Publisher: German Platform for Global Health (Deutsche Plattform für Globale Gesundheit DPGG), June 2014
Summary
In summer 2013, the German government approved the concept paper „Shaping global health policy – acting together – assuming responsibility” that was jointly developed by five ministries. The proposals expressed therein are intended to effectively use international cooperation in order to improve global health. Such a commitment is a positive sign - and urgently needed since the health situation remains dire for countless people all over the world, despite the isolated improvements in some health areas over the past decades. There still is a horrifying gap between North and South, respectively between rich and poor when it comes to the conditions for a healthy life. This involves both health care and protection against health threats. On top of that, health risks are further increased by crumbling social security systems in many parts of the world, rising social uncertainty, climate change, dwindling food sovereignty and an increasing number of new wars.
With this health crisis in mind, the „Deutsche Plattform für Globale Gesundheit (German Platform for Global Health)” (DPGG), founded in 2012 by social welfare organisations, non-governmental organisations, trade unions and scientists, has carefully examined the German government in its concept paper. The Platform welcomes that the government has acknowledged the urgency of the issue and is ready to take on the challenge of global interconnections in the health field. The Platform has, however, concluded that crucial health-related problems appear to have been addressed either insufficiently or even in a way that may be misleading. The following will go deeper into these considerations in some fields that are relevant to health such as nutrition, migration of health workers, climate change and international trade and taxation policies.
Basically, the German government refers to concept of „healthcare“ in its concept paper that is by far too narrow. Consequently, government action is principally aimed at „protecting the German population“ and is thus not addressing the health situation of everyone, everywhere on an equal footing.
It is also problematic that the German government relies on a pure clinical – medical/biomedical approach when addressing global health. Therefore, social, cultural and economic aspects, which can be both health promoting or hazardous to health, are being neglected. Starting from a broad and integrated understanding of health, the Platform came to different and, much more far-reaching conclusions than the German government.
The following statements evince essential aspects that are, according to the Platform, indispensable for a strategy that meets the complex demands of a global health policy. The Platform is deeply convinced that without preservation and protection of public and solidarity-based health care systems, effective means of fighting health threatening working, living and environmental conditions and strategies for more social justice and democracy, we will not be closer to achieving global health for everyone, everywhere. The Platform offers the German government support in further elaborating on the concept paper.
Foundations for a future interdepartmental strategy to promote global health
In the globalised world of the 21st century health policy is not a national issue. Key factors for health and well-being have an impact far beyond national borders. The liberalisation of the global flow of goods and money, the actions of transnational groups, the exploitation of our world's natural resources, climate change and, above all, the permanently growing inequality in the distribution of incomes and assets have a major impact on health.
Given the internationalisation of the economy and society global action is imperative. „Global Health“ has become a central political agenda for governments, non-governmental organisations and other actors in the field of health policy. Accordingly, the interdepartmental concept paper „Shaping global health policy – acting together – assuming responsibility“ presented by the German government in summer 2013 has to be appreciated. The concept paper was jointly developed by five ministries. Thereby, the issue of global health has finally been given the urgently needed attention by the German government.
In 2012, social welfare organisations, non-governmental organisations, scientists and trade unions founded the „Deutsche Plattform für Globale Gesundheit“ (German Platform for Global Health) PGG, that is aimed at raising public awareness of the close link between global and local health care systems and supports the efforts to promote a global health policy. Since health not only is an issue of global concern but also affects many different policy areas, an interdepartmental and interdisciplinary approach is more than overdue. Thus, the paper of the German government is going in the right direction but it does not go far enough. The paper contains goals that, on closer analysis, turn out to be even wrong.
The Platform offers support to the new German government for the urgently needed development of the concept paper. In this context it will be necessary to fully address aspects that have been neglected so far. The following will explain why these aspects are of vital importance when setting out a strategy for global health policy.
Global Health Policy must address all people worldwide.
