Routledge Handbook on the Politics of Global Health

Richard Parker, Jonathan García, Richard Parker, Jonathan García

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781315297231
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

In the early twenty-first century, key public health issues and challenges have taken centre stage on the global scene, and health has been placed at the heart of our collective aspirations for human development and well-being. But significant debate exists not only about the causes, but also about the possible solutions for nearly all of the most important global health challenges.

Competing visions of the values and perspectives that should underlie global health policies have emerged, ranging from an emphasis on cost eff ectiveness and resource constraints on one extreme, to new calls for health and human rights, and renewed calls for health and social justice on the other. The role of different intergovernmental agencies, bilateral or unilateral donors, public or private institutions and initiatives, has increasingly been called into question, whilst the spread of neoliberal policies and programmes, and existing international trade regimes and intellectual property rights, are deeply implicated in relation to global health responses.

This volume critically evaluates how the global health industry has evolved and how the interests of diverse political and economic stakeholders are shaping the context of a rapidly changing institutional landscape. Bringing together leading authors from across the world, the Handbook's eight sections explore:

• Critical perspectives on global health

• Globalisation, neoliberalism, and health systems

• The changing shape of global health governance

• Development assistance and the politics of global health

• Scale-up, scale-down, and the sustainability of global health programmes

• Intellectual property rights, trade relations, and global health

• Humanitarian emergencies and global health politics

• Human rights, social justice, and global health

The Routledge Handbook on the Politics of Global Health addresses both the emerging issues and conceptualisations of the political strategies, policy-making processes, and global governance of global health, along with expanding upon and highlighting the critical priorities in this rapidly evolving field. It provides an authoritative overview for students, practitioners, researchers, and policymakers working in or concerned with the politics of public health around the globe.

Part I

Critical perspectives on global health

1

Fault-lines in global health

Intersecting inequalities, human rights, and the SDGs

Gita Sen

At the heart of struggles over the modern day political economy of health is the public budget. Health protection and promotion policies would have the status of the proverbial ‘motherhood and apple pie’, absent any concern over financial resources! Such status has, however, been missing for over three and a half decades, ever since financialised globalisation put down deep roots in national and global economies and polities. The decades between the Declaration of ‘Health for All by the Year 2000’ in 1978 at Alma Ata, and the enunciation in 2015 of Sustainable Development Goal 3 (SDG3) to ‘Ensure healthy lives and promote well-being for all at all ages’ have seen many ups and downs in the resources, environment, and institutions affecting the health of people in both the global South and North. It is not an exaggeration to say that global health has been on a roller coaster. Periods of optimism have been followed by sharp downswings and backlashes belying the fragile consensus about ‘health for all’, only to be followed by new panaceas.

Synergies and contradictions between three factors have impacted this health roller coaster: (i) poorly regulated financialised globalisation and the consequent explosion in global and national economic inequality; (ii) South–North disagreements and fissures about development resources, inter alia trade, taxation, official development assistance (ODA), investment flows; and (iii) the growing potential for human rights versus backlashes against them.

In the period since Alma Ata, the rise and rise of the neoliberal financial agenda has led to sharp increases in economic inequality (Stiglitz, 2012; Piketty, 2014; Seguino, 2014), matched by the growth of private corporate power at multiple levels, national and multinational. Pitched battles between South and North have enlivened multinational forums such as the World Trade Organization, the UN Conference on Trade and Development, and the UN Economic and Social Council’s bodies. Rising public concern and knowledge about their implications for health outcomes and health policies (Benatar, et al., 2011) have been paralleled by a surge in popular mobilisation for human rights (Yamin, 2016). But such mobilisation has been countered by conservative, religion-referent organisations making common cause with a growing number of illiberal democracies (Rodrik and Mukand, 2015). This has fomented extra-judicial and state-sanctioned backlashes to the expanding potential of health and human rights for all (Corrêa, et al., 2016). It is clearly essential to locate health politics and agendas, global and national, in this larger political economy. Within this context, forces pushing for increases in health resources and budgets (aggregate and sector specific) co-exist with pressures to hold the line, if not to cut back.

The pressure for more resources is fuelled by the global epidemic of non-communicable diseases (NCDs) combined with untamed, resurgent, and new infectious diseases (Garrett, 1994; Osterholm, 2005). Large-scale public mobilisation, such as through the People’s Health Movement, has taken the primary health care agenda of Alma Ata forward to the concerns and language of universal health care (UHC), arguing for budgetary increases and expanded public services to ensure coverage and access for poor people. Intertwined, but often independent of this health movement, other social movements – of women, youth, disabled people, indigenous, LGBTQI, Dalit, ethnic/racial minorities to name only some – have come into their own, demanding access, affordability, quality, and accountability in health services as necessary to the fulfilment of their human rights (Sen, 2017).

