The Lancet Commissions – The political origins of health inequity: prospects for change

The Lancet  
Feb 15, 2014  Volume 383  Number 9917  p575 – 668  e12 – 14

Protecting health: the global challenge for capitalism
Richard Horton a, Selina Lo a

The quest to secure economic growth, after a financial crisis that raised serious questions about capitalism’s ability to protect and sustain the wellbeing of populations in rich and poor countries alike, is the overriding political priority for many governments today. And those prospects for growth seem good. The World Bank reported in January, 2014, that “advanced economies are turning the corner” and that “developing countries [will] regain strength after two weak years”.1 Specifically, global growth is expected to be 3·2% in 2014, rising to 3·5% by 2016. In high-income countries, growth is predicted to be 2·2% in 2014, rising to 2·4% in 2016. And for developing countries, the expectations are little short of spectacular: projected growth of 5·3% in 2014, rising to 5·7% in 2016. By 2015 it is projected that sub-Saharan Africa will host seven of the world’s fastest growing economies. The World Bank concludes that the world is “finally emerging from the global financial crisis”.

This change in economic fortune should be good news for health. It will mean more resources to invest not only in the health sector, but also in related sectors that shape and influence health, such as education and housing. However, there are disparities between regions. The World Bank1 estimates that China can expect growth of 7·7% in 2014. Sub-Saharan Africa’s growth will likely be 6·4%, excluding South Africa. South Asia should come in at 5·7%, with India at 6·2%. But Latin America and the Middle East are expected to deliver dismal 2·9% and 2·8% growth rates, respectively. Meanwhile, some countries will do less well than their neighbours. Pakistan, 3·4% growth. South Africa, 2·7%. Brazil, 2·4%. Egypt, 2·3%. Central and eastern Europe, 2·1%. Iran, 1%. These between-country disparities will be compounded by within-country inequalities. The World Bank has less to say on this issue. But the lack of inclusive growth within a nation—that is, the exclusion of sectors of the population from the overall benefits of economic growth which should include improved health—will deepen inequality in ways that headline gross domestic product figures fail to reveal.

Economic growth alone will not deliver good health to the most vulnerable sectors of society without addressing the intertwined global factors that challenge or destroy healthy lives. Beyond the economy, recent extreme weather events experienced across most parts of the world are tentative (and incompletely understood) signs that the effects of climate change are already with us. The effect that climate has on the agriculture sector and food security, and the likely impact on nutrition and health outcomes, requires further deep evaluation and cooperation between disciplines. The worsening conflict in Syria, and the continued violence in Iraq, Afghanistan, South Sudan, and the Central African Republic, show the frightening ability of violence to damage health and wellbeing, not only directly, but also indirectly through the social chaos violence inevitably causes. Recent episodes of civil strife in Turkey, Thailand, and Brazil prove that despite considerable health gains, the political systems within which those health gains have taken place are fragile and unstable—lessons that all societies need to relearn, no matter how secure they feel today.

These challenges can be addressed only by reaching beyond the health sector. This might seem an obvious notion but its common understanding and application in global policy debate is weak. Decisions made in different political domains rarely have health at the core of their thinking.

One great gap in thinking about the future of health and wellbeing are the arrangements we put in place to organise our international institutions and policies to sustain the fortunes of societies. These arrangements are inherently political, as Ole Petter Ottersen and his colleagues argue in the final report of The Lancet—University of Oslo Commission on Global Governance for Health.2 They are about power. They are about elites. And they are about a rigid consensus among these powerful elites that prevents most attempts to question the norms on which political decisions are made. Yet elites are only as powerful as the systems that support the status quo. And global systems, such as those in trade, investment, or security, should (but do not always) have mechanisms for civil society participation and links with international norms that already exist to protect health.

The Commission addresses seven political domains that shape health and contribute to inequity within populations: finance, intellectual property, trade and investment treaties, food, corporate activity, migration, and armed conflict. It examines the obstacles to effective global governance for health. And finally, it proposes mechanisms to improve the accountability of all those who influence health through these different sectors. Proposals that could better articulate a way in which civil society engages in global policy, together with ideas for how international institutions could be mandated to produce health equity impact assessments, are worthy of consideration and debate.

The Commission includes contributors from 13 countries, including India, Brazil, Thailand, Tanzania, Ghana, Namibia, South Africa, and the occupied Palestinian territory. They have provided an opportunity to pause and reflect on a problem of emerging and serious importance. The era after the Millennium Development Goals is one that will be substantially more complex than today. The link between poverty and sustainability is not simple. Exclusive anti-poverty measures will not solve some of the biggest health threats people face. Solutions will require specific input from different regions, countries, and individuals—and a more critical understanding than has hitherto been displayed by policy makers of the determinants of human survival and wellbeing. Success will demand courage and flexibility to challenge the consensus that so inhibits the changes needed to bring about greater equity. This Commission can, we hope, be a contribution to this need for greater critical understanding and challenge.

We would like to thank all of the Commissioners for their contributions to this project—and especially Professor Ole Petter Ottersen for leading this work—and are grateful for the support of the Commission from the Norwegian Agency for Development Cooperation, the Norwegian Ministry of Foreign Affairs, the Norwegian Ministry of Education and Research, the Board of the University of Oslo, the University of Oslo’s Institute of Health and Society and Centre for Development and the Environment, and the Harvard Global Health Institute.

1 The World Bank. Global economic prospects: coping with policy normalization in high-income countries. Washington, DC: The World Bank, 2014.
2 Ottersen OP, Dasgupta J, Blouin C, et al. The political origins of health inequity: prospects for change. Lancet 2014. published online Feb 11.

The Lancet Commissions
-University of Oslo Commission on Global Governance for Health
The political origins of health inequity: prospects for change
Ole Petter Ottersen, Jashodhara Dasgupta, Chantal Blouin, Paulo Buss, Virasakdi Chongsuvivatwong, Julio Frenk, Sakiko Fukuda-Parr, Bience P Gawanas, Rita Giacaman, John Gyapong, Jennifer Leaning, Michael Marmot, Desmond McNeill, Gertrude I Mongella, Nkosana Moyo, Sigrun Møgedal, Ayanda Ntsaluba, Gorik Ooms, Espen Bjertness, Ann Louise Lie, Suerie Moon, Sidsel Roalkvam, Kristin I Sandberg, Inger B Scheel
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Executive summary
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