The document of the German government focuses on the idea of „protecting and improving public health in Germany,“ while the Platform sees global engagement as an indispensable basis for the improvement of public health worldwide. A health policy that concentrates on the protection of national territories and populations by means such as the defence against cross-border threats to health is not in compliance with universal human rights to which the German government has committed itself. Global health policy has to develop strategies to promote the health situation of all people worldwide.
Of course, preservation and promotion of global health also is meant to control infectious illnesses and epidemics at home. Though, if it comes to „effectively fight cross-border health risks,“, action should not be restricted to „increasing cross-border trade and travel“ (Federal Ministry of Health BMG 2013: 7). What is needed, is an analysis of all negative side effects of globalisation from the increase of social inequality to climate change. Thus, a solution at the international level also needs political changes at home. Global health policy cannot be motivated merely by security interests and goes far beyond hazard prevention through the „International Health Regulations“.
Health promotion instead of biomedicine
In contrast to the German government that wants to promote health primarily with „access to drugs, technologies, knowledge and research“ as well as „the necessary medical knowledge and the required technical and financial means“ (BMG 2013: 7), the Platform understands global health policy mainly as a social and socio-political challenge. In this context, focusing on biomedical intervention meets neither the complexity of the concept of health nor the extensive demands of global health policy.
In its founding act the WHO defined health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" (WHO 1946). The concept paper of the German government, however, fails to adopt such a comprehensive understanding of health. In the tradition of Paul Ehrlich, who has developed the German health research model, the paper restricts the promotion of health primarily to biomedical disease control and neglects the approach of Rudolf Virchow who emphasised on social determination of health and the concept of public health. Since the paper gives scant regard to social determinants of health it sometimes tends to confuse cause and effect, which leads to wrong conclusions in health policy.
Many studies have demonstrated that good health depends less on factors such as individual behaviour, health-related knowledge and skills or healthcare systems and more on social, economic and environmental conditions. Thus, it is of crucial importance to take interdisciplinary action, which is not possible, without putting emphasis on aspects such as social determinants of health, distribution of income, living and working conditions, environment and other social factors. Granting sound medical care may be important, but it has less influence on the health situation than decent living conditions.
With this in mind, global health policy must always be understood in the context of international structural policy the puts universal human rights at the very centre while questioning particular interests, namely economic interests. Such a policy is much more than sharing experience, expertise and resources, however important this may be. International cooperation should not be limited to tackling the symptoms but also the structural causes of poverty and disease. Only a comprehensive interdisciplinary understanding of health that pays attention to the social determinants of health is able to meet the complex and dynamic requirements of global health.
Social inequality
In wealthy Germany, the average life expectancy of poor male citizens is of about 10.4 years lower than that of their wealthier peers; the corresponding difference for women is 8.4 years. Furthermore, poor people suffer from chronic degenerative diseases at an earlier age than better-offs. Poorer men and women have a „healthy life expectancy“ that is more than 14 and 9 years respectively, below that of their wealthier counterparts. Social inequalities between the rich countries of the North and the poor countries of the South are causing differences of up to 30 years in terms of life and healthy life expectancies.
Within market societies, income and money not only mean purchasing power but also participation in social processes such as living and socialising, education and nutrition or leisure and sports. All these aspects of life affect health, positively and negatively. People with more money have more opportunities to participate, more creative freedom, possibilities for self-empowerment/self-determination/autonomy. People with low incomes are prone to health risks and have less access to health resources which leads to a less mindful attitude towards themselves and a riskier health-related behaviour. Though, behaviour-related lifestyle factors cannot fully explain socially induced inequalities in health and life expectancy. All the rest is directly attributable to different opportunities in terms of livelihood and participation. The opportunities for moneymaking, however, depend heavily on occupational status and career which in turn depend strongly on education.
