms. Their actions are not designed to harm health, but can have negative side-effects that create health inequities.    The norms, policies, and practices that arise from global political interaction across all sectors that affect health are what we call global political determinants of health.    The Commission argues that global political determinants that unfavourably affect the health of some groups of people relative to others are unfair, and that at least some harms could be avoided by improving how global governance works.    There is an urgent need to understand how public health can be better protected and promoted in the realm of global governance, but this issue is a complex and politically sensitive one. Global governance processes involve the distribution of economic, intellectual, normative, and political resources, and to assess their effect on health requires an analysis of power.    This report examines power disparities and dynamics across a range of policy areas that affect health and that require improved global governance: economic crises and austerity measures, knowledge and intellectual property, foreign investment treaties, food security, transnational corporate activity, irregular migration, and violent conflict.    The case analyses show that in the contemporary global governance landscape, power asymmetries between actors with conflicting interests shape political determinants of health.    Key messages    The unacceptable health inequities within and between countries cannot be addressed within the health sector, by technical measures, or at the national level alone, but require global political solutions.    Norms, policies, and practices that arise from transnational interaction should be understood as political determinants of health that cause and maintain health inequities.    Power asymmetry and global social norms limit the range of choice and constrain action on health inequity; these limitations are reinforced by systemic global governance dysfunctions and require vigilance across all policy arenas.    There should be independent monitoring of progress made in redressing health inequities, and in countering the global political forces that are detrimental to health.    State and non-state stakeholders across global policy arenas must be better connected for transparent policy dialogue in decision-making processes that affect health.    Global governance for health must be rooted in commitments to global solidarity and shared responsibility; sustainable and healthy development for all requires a global economic and political system that serves a global community of healthy people on a healthy planet.    We identified five dysfunctions of the global governance system that allow adverse effects of global political determinants of health to persist.    First, participation and representation of some actors, such as civil society, health experts, and marginalised groups, are insufficient in decision-making processes (democratic deficit).    Second, inadequate means to constrain power and poor transparency make it difficult to hold actors to account for their actions (weak accountability mechanisms).    Third, norms, rules, and decision-making procedures are often impervious to changing needs and can sustain entrenched power disparities, with adverse effects on the distribution of health (institutional stickiness).    Fourth, inadequate means exist at both national and global levels to protect health in global policy-making arenas outside of the health sector, such that health can be subordinated under other objectives (inadequate policy space for health).    Lastly, in a range of policy-making areas, there is a total or near absence of international institutions (eg, treaties, funds, courts, and softer forms of regulation such as norms and guidelines) to protect and promote health (missing or nascent institutions).    Recognising that major drivers of ill health lie beyond the control of national governments and, in many instances, also outside of the health sector, we assert that some of the root causes of health inequity must be addressed within global governance processes.    For the continued success of the global health system, its initiatives must not be thwarted by political decisions in other arenas. Rather, global governance processes outside the health arena must be made to work better for health.    The Commission calls for stronger cross-sectoral global action for health. We propose for consideration a Multi-stakeholder Platform on Governance for Health, which would serve as a policy forum to provide space for diverse stakeholders to frame issues, set agendas, examine and debate policies in the making that would have an effect on health and health equity, and identify barriers and propose solutions for concrete policy processes.    Additionally, we call for the independent monitoring of how global governance processes affect health equity to be institutionalised through an Independent Scientific Monitoring Panel and mandated health equity impact assessments within international organisations.    The Commission also calls for measures to better harness the global political determinants of health. We call for strengthened use of human rights instruments for health, such as the Special Rapporteurs, and stronger sanctions against a broader range of violations by non-state actors through the international judicial system.    We recognise that global governance for health must be rooted in commitments to global solidarity and shared responsibility through rights-based approaches and new frameworks for international financing that go beyond traditional development assistance, such as for research and social protection.    We want to send a strong message to the international community and to all actors that exert influence in processes of global governance: we must no longer regard health only as a technical biomedical issue, but acknowledge the need for global cross-sectoral action and justice in our efforts to address health inequity.    The political nature of global health    Global sources of health inequity    “We are challenged to develop a public health approach that responds to the globalised world. The present global health crisis is not primarily one of disease, but of governance…” states Ilona Kickbusch.    The Commission on Global Governance for Health is motivated by a shared conviction that the present system of global governance fails to adequately protect public health.    This failure strikes unevenly and is especially disastrous for the world''s most vulnerable, marginalised, and poorest populations.    Health inequalities have multiple causes, some of which are rooted in how the world is organised.    Global health inequities    Over 842 million people worldwide are chronically hungry, one in six children in developing countries is underweight, and more than a third of deaths among children younger than 5 years are attributable to malnutrition.    Unequal access to sufficient, safe, and nutritious food persists even though global food production is enough to cover 120% of global dietary needs.    1·5 billion people face threats to their physical integrity, their health being undermined not only by direct bodily harm, but also by extreme psychological stress due to fear, loss, and disintegration of the social fabric in areas of chronic insecurity, occupation, and war.    