Navigation – Plan du site

Global Governance for Health

José Roberto FERREIRA, Claudia HOIRISCH et Paulo Marchiori BUSS

Résumés

Les auteurs abordent la question de la gouvernance en matière de santé sous une perspective critique, ayant comme axe la mondialisation. Ils discutent la question de la gouvernance en matière de santé ayant pour base la tendance de stimulation à la production/consommation mondiale selon les intérêts des pays développés. La crise euro-américaine et la façon par laquelle le multilatéralisme est mis en œuvre, contribuent pour perpétuer « le statu quo » et rendre difficile des changements de la gouvernance mondiale au profit de l’équité sociale et de la santé. Ils soulignent également le rôle des sous-crises financière, sociale, environnementale, climatique, alimentaire, sanitaire, éthique et du développement lui-même, dont le suivi peut générer des recommandations à propos de la gouvernance mondiale en matière de santé. À la recherche d’une gouvernance adaptée à un « développement équitable » à l’échelle mondiale, ils proposent une révision approfondie du rôle de l’Organisation des Nations Unies, à partir d’une approche plus intersectorielle, mettant en cause, en particulier, la réforme qui est en discussion à l’OMS et attirant l’attention sur le besoin de promouvoir une articulation plus efficace entre l’État, le secteur privé, les travailleurs et la société civile en général. Et pour conclure, des réflexions qui indiquent les stratégies qui, dans le contexte de la mondialisation, peuvent produire des changements dans les déterminants sociaux, dans le but d’avancer en direction d’atteindre mondialement une plus grande équité en matière de santé.

Haut de page

Texte intégral

Introduction

1Human health is undoubtedly the result of complex biological and socio-historical process. It is profoundly conditioned by the so-called « social determinants of health ». This area acknowledged set of factors that are distributed according to the social gradient, rendering health inequities as the basis for health problems and for the situation of individual and public health. To act effectively on human health and attain positive results it is necessary to address the social determinants of health which are of a political, economic, social, cultural and also environmental nature (Buss, Pellegrini, Filho, 2007), and are strongly influenced by the processes of production and consumption (Buss et al, 2012).

2These influences are exerted by the complex processes that develop in all the dimensions mentioned above under « socio-geographic territories » where the populations live. For this reason, human health is influenced by political, social and economic processes at local, national and even global levels.

3These processes generate significant evidence, which, among others, include consensus that the mode of development (mode of production and consumption, distribution of power, money and resources) is the basis of social and health outcomes. These are characterized by social and sanitary global inequities between and within countries, becoming « the causes of causes » as stated in the document of the Commission on Social Determinants of Health (CSDH, 2007).

4On the other hand, as the basic document of the Lancet-UiO Commission points out, the way in which the “global governance” of the sectors that have an impact on global governance for health is organized is as important as the internal governance of the sector, namely « global health governance » (LANCET, 2011).

5This paper is a critical thinking that highlights some important aspects to be considered in the current debates on a controversial and political subject, namely “governance in health” and suggests ways to move forward.

The status of « global governance for health »

6The current global changes (and challenges) include, among others, the displacement of populations, goods and services, monetary resources, ideas and information in such a way that they intercept or even transcend the geographical boundaries (known as globalization) as well as global environmental change, such as climate change and desertification. All of these dimensions and others have a strong influence on the living and health conditions of people globally and within any country.

7One should avoid trying to understand this complex process, and initially examine its component parts. The expression of its various parts results in the whole which is explained by the profound structural crisis of the capitalist industrial civilization itself that affects the world today, with its productivism and consumerism, driven by the incessantly growing accumulation of wealth. The goal of business growth at any cost was favored by liberalization, deregulation and flexibilization, all the while dismantling the inherent capacity to promote rights and the regulatory ability of States. The result has been the coexistence of excessive abundance with extreme poverty, with major repercussions for human health and the environment.