On the lower levels of the working world the salary potential is low and both the jobs themselves and the working conditions hold an above average risk of disease. Right from the start, training, income and occupational status represent important factors for a successful and healthy life. Children of poor families face more and less predictable emotional, cognitive, social and material obstacles on their way to becoming an adult. Their lives are characterised not only by a lack of money, but also of self-confidence, positive experience and trust in the reliability of mutual support.
In Germany, the correlation between wage and health diminishes above an income of about €30,000 per year and person. Above this threshold, health and life expectancy no longer rise with the salary – exorbitant salaries have no positive impact on health. Though, the more unevenly distributed the salaries are, the more detrimental the effects on the lower classes are. Wealthy citizens in more equal societies are happier, or as the British social epidemiologist Richard Wilkinson, put it: More equal societies almost always do better.“ Social inequality is a challenge for both national and global health policy.
Good jobs, bad jobs
In Germany as anywhere in the world, the trend to subordinate well-being and health-related opportunities of the working population in the pursuit of profit and economic growth intensifies the effects of social inequality. In global competition, low wages, exploitation and the associated working conditions that cause people to become ill, job uncertainty as well as weak trade unions are rated as positive location factors. These have, however, considerable negative impact on the health of the people involved. The situation is even worse for people with no paid work since they are confronted with substantially higher health risks and lower life expectancy. The health risks for the 21 million forced labourers – with nearly one million in the European Union (EU) - and the 215 million child labourers worldwide are hardly predictable. Stressful, unhealthy and exploitative working conditions go hand in hand with other risks of the 21st century such as the deterioration of environmental conditions and increasing social inequality. In its „Decent Work Agenda“ the International Labour Organisation (ILO) has set standards and priorities for the shaping of decent living and labour conditions worldwide.
The „Platform for Global Health” calls for an end of unbridled market policy and neoliberal ideology and their disease-causing effects. What is needed is a responsible, democratic control of the world economy that addresses economic, social and ecological aspects and acts as a harmoniser between the different interests. An interdepartmental health strategy must focus on the universal observance of fundamental labour rights and decent work for everyone. To achieve this, it is necessary to critically review the ideology of growth, promote better income distribution, and put an end to mass poverty and to reduce inequality within countries and between nations.
Social security
Germany is regarded as the cradle of comprehensive social security systems and seen globally as a still successful model for universal social security. A fact the German government is referring to when it calls for to fundamental socio-political values in international fora: „When it comes to values such as social security, solidarity and universal access to high-quality health services Germany is, based on its own experience, particularly credible in a global context.“ (BMG 2013: 12). Indeed, Germany, as most of its EU neighbours, is among the countries that guarantee comprehensive social security for their citizens and have been campaigning for better social security on the international level over the past few years. The German export hit „Universal Social Security“ is becoming less convincing given the current developments in Germany, however. The neoliberal inspired ideology individual responsibility is increasingly replacing the traditional pillars solidarity and social distribution.
Furthermore, the current crisis policy/management of Germany and the EU is raising doubts about the wholeheartedness of the commitment to comprehensive social security systems. Germany's policy within the EU and its rigid austerity measures, with respect to crisis-ridden member countries contributes considerably to undermining existing social and health systems. The attitude towards Greece for example where every third citizen is no longer covered by sickness insurance is in total contradiction to Germany's international debate.
The „German Platform for Global Health” understands that universal social security is the right of everyone to medical care in case of need and the protection against excessive financial burdening. The responsibility to guarantee the human right to social security lies with the state. The commitment to universality should translate into a clear engagement for the promotion of social security systems within the EU and on the international level.
Food sovereignty
The hunger in the world constitutes a serious threat to global health. Malnutrition and malnourishment increase vulnerability to disease and cause early death. Hunger is an obstacle to healthy physical and mental development; it hampers the potential of the individual and thus the economic and general development of a country. All this has led to a vicious circle of hunger and poverty. Food sovereignty and access for everyone to sufficient food is thus, an indispensable pillar for global health.