Life expectancy differs by 21 years between the highest-ranking and lowest-ranking countries on the human development index.    Even in 18 of the 26 countries with the largest reductions in child deaths during the past decade, the difference in mortality is increasing between the least and most deprived quintiles of children.    More than 80% of the world''s population are not covered by adequate social protection arrangements. At the same time, the number of unemployed workers is soaring.    In 2012, global unemployment rose to 197·3 million, 28·4 million higher than in in 2007. Of those who work, 27% (854 million people) attempt to survive on less than US$2 per day.    More than 60% of workers in southeast Asia and sub-Saharan Africa earn less than $2 per day.    Many of the 300 million Indigenous people face discrimination, which hinders them from meeting their daily needs and voicing their claims.    Girls and women face barriers to access education and secure employment compared with boys and men, and women worldwide still face inequalities with respect to reproductive and sexual health rights. These barriers diminish their control over their own life circumstances.    Although the poorest population groups in the poorest countries are left with the heaviest burden of health risks and disease, the fact that people''s life chances differ so widely is not simply a problem of poverty, but one of socioeconomic inequality.    The differences in health manifest themselves as gradients across societies, with physical and mental ills steeply increasing for each step down the social ladder, along with other health-related outcomes such as violence, drug misuse, depression, obesity, and child wellbeing.    It is now well established that the more unequal the society, the worse the outcomes for all—including those at the top.    The WHO Commission on Social Determinants of Health recognised that societal inequalities skew the distribution of health. It concluded that “social norms, policies, and practices that tolerate or actually promote unfair distribution of, and access to, power, wealth, and other necessary social resources” create systematic inequalities in daily living conditions.    In a groundbreaking analysis, the report showed how daily living conditions make a major difference to people''s life chances.    These conditions include safe housing and cohesive communities, access to healthy food and basic health care, decent work, and safe working conditions. They also include underlying factors: political empowerment, non-discriminatory inclusion in social and political interactions, and the opportunity to voice claims.    In our view, the report rightly characterised vast health gaps between groups of people as unfair, labelling them health inequities rather than inequalities.    According to Margaret Whitehead, health equity implies that: “ideally everyone should have a fair opportunity to attain their full health potential and, more pragmatically, that no one should be disadvantaged from achieving this potential, if it can be avoided. The aim of policy for equity and health is not to eliminate all health differences so that everyone has the same level and quality of health, but rather to reduce or eliminate those that result from factors considered to be both avoidable and unfair.”    Nation states are responsible for respecting, protecting, and fulfilling their populations'' right to health, but with globalisation many important determinants of health lie beyond any single government''s control, and are now inherently global.    Besides local and national action, combating health inequity increasingly requires improvement of global governance. Although determinants of health exist at many levels—from individual biological variance to local and national societal arrangements—some determinants are tied to transnational activity and global political interaction.    These global factors have received insufficient attention, perhaps because the causal linkages are complex and difficult to untangle, or because the implications can be controversial and unwelcome to some.    An abundance of scientific evidence shows the existence of a social gradient in relation to health inequalities and exposure to health risks.    We assert that health inequity requires a moral judgment—it must be considered unfair and avoidable by reasonable means.    We argue that the norms, policies, and practices that arise from global political interaction (the global political determinants of health) and that unfavourably affect the health of some groups of people compared with others are indeed unfair.    Some of these global political determinants could be avoided by improving the way global governance works. Tackling these global political determinants could thereby improve fairness in health.    The 2008 report of the Commission on Social Determinants of Health drew attention to political conditions that underpin unfair economic and societal arrangements. However, its analysis did not aim to address the underlying global forces, processes, and institutions that create the conditions that cause health inequity.    As stated in a 2011 Comment in The Lancet: “An increased understanding of how public health can be better protected and promoted in various global governance processes is urgent, but complex and politically sensitive. These issues involve the distribution of economic, intellectual, normative, and political resources, and require a candid assessment of power structures.”    Our response to this challenge requires the exploration of the plausible pathways through which transnational actions and global governance processes affect health equity.    The sections that follow serve as a conceptual framework that guides analyses of a series of case examples. These examples have been selected from among important policy intervention areas in which global governance has failed to protect people''s health against “factors considered to be both avoidable and unfair”.    We show how power asymmetry and global norms limit the range of choice and constrain action, but also sometimes provide opportunities. Looking across the cases, we also identify systemic dysfunctions that hinder global governance from shaping positive determinants of health and from tackling the negative determinants.    We urge responsible actors and opinion leaders to act, and we offer a range of actionable ideas for further consideration and development.    * Access the link below for complete essay.    http://www.thelancet.com/commissions/global-governance-for-health    (Prof Ole Petter Ottersen PhD, Jashodhara Dasgupta MA, Chantal Blouin PhD, Paulo Buss MD, Prof Virasakdi Chongsuvivatwong PhD , Prof Julio Frenk PhD, Prof Sakiko Fukuda-Parr MA, Bience P Gawanas EMBA , Prof Rita Giacaman PharmD , Prof John Gyapong PhD, Prof Jennifer Leaning MD, Prof Michael Marmot FRCP, Prof Desmond McNeill PhD, Gertrude I Mongella HonD, Nkosana Moyo PhD, Sigrun Møgedal MD, Ayanda Ntsaluba FCOG [SA], Gorik Ooms PhD, Prof Espen Bjertness PhD, Ann Louise Lie MSc, Suerie Moon PhD, Sidsel Roalkvam PhD, Kristin I Sandberg PhD, Inger B Scheel PhD) Visit the related web page
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