On the other side of the debates over resources stand the forces of neoliberalism, calling for fiscal austerity, a shrinking state, and privatisation (Stuckler, et al., 2009) leading to reduced real resources for health, education, and social services generally, in both South and North (Ortiz, et al., 2015; Rowden, 2009). These forces operate in uneasy juxtaposition to the backlash against human rights, not only against basic civil and political freedoms, but also against feminist, youth, and LGBTQI demands for greater attention and resources for gender equality, and the fulfilment of sexual and reproductive health and rights.

What may these fault-lines imply for forward movement from the Millennium Development Goals (MDGs) to the Sustainable Development Goals (SDGs), in particular SDG3 on health, and towards a genuinely universal agenda of health for all people? A feminist lens provides some promise but also raises troubling questions.

Exploding and intersecting inequalities

There is ample evidence of the increase in economic inequality during the last two to three decades of financialisation (Piketty, 2014; Stiglitz, 2012; OECD, 2008; Vázquez Pimentel, et al., 2018). What has been its impact on health? While there are some direct answers (Benatar, 1998; Navarro, 2007) to this question, pathbreaking work by Wilkinson and Pickett (2009) brought together evidence on the importance of economic inequality for health and well-being. While disparate research linking health access and outcomes to inequality in household incomes (Subramanian and Kawachi, 2004; Arcaya, et al., 2015) has existed for many contexts and different aspects of health, Wilkinson and Pickett’s work argued strongly that inequality per se was more important than average levels. Economic inequality within countries belonging to a high-income cross-section appeared to have significantly greater impact on a range of health and well-being outcomes than average national per capita incomes. These national level comparisons complement evidence from within-country studies about the importance of economic differentials for specific health issues.

Multiple pathways may work separately or together to link socio-economic status inequalities to health:

•Financial burdens: Shrinking public resources and rising out of pocket health expenditures are known to be regressive in their impact. The growing incidence of NCDs in many countries (high-, low-, or middle-income) affects both rich and poor but exacerbates the greater real burdens on the poor and marginalised. The resulting need for longer-duration and more expensive care implies higher costs over longer time-spans which can mean higher burdens on the poor in terms of opportunity costs including foregone income, larger proportions of health to non-health expenditure in household budgets, and higher debt-burdens due to borrowing for health care.

•Capacity to care: An important contributor to rising economic inequality is the global increase in the share of precarious work (Standing, 2011; Vázquez Pimentel, et al., 2018) in total employment. Such jobs are not only poorly paid but also lack stability and have minimal health or other benefits. They are often under working conditions that fall below the minimal International Labour Organisation (ILO) standards for decent work. The burden of health care, in terms of both financial costs and human labour, falls disproportionately on those at the lower ends of the spectrum who have the least financial and physical capacity to provide for care. It particularly affects those responsible for unpaid caring labour within households, usually women and girls.

•Policy voice and attention: The higher the extent of inequality, the greater the distance separating those above from those below, and the lower the levels of empathy or solidarity across groups (Benatar, et al., 2003; Sen, 2007). The greater this separation of the powerful from those with less economic and social power, the greater the substantive disenfranchisement of the latter; and the lower the voice of the latter in policy decisions, or even in being able to draw policy attention to their concerns.

•Public resources: The above impacts the volume and stability of commitment of public financial resources to the health needs of those at the lower ends of the socio-economic order.

A closer examination of these pathways points to the importance of intersecting inequalities (Sen, et al., 2009; Krieger, 2011; Sen and Iyer, 2012; Walby, et al., 2012; van Deurzen, et al., 2014). Health is affected not only by economic inequality, but also by the ways in which economic income/wealth differentials interact with other drivers of social inequality such as gender, ethnicity, caste, race, disability, sexual orientation, and gender identity or expression, to name some. The rapidly growing literature on such intersections makes it clear that it is insufficient to focus on the impact of economic inequality alone as did earlier work on social determinants of health. In fact, such a narrow focus can both exclude and distort the effects of other drivers of inequality, masking the true impacts of social (as opposed to economic) inequality. Attention to horizontal inequality, as the inequality across social groups has been called, has grown but much of it still does not tackle intersectionality, per se.

What health policies need to account for better is the challenge posed by what may be called ‘deep poverty’ (Sen and Iyer, forthcoming). When economic poverty is intertwined with other social drivers (such as those mentioned earlier), this can make its impacts more obdurate and resistant to change. Economic poverty is not randomly distributed across a population, but inheres in groups distinguished by social, geographic, physical, or other characteristics (Sen, 1997; Sen, et al., 2009). Recent work by UN Women (2018) builds on these ideas, referring to this as the phenomenon of ‘clustering’. The economically impoverished are often female, disabled, indigenous, Dalit, members of religious or ethnic minorities, non-heterosexual, and so on.