The lack of food that persists in some regions of the world is not so much a consequence of draughts or other natural disasters, however alarming as it may be, but rather of unequal global incomes and their distribution. Even today the existing agricultural production capacities would be sufficient to nourish a world population of 9.2 billion people that is predicted for 2015. This is, however, thwarted by an agricultural model that aims at maximum private profit rates rather than on food sovereignty.
In order to guarantee food supply for everyone, the export oriented and industrialised agriculture, which dominates today, must be replaced by a production concept that relies on non-industrial farming for regional markets. Food supply for the world population does not require massive use of artificial fertilisers and agro-chemicals or intensive animal husbandry and genetic engineering. The solution is not cheap mass production of frequently nutritionally poor food for the world market but autonomous and sovereign access to seed, knowledge and machinery for all agricultural producers.
Thus, striving for global health means to (re)install a food sovereignty that does not solely focus on calorie intake. Actually, food sovereignty means to guarantee both biodiversity and the multiplicity of food provision, to prevent soil compaction and land degradation and to address the health damaging effects of agro-chemicals. Furthermore, focus must be set on monitoring genetically engineered food that is increasingly threatening food sovereignty. The industry, as such, is characterised by an oligopoly; all farmers that get involved in growing genetically engineered crops rely heavily on huge multinational groups such as Monsanto and Syngenta that will levy licence fees for every new seed or modify their products in way that they are no longer suitable for renewed sowing.
Because of unequal market power, any further admission of genetic engineering in agricultural production will contribute to the on-going destruction of regional agriculture worldwide and thus, reproduce hunger and malnutrition and the associated negative impact on health. Though it will be the poor countries of the South that are primarily affected, the consequences may reach far beyond their boundaries since the long-term impact of genetically engineered food on man and animal still is widely unknown.
As long as industrial food is traded on international markets, global health policy requires efficient control and targeted strategies to avoid health-damaging effects caused by mere commercial interests. The trade with soft drinks and sugary foods has substantially contributed to obesity and non-communicable diseases in both poor and rich countries. Subsidised exports of European powdered milk, poultry and tomato paste destroy local markets with dumping prices; the outcome is even more hunger. Due to inadequate regulations for international trade, problematic slaughterhouse waste, that otherwise should be disposed by the polluter, are profitably sold to the poor countries of the South. In all these areas, international action is needed.
Trade and taxation policies
Global health policy must strive for adequate regulations on trade as well. The international exchange of goods and the associated international division of labour including the outsourcing of jobs to countries with low-cost labour, inadequate labour and environmental standards, are of vital importance to global health. The damage to health caused by international business is immense and becomes evident not only in the textile industry, where serious accidents continue to occur. In other globalised sectors such as raw materials, goods and services, the working conditions are characterised by modern slavery, violation of human rights and, in every aspect, health damaging labour conditions.
A serious commitment to global health must not turn a blind eye to the health risks that arise from the internationalisation of production. Important steps towards a better global health would be to link imports to compliance with labour standards in the producer countries and an adequate participation in the value-added chain of the workers in the South through fair salaries. To achieve this, the German government has to intensify its extra-territorial state obligations in the case of human rights violations by transnational groups with headquarters in Germany.
The European Partnership Agreements are a source of major health risks, as they urge the countries of the South to open their markets and to renounce their import duties. Such free trade agreements contribute to social disruption in the countries of the South. If traditional sectors of the domestic economy are no longer able to compete with cheaper, sometimes subsidised goods such as agricultural products, the economic performance decreases, triggering a precarious combination of shrinking salaries, de-industrialisation, uprooting of labour, budget bottlenecks and other growth-hampering effects. Thus, free trade agreements restrict the margin for a fiscal manoeuvre of poor countries and obstruct public investments in the infrastructure, economic development and social services including health care. This has immediate impact on livelihood, the social determinants of health and the efforts of many developing and emerging countries to promote universal social health protection despite shrinking budgets.