8The social justice agenda (which does not go as far as changing the causes of injustice) was relegated to the so-called Millennium Development Goals (MDGs).These consist of eight points, which in addition to not being very ambitious, are restricted to just three in the area of health dealing more specifically with disease, whereas in fact almost all of them are strongly linked to living and health conditions, highlighting in particular the importance of the reduction of poverty. Thus, the post-MDGs phase will not lead to compensatory policies, but to the political will to change the way societies, their economies and distribution of power, resources and money are organized.

9At the global level, there are forces at play that are organized according to dominant modes of production and consumption², the complexity of which needs to be carefully analyzed in view of the powerful influence they have on development and human and environmental health in each and every one of the countries.

10Multilateralism, represented by the United Nations has been increasingly depleted while the G8 has grown in importance, under the leadership of some of the most developed countries. In the midst of the crisis, there emerges the G20, an expansion of the closed club of world power of the G8, which does not change the essence of the asymmetry of power and the domination that it fosters. The most important guidelines on other mega-players on the global scene emanate from the G8 and the G20: World Bank (WB), International Monetary Fund (IMF), World Trade Organization (WTO), World Intellectual Property Organization (WIPO) and some others.

11The governments of developed countries for their part have been more concerned with solving the crisis of private financial capital, established since 2007 and the eradication of speculative capital that is now occurring on the stock exchanges around the world, than with the multiple sub-crises arising from the aforementioned structural crisis. These are the crises of climate, food, sanitary, unemployment, living conditions, political and ethical values, which are affecting billions of people around the world.

12The developing world, for its part, is of little or no account as usual. It has been manipulated in accordance with the economic interests of the major powers, limited in general to providing cheap labor, basic consumer goods and markets, commodities necessary for the transformation industry of the developed countries and space for the dirtiest and most pollutant work.

13Inequities in health possibly constitute the most important challenge facing global health that persists in spite of the increase in funding and foreign aid programs. Despite the governments of sub-Saharan Africa doubling their spending per capita on health in the period from 2000 to 2008, international aid for health increasing from US$ 6 billion in early 1990 to US$ 10 billion in 2000 and rising to US$ 27 billion in 2010; despite various programs being introduced including the Global Fund to Fight AIDS, Tuberculosis and Malaria and bilateral programs such as the U.S Global Health Initiative and others, these combined efforts failed when dealing with the unfair distribution of the burden of disease (Gostin, 2012: 2087).

14The rise of some emerging power blocks, such as the BRICS– Brazil, Russia, India, China and South Africa −might eventually bring more negotiating power that could change the situation, especially with the financial crisis that is now spreading into other areas. However, these emerging economies do not alter the dominant paradigm, as they focus their ambitions on rapid growth at any cost, with socio-environmental and health impacts, making them part of the problem instead of the solution. On the other hand, major differences between countries involved in this initiative, and marked inequalities in each of them, can be an additional hardship.

THE GLOBAL ECONOMIC AND SOCIAL CRISIS AND HEALTH: PRELIMINARY CONSIDERATIONS

15Among the forces present in the prevailing mode of production and consumption one finds the concentration of wealth and power in the central countries of global capitalism and in major transnational corporations, which are no longer confined to the traditional boundaries of nation states. The Euro-American economic crisis of 2008, which has yet to reach its climax, is a perfect example of this issue. It started in the real estate and financial markets in the United States and Europe, turned into a crisis of sovereign States due to the crisis rescue of some powerful financial institutions in the private sector, which in turn led to a crisis in the public sector. In other words, profits are privatized and losses are socialized.

16One of the worst consequences of the Euro-American crisis, transformed into a global crisis due to the inherent nature of markets, was brutal unemployment, which afflicts a multitude of nations, with the impressive and well-known detrimental effects on human health.

17Also the food and environmental crises, both with powerful influences on human health, underscore the need to identify effectively where global governance of these two dimensions lies and what their tendencies and orientations are. The tracking of these specific sub-crises may provide clues and generate recommendations on the governance of modes of production and consumption that underpin it.

