TY - JOUR
T1 - The political origins of health inequity
T2 - Prospects for change
AU - Ottersen, Ole Petter
AU - Dasgupta, Jashodhara
AU - Blouin, Chantal
AU - Buss, Paulo
AU - Chongsuvivatwong, Virasakdi
AU - Frenk, Julio
AU - Fukuda-Parr, Sakiko
AU - Gawanas, Bience P.
AU - Giacaman, Rita
AU - Gyapong, John
AU - Leaning, Jennifer
AU - Marmot, Michael
AU - McNeill, Desmond
AU - Mongella, Gertrude I.
AU - Moyo, Nkosana
AU - Møgedal, Sigrun
AU - Ntsaluba, Ayanda
AU - Ooms, Gorik
AU - Bjertness, Espen
AU - Lie, Ann Louise
AU - Moon, Suerie
AU - Roalkvam, Sidsel
AU - Sandberg, Kristin I.
AU - Scheel, Inger B.
N1 - Funding Information:
The work of the Commission was made possible by unrestricted grants from the Norwegian Agency for Development Cooperation (NORAD), the Norwegian Ministry of Foreign Affairs, the Norwegian Ministry of Education and Research, the Board of the University of Oslo (Oslo, Norway), and by financial and in-kind support from the Institute of Health and Society and the Centre for Development and the Environment (both at the University of Oslo), and the Harvard Global Health Institute (Harvard University, Cambridge, MA, USA). The funding bodies had no influence on the direction, progress, writing, or publication of the report. Finances were administered in accordance with Norwegian law, and with full public disclosure. In addition to constructive advice and input, Jeanette H Magnus provided the administrative base and infrastructure for the Commission at the Institute for Health and Society at the University of Oslo. We are grateful to Harald Siem, who played an important part in establishing the Commission and led the Commission's Secretariat through the project's first phase, until summer, 2012. Valuable research assistance was provided by Emmanuella Asabor, Lotte Danielsen, Unni Gopinathan, Just Haffeld, Sverre O Lie, Diego Solares, Larissa Stendie, Elina Suzuki, Rosemary Wyber, and Alyssa Yamamoto. We also thank Maren O Kloster for her technical assistance, and Svein Hullstein for his administrative support. We are very thankful for Ron Labonté's insightful and constructive comments about, and input to, the draft report at various stages. We offer a special thanks to the People's Health Movement, which contributed with six background papers via an editorial group consisting of Bridget Lloyd, David Sanders, Amit Sengupta, and Hani Serag. The authors of these backgrond papers were Susana Barria, Alexis Benos, Anne-Emanuelle Birn, Chiara Bodini, Eugene Cairncross, Sharon Friel, Sophia Kisting, Elias Kondilis, David Legge, Mariette Liefferink, Baijayanta Mukhopadhyay, Lexi Bambas Nolen, Jagjit Plahe, Farah M Shroff, Angelo Stefanini, Anne-Marie Thow, Pol De Vos, David van Wyk, and Aed Yaghi. Three additional highly useful background papers were developed by David Woodward; Bjørn Skogmo and Sigrun Møgedal; and the Oslo Church City Mission (led by Per Kristian Hilden, with coauthors Christina Marie Brux Mburu, Arnhild Taksdal, Frode Eick, Kari Gran, Hanne Haagenrud, Olav Lægdene, Linnea Näsholm, Anna Olofsson). We also thank Bruce Ross-Larson for his excellent editorial advice; John-Arne Røttingen, who had an important role in the initiation of the project; and Tim Cadman for fruitful discussions. Our special thanks are extended to the Youth Commission on Global Governance for Health, chaired by Unni Gopinathan, for continuous feedback on the Commission's work, and to the Rockefeller Foundation for hosting the Commission at its centre in Bellagio, Italy. We are also very grateful to Jashodhara Dasgupta and Gertrude I Mongella for hosting Commission meetings in New Delhi, India, and Arusha, Tanzania, which involved invaluable contributions from local civil society actors and national authorities.