Political communities can only fulfil the obligation to implement the right to health if their fiscal conditions allow it. The funding of health requires effective taxation that includes, besides the taxation of global profits, shutting down tax oasis and fighting tax evasion respectively the competition in the field of tax dumping. On the international level, for example in the current treaties about international taxation, coherent global health policy must push for the implementation of necessary regulations.
The WHO tobacco convention illustrates exemplary how global health policy can tackle health risks that are caused by global trade. Comparable international regulations are needed in the field of trade policy in order to facilitate the implementation of national taxation on health damaging products and their advertising and to restrict imports of health damaging goods or food such as soft drinks.
Disease management
Drugs and medical engineering play a crucial role in the treatment and the prevention of diseases worldwide. At the same time, they stand for powerful economic interests and high profits. Since product development in the pharmaceutical industry is more focused on profit expectations than on medical need, products are put on the market even if they have no apparent therapeutic value. At the same time, one third of the world's population has no access to fundamental drugs. Poor countries with fewer resources are suffering most from the irrationality of the pharmaceutical market. High prices for some important products such as AIDS medicines, run over available budgets because drugs are subject to twenty years of protection by patents, a regulation imposed by the World Trade Organisation upon pressure of the big pharmaceutical groups.
If profit interests and shareholder's expectations determine the behaviour of the „health economy“ medical products are likely to cause more damage than benefit to global health and unnecessarily increase the spending pressure on publicly financed social security systems. Global health policy must prevent drugs and medical products from becoming play balls of transnational pharmaceutical groups and must guarantee access to affordable medicine. Every attempt to prolong patent and data protection for drugs through bilateral agreements with poor countries is an attempt to undermine multilateral agreements and thus, jeopardizing the efforts to improve global health. The current patent system is a strategic means for economic predominance and needs substantial reforms.
Global health policy must push for reforms of the prevailing research paradigm. The existing patent-based research concept that is refinanced by public and individual spending for health is an obstacle to systematic research on the health requirements of the poor. The proposal to make research and development of essential drugs a public task financed by public funds that has been launched by a WHO expert group could be a solution. Public funding of research that aims at promoting public welfare rather than the industry encourages a turn away from the development of expensive „pseudo-innovations“ with questionable benefits towards a concept of research that focuses on the treatment of the globally predominant diseases. Alternatives for research, admission and patent models require more public interference in drug research – not only because of the prevailing public interest but also because it is merely funded by public health systems.
The pharmaceutical industry is by no means the only source of highly health damaging German exports in the field of health care. Private health insurers have been supported in their attempt to enter the markets in developing and emerging countries even before the conservative-liberal government (2009 – 2013) came into power. However, only a minority benefits from private providers, whereas universal protection, , is only possible through public funding. Private health insurers and financial groups behind them challenge global health by preventing social justice and redistribution and by impeding universal protection.
Migration of health professionals
The lack of skilled health care workers is an increasing problem. In Germany, the shortage refers particularly to nurses and geriatric nurses. Hiring medical staff in the East and the South can remedy the situation. The German government and employer's associations are increasingly recruiting health workers from Vietnam, China, Tunisia, the Philippines and poor or crisis-ridden EU countries. In this context, it must be mentioned that there are ten times more health workers per person in Germany than, for example, in Vietnam.
Government/state- promoted recruiting agreements between rich and poor countries encourage the worldwide migration of physicians and health workers. The Platform appreciates the compliance of the German government to international standards and WHO recommendations as well as the high profile the concept paper gives to the WHO Global Code of Practice on the International Recruitment of Health Personnel (WHO 2010). In doing so, the government is particularly committed to the obligation not to recruit health workers from countries that face a critical shortage of health care professionals (BMG 2013: 20).
Though, it is striking how little interest is shown in both, the paper and the political debate in Germany, to another essential aspect of the WHO code. Apart from regulations to control the migration of health care professionals, the Code also addresses that international recruiting is to be kept low by providing health training for local staff (WHO 2010, page 5). In the meantime, caring professions in Germany have become so unattractive that employers have to recruit health care workers on the global market that are prepared to accept the increasingly deteriorating working and income conditions. This development was among other things induced by the introduction of fee-per-case systems that force hospitals to adopt an entrepreneurial logic.