Some proposals for action

18The United Nations will review the MDGs in 2015, which will possibly redefine the agenda for health and development in the coming decades. There is a global coalition of civil society and academia in the south and north -The Joint Action and Learning Initiative on National and Global Responsibilities for Health (JALI) - , which advocates a Framework Convention on Global Health (FCGH) (Gostin et al, 2010). It was recently endorsed by the UN Secretary-General and JALI will rethink global governance for health, offering a new post-MDGs vision. Although creating a bold global health treaty, it is an enormous task that may start as a « soft » non-binding legal instrument, namely a Framework for Global Health (Gostin, 2012: 2088).

19The objectives of a Framework Convention on Global Health are: to define State´s responsibilities for the health of their populations; to define the international responsibilities to provide sustainable funding; to stipulate global health priorities to improve health and reduce inequities; to coordinate fragmented global health activities; to redefine Global Governance for Health and ultimately provide strong global health leadership (Gostin, 2012: 2088-2091).

20To play a positive role in global governance and achieve outcomes in health, it will be necessary to concentrate on the field of « equitable development » between regions and countries, as well as within national societies.

21In order to achieve this, it is necessary to forge a new political pact around are formed United Nations, with the broadest and most fluid connection between its various agencies, some of which could be closed down, with their functions transferred to other similar agencies. In the specific case of health, it makes no sense for there to be the World Health Organization (WHO), the Joint United Nations Programme on HIV/AIDS (UNAIDS) and The International Drug Purchase Initiative (UNITAID) – an international facility for the purchase of drugs against HIV/AIDS, Malaria and Tuberculosis – the last two initiatives, for example, to treat a single disease, namely AIDS. The restructuring of the United Nations would reduce its expensive bureaucracy and increase its effectiveness.

22Nowadays, the WHO – the main actor in global governance for health –is being profoundly queried, with special emphasis on the reform process proposed by the Member States and to be led by them in a participatory and transparent manner.

23In the draft strategic overview of the Twelfth General Programme of Work of the WHO (2014-2019) « equity and social justice », « global solidarity » and « determinants of health » were presented as general principles and values, which are ​​in our opinion important albeit insufficient guidelines. The programme includes five categories, two of which are based on diseases: communicable diseases; no communicable diseases; health through the life course; health systems; and preparedness, surveillance and response (WHO, 2012a).

24Efforts in the reform process should be guided by the strategic vision of « health and development » and that the « health and welfare of all people should be the driving force and not primarily disease » (WHO, 2012b).

25Throughout the discussions of the reform process there was a dilution of the « health and development » equation as a strategic objective of the WHO, which represents an unacceptable step backwards in terms of the fundamental role that the Organization should play in this field (WHO, 2012c). Moreover, « health and development » not featuring in a work program that covers a period in which, in 2015, the Millennium Development Goals (MDGs) will be revised, seems incongruous and even detrimental to the proposals to keep health as the highest priority on the global agenda.

26The inclusion of a category called « Health, Determinants and Sustainable Development » to address these issues, as well as underpin and guide the work of other sectors of the WHO, UN agencies and Member States is paramount.

27In the operational area, the future should see the update of development planning under the aegis of the State, based on the tripod: ethical and social goals – ecological conditionality – economic viability. There must be a planning capable of articulating a quadripartite cooperation between States – guided by a developmental and non-recessive vision – businessmen, workers and organized civil society. In addition to this, there must be planning linked to the proper functioning of democracy at all levels, from local to national and to the supranational/global.

28It will be very important to articulate programs of international scientific and technical cooperation at the global level, organized under the aegis of the United Nations and according to the « geography of biomes » and not to territorial proximity. It requires the horizontal exchange via the parallels and not via the meridians.