In addition, members of socially oppressed or marginalised groups may have specific health concerns or needs that affect them regardless of income level. For instance, even if access to income may provide some cushioning for some, trans or lesbian women may fear violence in a homophobic society. All people with disability may face stigma, and Dalits, indigenous people, or racial/ethnic minorities may be excluded from access to health services or oppressed in health facilities.

Overall it can be argued that the explosion of global inequality in recent decades has very likely had deleterious effects on health. Its impacts on the health of specific sub-groups such as children may have been somewhat ameliorated by targeted programmes. But continuing weakness in health system capacities, the sharp increase in the prevalence of NCDs, growing reliance on the unpaid care work of women within households that are increasingly reliant on precarious incomes, and non-recognition of the health needs of vulnerable groups and geographies mean that the pathways of voice and choice may continue to deepen the grooves of exclusion and marginalisation.

This context of growing inequality makes the volume and stability of public resources an important predictor of future trajectories. Global debates and agendas have played a key role in this.

South versus North

The target of 0.7 per cent for the ratio of ODA to Gross National Income (GNI) was adopted by the OECD/DAC countries (except for the US and Switzerland) in the early 1970s, following on the report of the Pearson Commission on International Development, and the need estimates worked out by the Nobel winning economist, Jan Tinbergen. Some donors, mainly from Nordic countries, were able over the next decade to actually meet this target or to make significant progress towards it, amplifying thereby the resources available for development assistance, including for health and other aspects of human development. The climate for development resources in the 1970s was largely an expansive one, with the World Bank following the ILO’s lead in prioritising basic needs, anchoring its lending policies on ‘redistribution with growth’. It provided the larger platform for the Alma Ata Declaration of ‘health for all’ in 1978, and for an emerging global policy response to the rising social movements of this decade. While these movements were largely led by feminists demanding gender equality and minorities calling for racial/ethnic justice, other groupings emerged and grew in the following decades.

By the early 1980s, this climate had changed drastically. A sharp turn towards fiscal austerity and shrinking national budgets was integral to the so-called Reagan–Thatcher revolution, marking the rise to policy dominance of the forces of neoliberal globalisation and financialisation. The impacts on health outcomes and budgets of the ensuing decades of hard and then more moderated structural adjustment programmes have been well documented. While the World Bank did increase its resources for the social sectors in the 1990s, together with the IMF it continued its pressure on government spending, and in support of increased reliance on the private sector.

Needless to say, the Alma Ata goal of health for all did not make much progress in such a climate. Selective primary care replaced the goal of full primary health care, which was overshadowed in time by specific concerns such as child, infant, and maternal mortality rates, the growth of the HIV pandemic, shortages in human and financial resources, and the weakening of health system capacities.

Globally, the 1980s and 1990s witnessed the emergence of sharp clashes over resources and policy autonomy between high- and low- to middle-income countries under the auspices of the UN, as real ODA stagnated, and national spending was brought under fiscal austerity programmes. The World Trade Organization (WTO), which came into existence in 1995, became the principal multilateral site for trade regulation, negotiation of trade agreements, and enforceable dispute resolution. The WTO has been criticised for becoming the third leg of the global neoliberal framework (along with the IMF and the World Bank), for being less than transparent, and for serving the North’s interests. At the same time, thanks to strong mobilisation by HIV/AIDS activists and Southern governments, it is the site of both the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPs) and later the Doha Declaration on the TRIPS Agreement and Public Health, with flexibilities to protect public health and provide access to medicines for all.

Sadly, this advance is an exception, and the fault-line between South and North has never been adequately bridged (Petchesky, 2003), even though the following years saw shifts in position through the rise of important low-income countries to middle-income status, and the creation of the G20, the BRICS (i.e., the growing regional role of Brazil, Russia, India, China, and South Africa), and the meteoric rise of China to the position of the world’s second largest economy.

The South versus North fault-line carried through into the formulation of the MDGs. The actual goals, targets, and indicators of the MDGs belied the soaring aims of the Millennium Declaration. They have been critiqued as having been written in the UN’s basement by a group of international bureaucrats, heavily influenced by OECD/DAC pressure and ideas (Fukuda-Parr and Hulme, 2009). Partly as a reaction to this, the processes for the discussion and finalisation of the SDGs (including their targets and indicators) were much more open, inclusive, and drawn out. As a result, the implications for health are more robust...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• List of figures
• List of tables
• Contributing authors
• Introduction: Routledge Handbook on the Politics of Global Health
• Part I Critical perspectives on global health
• Part II Globalisation, neoliberalism, and health systems
• Part III The changing shape of global health governance
• Part IV Development assistance and the politics of global health
• Part V Scale-up, scale-down, and the sustainability of global health programmes
• Part VI Intellectual property rights, trade relations, and global health
• Part VII Humanitarian emergencies and global health politics
• Part VIII Human rights, social justice, and global health
• Index