Responsible global health policy must not turn a blind eye to the fact that the shortage of health workers in Germany is home grown and has to be solved primarily on the domestic labour market. Recruiting professionals in other countries endangers appropriate medical care in their home countries and is thus, jeopardising the essential human right to health and universal access to health services to which the German government has committed itself (BMG 2013: 2). It is mandatory, that the occupation of professional staff from the countries of the South require compensation by providing medical equipment and other kinds of support in order to strengthen the health systems in the home countries of the recruited workers and to improve the working conditions for the health care workers at home.
Climate change
Doubtlessly, climate change and global warming that are causing increasing dangers of extreme weather events such as storms, heat waves and rising sea levels are among the major hazards to global health. Such extreme events are threatening above all those that are less responsible for climate change. Particularly, the poor in the developing countries have been pushed into the most endangered areas such as floodplains and slopes. Danger to life is most pronounced in areas where infrastructure, disaster management and other protective measures are missing and where, in the case of disaster, infectious diseases can spread rapidly. Global warming and climate change are threatening the success in the field of health that has been achieved over the past century.
Heat waves and draughts endanger the lives of millions of people and transform fertile soil into deserts. High temperatures are expanding the habitats of mosquitoes and thus giving rise to Malaria or Dengue Fever for which up to now neither immunisation nor causal therapies are available. Rising sea levels will enhance flight and migration to moderate climatic zones – such as Germany.
Coherent global health policy requires immediate action. Unfortunately, the contrary happens as previously agreed climate protection goals are postponed and weakened. Efforts must aim at drastically reducing CO2 emissions as well as other pollutant emissions. As a contributor to climate change, Germany carries a particular burden of responsibility. Therefore, it should not only provide technical and financial support for poor countries for example in the field of early warning systems and management capacities but also push forward efforts to transform its own environment threatening economy. This includes providing alternatives to the current growth strategy on the agenda of a global health policy.
Nuclear and energy policies
In this context, energy production is an essential topic. The use of fossil fuel and the associated major damage to the environment and health has been a global problem for many years. Air pollution in the north of China has shortened the life expectancy of the population by five years. Processing, enrichment and reprocessing of uranium for military or civil purposes generate large quantities of radioactive waste that frequently ends up in the sea. The uranium deposits in developing and emerging countries such as Brazil, Niger or Tanzania are exploited under conditions that show no attempt to avoid either damage to the environment or to the health of the workers and their descendants. The accidents of Chernobyl and Fukushima are only the top of the iceberg; the list of disasters caused by nuclear energy production is long. Moreover, it remains completely unclear what to do with nuclear waste, which will impact the health of generations worldwide.
The Platform welcomes Germany's decision to exit from nuclear energy as an important step in the promotion of global health. Other countries should follow the example in order to limit the damage to health caused by radiation worldwide. Thereby, Germany must assist other, financially weaker countries in particular, with funding and technological know-how in the dismantling of nuclear facilities and the conversion of their energy supply towards renewable energies.
The conversion from nuclear energy to fossil fuel as in the case of coal-based power production would be the wrong track not only from a health policy perspective. Exploitation and trade of coal in the countries concerned would not only contribute to air pollution but also prolong health damaging and economically unnecessary mining business and transports. Because of the massive impact on the environment and global health it is essential to exit from both fossil resources such as coal and nuclear power and to emphatically promote renewable, relatively environmental and health friendly resources.
In the context of global health and nuclear energy, attention must be paid to the role the military use plays. Over the past seven decades, more than 2,000 nuclear weapons tests have covered the globe with nuclear fallout and caused the number of cancerous diseases, malformations and miscarriages to surge, particularly in the surroundings of the test areas. Though, even civil use of nuclear energy hazards health, a significant increase in the rate of leukaemia among exposed children was observed.