29For this new pattern of political and technical cooperation to expand, the role of the United Nations is essential in the context of a « renewed multilateralism ». This must include a cross-sectoral approach that promotes the development of all the millennium goals, ideally extended to the post-2015 period. Thus, in order to finance a process such as this the United Nations should create an inclusive and sustainable fund for development, which could be financed with the fulfillment of the commitment to allocate 0.7 % of GDP as a contribution to the development of poorer countries (not honored so far by the majority of developed countries). In addition to this there should be the introduction of the Tobin Tax to curb financial speculation and possible tolls on the use of airspace and oceans, charged to airplanes and ships that are using the communal property of humanity (Sachs, I., 2012: 16).

30By way of conclusion in the context of current globalization, we stress the importance of attaining and preserving equity in health, reducing poverty with potential economic restructuring and reorganization of production and the labor market. This should be implemented with innovations in the international community, which include improving and expanding development assistance, debt relief and international trade mechanisms. It also calls for making more resources available for health systems and addressing the social determinants of health.

31This analysis essentially highlights the importance of reviewing the Millennium Development Goals for the post-2015 period in the context of globalization and in light of the current economic crisis and the reforms being discussed at a multilateral level to ensure health governance for an equitable development in the modern world.

Haut de page

Bibliographie

BUSS, P.M., PELLEGRINI FILHO, A., 2007. A Saúde e seus DeterminnatesSociais.Physis. Rev.Saude Coletiva. Rio de Janeiro. Volume. 17. Issue1. Pages 77-93. [on line]. Available from : http://www.scielo.br/pdf/physis/v17n1/v17n1a06.pdf. Accessed 9 July 2012.

BUSS, P.M., Machado, J.M.H. , Gallo, E., Magalhães, D. P., Setti, A. F. F., Netto, F. A. F. , Buss, D. F. , 2012. Governança em saúde e ambiente para o desenvolvimento sustentável. Cienc.SaúdeColetiva. Volume 17.Issue. 6. Pages 1479-1491. Rio de Janeiro. June 2012. [on line]. Available from : http://www.scielo.br/scielo.php?pid=S1413-81232012000600012&script=sci_arttext. Accessed 9 July 2012.

CSDH, 2007. Achieving Health Equity : from root causes to fair outcomes. Interim Statement. 2007.

Commission on the Social Determinants of Health, 2008.« Closing the gap in a generation ». [on line]. Available from : www.cmdss2011.org.Accessed 12july 2012Accessed 9 July 2012.

GOSTIN, L.O., OOMS, G., HEYWOOD, M., HAELD, J., MØGEDAL, S., RØTTINGEN, J.A., FRIEDMAN, E.A., HARALD, S., 2010. The Joint Action and Learning Initiative on National and Global Responsibilities for Health. World Health Report, 2010. Background Paper, 53.[on line]. Available from : http://www.who.int/healthsystems/topics/financing/healthreport/JALI_No53.pdf. Accessed 16 July 2012.

GOSTIN, L. O., 2012. « A Framework Convention on Global Health : Health for All, Justice for All ». Georgetown Public Law and Legal Theory Research Paper No. 12-066. Georgetown Business, Economics and Regulatory Law Research Paper No. 12-019. JAMA, May 16, 2012 – Volume307, Issue. 19. Pages 2087-2092. [on line], Available from : http://scholarship.law.georgetown.edu/cgi/viewcontent.cgi?article=1972&context=facpub. Accessed 13 july 2012.

GRZYBOWSKI C., 2011. « Não deixemos passar a hora ! » Le Monde Diplomatique Brasil, December 2011, p.

LABONTÉ, R, SCHRECKER, T., 2007 « Globalization and social determinants of health: Promoting health equity in global governance. Part 3 of 3 ». Globalization and Health 2007, Volume 3, Issue7, Pages 1-15.

OTTERSEN, O.P. , FRENK, J, & HORTON, R. University of Oslo Commission on Global Governance for Health, in collaboration with the Harvard Global Health Institute. The Lancet, 5 November 2011. Volume 378, Issue 9803, Pages 1612-1613.

