medico networks globally with health actors to establish global legislative frameworks. An overview of movements, networks and platforms. By Thomas Gebauer
Liberalisation of international flows of goods and capital, depletion of natural resources, climate change, steadily growing inequality of income and wealth – all these affect people's health, whatever country they live in. It is not surprising, therefore, that politicians, scientists, journalists and civil society actors today are talking more and more about global health. Admittedly, closer examination reveals different interpretations and diverging interests at work. Governments mostly understand global health as a bundle of measures to protect their own population, e.g. against pandemics, or to promote exports of health products from their own countries, while medico and its partners emphasise the universal dimension of health, as set forth in the human rights conventions.
The goal is to give everyone access to the best possible health care, a goal set by the World Health Organisation at the time of its foundation in 1948. To achieve this goal, health must be understood as a global common good, which can only be achieved through global responsibility. A global health policy must not be allowed to peter out in charity. It must not be concerned solely with care for the poor, which has dominated conventional development policy, nor with efforts motivated by security policy to keep the poor and their health problems away from the prosperous parts of the world. The goal medico has set itself is health for all – global health.
Poverty makes people sick, and disease makes them poor. Based on this recognition, medico published ideas back in 2001 for multinational solidarity-based health financing. Since then, we have systematically developed our ideas and expanded our concern with issues of global health into a practical focus. Even today, 100 million people a year slide into poverty because they do not have insurance and must pay for health services out of their own pocket. To break this vicious circle, access to health must be made independent of private wealth and purchasing power. The idea that medico came up with in 2001 involved 'global financial equalisation', a binding mechanism under international law which uses mandatory contributions by rich countries to ensure adequate financing of health services for poorer countries as well.
Something which was provocative at the time and evoked a sympathetic grimace from many official development policy representatives is now a key issue in academic discussion and, increasingly, international policy. The idea of solidarity-based health financing has now reached the deliberations of the UN General Assembly, and just recently the World Bank Director for Health, Nutrition and Population indicated that in the long term there would be no way around international financial equalisation guaranteed by international agreements. This willingness to consider a paradigm shift in health financing, which to date has been driven by special interests, didn't just happen – medico has worked together with others for years to bring this about. Pushing for structural changes requires persistence and capable allies.
Since global responsibility is nothing more than a fine-sounding phrase without the legal framework, medico is working with health activists, international lawyers and public health institutions from all over the world on a Framework Convention on Global Health. A convention like this, based on the principles of universality, solidarity and democracy, is the only way to establish in binding form what global responsibility for health means. The goal must be to give the universal right to health priority over commercial special interests, creating the conditions for every person everywhere in the world to live in conditions which make possible the development of an autonomous and democratically-constituted health service. The first initiative for a Framework Convention on Global Health, which medico was part of from the start, has now become a platform with worldwide activities, which published its principles in 2013.
We can only talk of universal access to health services when there is health care for those who cannot care for themselves. Solidarity-based financing is the prerequisite for what is being debated today worldwide by health care policy makers and activists under the heading Universal Health Coverage (UHC). However, many medico partners in the South fear that their governments see UHC as merely a form of health care for the poor, under which poor people are fobbed off with minimal services and the private insurance sector profits from this. Together with Medicus Mundi International (MMI), a network of health organisations active in development policy, medico issued a critical report on UHC in 2013 which lists the risks and opportunities of the concept.
Not the least reason for taking a critical look at universal health coverage is that the idea could become one of the post-2015 development goals currently the subject of international negotiations as a replacement for the Millennium Development Goals. However, it is already clear that the heads of state and government will only agree on pragmatic goals at the end of the post-2015 process. For example, they will use medical and pharmaceutical inputs to combat individual diseases such as diabetes, but not attempt structural prevention by regulating the internationally-active food and beverage industry.
Future development goals must be anchored in human rights, as medico jointly emphasises with Go4Health, a global network of grassroots organisations and research institutes. To achieve an appropriate and socially equitable basic health service, structural interventions need to make possible social redistribution and democratic participation. Go4Health has taken on the task of developing indicators to capture fundamental changes like these. An interim report was presented in Copenhagen in 2013.
Social change needs an active public, and this also applies to implementing the right to health, which activists and social movements all over the world are fighting for. However, the maxim from the environmental movements – think globally, act locally – has yet to find strategic value in the struggles for social rights and democracy. In contrast to economic globalisation, as a result of which the subjugation of people and nature to the dictates of exploitation and political control has been extended to the furthest corners of the earth, the project of creating an independent transnational public which could effectively support an alternative global health policy is still evolving.
To promote this process, medico has in the past few years repeatedly brought together health activists from all over the world in workshops. The first meeting in Delhi was followed by a second in Rome in 2013. One of the goals was to develop joint transnational strategies, but in the process the activists discovered far-reaching differences in the understanding of central concepts such as human rights, solidarity, common goods, participation etc. In order to establish a transnational health movement, it is accordingly necessary to start by developing a common language – a process which has just begun.
At one of the workshops we arrived at the formulation 'Global governance for health starts at home' – but as decisions on the global framework for health are still made at the level of the nation state, a commitment to global health naturally also requires tackling the policies at home in their individual countries. To promote public awareness in Germany of the close cooperation between global and national health, a medico initiative led to the creation of the Deutsche Plattform für globale Gesundheit (German Platform for Global Health) in 2012 by staff of social associations, trade unions, development organisations, universities and social movements.
Joint learning processes are also needed to develop policy alternatives and common strategies. How far these can go is shown by the platform's recent response to an interministerial concept for 'Global Health Policy' submitted by the German Federal Government in 2013. In contrast to the Federal Government's concept, the platform emphasises the need for an international structural policy giving priority to universal human rights which also ensures regulation of special – i.e. commercial – interests.
Health policy must not be restricted to treating symptoms, but must tackle the causes of poverty and disease. A comprehensive, interdisciplinary understanding of health which takes adequate account of the political determinants of health is the only way to meet the complex and dynamic requirements of global health.