Armament and war
Wars, armed conflicts and weapons of any kind pose substantial risks to physical integrity and thus to health, but nuclear weapons are not the only cause for this problem. Every year, small weapons kill and hurt between 50,000 and 100,000 people worldwide; the number of injured people is difficult to estimate. Indirect detrimental impact on health arises from the disastrous effects of armed violence on infrastructure, working and living conditions, food supply, and health care and not least from psychological strain. Economic damage caused by armed conflicts and wars amounts to hundreds of billion euros every year. In addition, there is a spiral of violence with a terrifying number of victims, traumatised population and civil wars as well as states that are pulverised by internal violence.
Germany has a particular responsibility for peace not only since the end of Second World War. As the world's third-largest (even second-largest in terms of small weapons) arms exporter Germany has the obligation to restrict if not to stop the trade with arms. The truth is, however, that the value of German arms exports has been rising for many years, independently of the current party in power. Weapons are supplied not only to „friendly” countries but also to countries with a questionable human rights situation or armed conflicts such as Mexico, Saudi Arabia and Libya.
Global health policy must not restrict itself to verbal claims for peaceful solutions. German could contribute to effectively improve global health by establishing an armament conversion programme that completely renounces arms exports, restricts armament spending, prepares the exit from weapons production and allows for the about 80,000 employees to switch to other economic sectors.
Germany also has the power to influence the treaties on nuclear non-proliferation and disarmament. The strategy of peacekeeping through nuclear deterrence based on the still existing approximately 20,000 atomic bombs - which would, if unleashed, cause unpredictable humanitarian and health-related consequences - reduces itself to absurdity. Not least because storing, guarding and maintenance of these weapons devour several billion euros.
Migration and illegality
The Platform appreciates the commitment of the German government to universal access to security in health. However, such a commitment should translate in the government's policy. To this effect, Germany has still further to go as even in rich Germany, not everyone has equal access to medical care. According to the Asylum Seekers Benefits Act, undocumented migrants are entitled only to emergency medical aid; anything beyond needs a health insurance voucher from the social security office. Authorities, unlike schools and other educational institutions, are obliged to report every irregular stay of non-citizens thus, it is impossible to achieve this in practice. The reporting obligation poses a substantial obstacle for the people concerned to claim their right to medical care.
Such a regulation is unknown in other European countries. The UN Human Rights Council has repeatedly blamed Germany for this behaviour, as it constitutes a violation against the general prohibition of discrimination. In 2012, the Asylum Seekers Benefits Act was deemed unconstitutional by the Federal Constitutional Court and many civil society actors as well as several governments of the states have claimed the abolishment of the act. The decision of the government on cancellation or new version is overdue.
Even migrants from EU member states who stay legally in Germany frequently have no access to the health system. Those who have no employment subject to social security contributions or are not able to pay for health insurance themselves are excluded from the German system. Theoretically, non-German citizens may settle the costs for health services through the health insurance systems in their home countries but this is mostly not practicable. Furthermore, there still is legal uncertainty in terms of security entitlements with respect to citizens of the European Union since authorities and advisory offices differ in their interpretations of regulations. Thus, many migrants that live in Germany depend on parallel structures that cannot ensure adequate health care.
Democratisation of the WHO
As the guiding and coordinating special organisation for health policy of the United Nations the WHO has the public task/mandate to ensure the realisation of the universal right to health. Though, chronic under-funding has massively contributed to substantial structural problems over the past few years. The de facto freezing of the WHO budget since the 1980s was caused, in the first line, by the rich member states. Since mandatory contributions currently make up only for one quarter of the total budget, the WHO has become dependent on private donors. In the meantime, a large number of public and private organisations such as Global Funds against AIDS, Tuberculosis and Malaria (GFATM), several public and private Partnerships or the Bill-and-Melinda-Gates-Foundation joined the terrain of global public health. This leads to a fragmentation of health policy and opens the gates for partial and profit interests.