NG, N. Y. ; RUGER, J. P.,2011. « Global Health Governance at a Crossroads ».[on line], Available from : http://blogs.shu.edu/ghg/2011/06/21/global-health-governance-at-a-crossroads/. Accessed 15july 2012Accessed 9 July 2012.

SACHS, I., 2011. « Os desafios da segunda cúpula da terra ». Le Monde Diplomatique Brasil, dezembro de 2011, p.

SACHS, I., 2012. « De volta à mão visível : os desafios da Segunda Cúpula da Terra no Rio de Janeiro ». Estud.av., São Paulo,Volume26,Issue74,2012. Pages.5-20. Available from : http://www.scielo.br/pdf/ea/v26n74/a02v26n74.pdf. Accessed : 23 July 2012.

World Conference on the Social Determinants of Health, 2011. « Rio Political Declaration on the Social Determinants of Health ». Rio de Janeiro, Brasil, Outubro 2011. [on line], Available from : www.cmdss2011.org.Accessed 10july 2012Accessed : 23 July 2012.

WHO, 2011. « WHO reforms for a healthy future ».EBSS/2/2.[on line], Available from : www.who.int/dg/reform/en/index.html.Accessed 17july 2012Accessed : 23 July 2012.

WHO, 2012a. 65th WHA. A65/5 Add. 1 26 abril 2012. Provisional Agenda item 12. « WHO reform ».[on line], Available from : http://apps.who.int/gb/ebwha/pdf_files/WHA65/A65_5Add1-en.pdf. Accessed 30 July 2012Accessed : 23 July 2012.

WHO, 2012b. The Brazilian perspective on Rio+20 and its link to the World Conference on Social Determinants of Health. BUSS, P.M. PAHO Seminar, 6 June 2012.

WHO, 2012c. 65th WHA. « WHO reform ».Statement by the delegation of Brazil. Geneva, May 2012.

Haut de page

Pour citer cet article

Référence électronique

José Roberto FERREIRA, Claudia HOIRISCH et Paulo Marchiori BUSS, « Global Governance for Health », Face à face [En ligne], 12 | 2013, mis en ligne le 21 octobre 2013, consulté le 23 juin 2017. URL : http://faceaface.revues.org/801

Haut de page

Auteurs

José Roberto FERREIRA

Oswaldo Cruz Foundation. Av. Brasil 4.365. Manguinhos. Fiocruz Center for Global Health. E-mail : ferreirj@fiocruz.br. Tel. (55 21) 3885-1623. Former Director of the Department of Human Resources of the Pan American Health Organization (PAHO) (Washington, DC. 1974 - 1995). Doctor Honoris Causa of the University of Brasilia and the National School of Public Health/Fiocruz. Coordinator of the Fiocruz Center for Global Health (CRIS/Fiocruz, in its Portuguese acronym).

Claudia HOIRISCH

Oswaldo Cruz Foundation.Av. Brasil 4.365. Manguinhos. Fiocruz Center for Global Health. Email : claudiah@fiocruz.br. Tel. (55 21) 3885-1079.Master´s degree in Business Management at the Brazilian School of Public and Business Administration, Getúlio Vargas Foundation (EBAPE/FGV).Researcher at Fiocruz Center for Global Health.

Paulo Marchiori BUSS

Oswaldo Cruz Foundation. Av. Brasil 4.365. Manguinhos. Fiocruz Center for Global Health. Email : buss@fiocruz.br. Tel. (55 21) 3885-1763.Former-President of Oswaldo Cruz Foundation (2001-2008), Director of FIOCRUZ Center for Global Health, Brazil´s representative at the Executive Committee of the World Health Organization (WHO) (2008-2011), Full Member of the Brazilian National Academy of Medicine.

Haut de page

Droits d’auteur

Tous droits réservés

Haut de page
  • Revues.org