Adequate, public, democratically managed funding, which is dedicated to common good is the basis of the WHO. The Platform expects the German government to reinforce its commitment to the WHO as „the centre of the engagement of the German government in the area of global health policy” (BMZ 2013: 10) by increasing its mandatory contributions and consequently campaigning for a democratic reform. The efforts should enhance the potential influence of critical social societies and to allow more participation. Only as an independent organisation with a clear public mandate, the WHO will be able to fulfil its constitutional obligation to ensure the human right to health.
Conclusions
In our globalised world, global health policy is a crucial and complex cross-sectional task. It is encouraging that the interrelations in the field of health have increasingly moved into the focus over the past few years. And it is also encouraging that the German government has responded to this challenge by publishing this concept paper. Though, the paper also demonstrates that much work still needs to be done to achieve a comprehensive understanding of health policy and to establish appropriate structures to improve global health. Proposals that are based on particular national and economic interests that disregard essential influencing factors offer no promising solutions for urging global health problems such as rising non-communicable diseases, impact of climate change on health or the widening income gap.
With the appropriate political determination of the involved ministries, the concept paper of the German government could have been far more comprehensive. The facts and many of the correlations are widely known. If the German government had considered long existing social-epidemic knowledge, fundamental findings of public health sciences and the experience of civil society actors from trade unions, social associations or development organisations the concept would have been much closer to meet the complex challenges of the issue.
It is out of the question that the German government could have done better, not least with a view to the treaties about future development and sustainability goals as from 2015. What is needed is a coherent concept that is less focused on particular interests in order to put more emphasis on health goals and to implement sustainable strategies for achieving these goals. A forward-looking global health policy that pushes for at a good life for everyone and simultaneously takes preventive measures against health risks would demonstrate that Germany is serious in its programmatic desire to assume more global responsibility in the future.
Even though a chance could be wasted in view of the current post-2015 process, the „Platform for Global Health” has no doubt that the path taken is moving in the right direction. What is needed, however, is a clear commitment to a human rights approach that does not understand health as a profitable „business model” but as a right every human being is entitled to. The current crises in health policies are not least attributable to an „imprisonment” in attitudes and convictions that merely prolong and not overcome problems. As Albert Einstein already pointed: „No problem can be solved from the same level of consciousness that created it”.
„Global Health Policy for Everyone, Everywhere” was written by the Deutsche Plattform für Globale Gesundheit (DPGG)
In 2011, several German civil society health care actors formed a platform for global health with the objective to raise public awareness for the close links between global and local health-influencing factors in view of the increasing internationalisation of living conditions and, to pool existing efforts and to participate in the German decision-taking process. The platform, which is composed of trade union members, social organisations, development and migration policy organisations, scientists as well as social projects and movements, does not consider itself a new health or development lobby group but an interdisciplinary initiative that aims at bringing the social conditions for health more sharply into the focus of national and international discussions about health. Moreover, the platform wants to strengthen national and international initiatives and help to overcome the still existing discrepancy between domestic and global health policy.
Signatories:
• Attac working group Social Security Systems
• Dr. Anja Dieterich, Diakonie Deutschland – Evangelischer Bundesverband.
• Health Workers for All
• Dr. Dr. Jens Holst (Health Care researcher and consultant)
• International Physicians for the Prevention of Nuclear War (IPPNW)
• medico international
• Prof. Dr. med. Oliver Razum, Dean of the Faculty for Health Sciences, University Bielefeld
• Prof. Dr. Rolf Rosenbrock, Chairman of the Paritätischer Wohlfahrtsverband
• Verein Demokratischer Ärztinnen und Ärzte (VdÄÄ) (Association of Democratic Physicians)
• Verein demokratischer Pharmazeutinnen und Pharmazeuten (VdPP) (Association of Democratic Pharmaceuticals