PY - 2014
Y1 - 2014
N2 - 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 aff ect 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. We identified five dysfunctions of the global governance system that allow adverse eff ects of global political determinants of health to persist. First, participation and representation of some actors, such as civil society, health experts, and marginalised groups, are insufficient in decision-making processes (democratic deficit). Second, inadequate means to constrain power and poor transparency make it difficult to hold actors to account for their actions (weak accountability mechanisms). Third, norms, rules, and decision-making procedures are often impervious to changing needs and can sustain entrenched power disparities, with adverse eff ects on the distribution of health (institutional stickiness). Fourth, inadequate means exist at both national and global levels to protect health in global policy-making arenas outside of the health sector, such that health can be subordinated under other objectives (inadequate policy space for health). Lastly, in a range of policy-making areas, there is a total or near absence of international institutions (eg, treaties, funds, courts, and softer forms of regulation such as norms and guidelines) to protect and promote health (missing or nascent institutions). Recognising that major drivers of ill health lie beyond the control of national governments and, in many instances, also outside of the health sector, we assert that some of the root causes of health inequity must be addressed within global governance processes. For the continued success of the global health system, its initiatives must not be thwarted by political decisions in other arenas. Rather, global governance processes outside the health arena must be made to work better for health. The Commission calls for stronger cross-sectoral global action for health. We propose for consideration a Multistakeholder Platform on Governance for Health, which would serve as a policy forum to provide space for diverse stakeholders to frame issues, set agendas, examine and debate policies in the making that would have an eff ect on health and health equity, and identify barriers and propose solutions for concrete policy processes. Additionally, we call for the independent monitoring of how global governance processes aff ect health equity to be institutionalised through an Independent Scientific Monitoring Panel and mandated health equity impact assessments within international organisations. The Commission also calls for measures to better harness the global political determinants of health. We call for strengthened use of human rights instruments for health, such as the Special Rapporteurs, and stronger sanctions against a broader range of violations by nonstate actors through the international judicial system. We recognise that global governance for health must be rooted in commitments to global solidarity and shared responsibility through rights-based approaches and new frameworks for international financing that go beyond traditional development assistance, such as for research and social protection. We want to send a strong message to the international community and to all actors that exert influence in processes of global governance: we must no longer regard health only as a technical biomedical issue, but acknowledge the need for global cross-sectoral action and justice in our eff orts to address health inequity.
AB - 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 aff ect 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. We identified five dysfunctions of the global governance system that allow adverse eff ects of global political determinants of health to persist. First, participation and representation of some actors, such as civil society, health experts, and marginalised groups, are insufficient in decision-making processes (democratic deficit). Second, inadequate means to constrain power and poor transparency make it difficult to hold actors to account for their actions (weak accountability mechanisms). Third, norms, rules, and decision-making procedures are often impervious to changing needs and can sustain entrenched power disparities, with adverse eff ects on the distribution of health (institutional stickiness). Fourth, inadequate means exist at both national and global levels to protect health in global policy-making arenas outside of the health sector, such that health can be subordinated under other objectives (inadequate policy space for health). Lastly, in a range of policy-making areas, there is a total or near absence of international institutions (eg, treaties, funds, courts, and softer forms of regulation such as norms and guidelines) to protect and promote health (missing or nascent institutions). Recognising that major drivers of ill health lie beyond the control of national governments and, in many instances, also outside of the health sector, we assert that some of the root causes of health inequity must be addressed within global governance processes. For the continued success of the global health system, its initiatives must not be thwarted by political decisions in other arenas. Rather, global governance processes outside the health arena must be made to work better for health. The Commission calls for stronger cross-sectoral global action for health. We propose for consideration a Multistakeholder Platform on Governance for Health, which would serve as a policy forum to provide space for diverse stakeholders to frame issues, set agendas, examine and debate policies in the making that would have an eff ect on health and health equity, and identify barriers and propose solutions for concrete policy processes. Additionally, we call for the independent monitoring of how global governance processes aff ect health equity to be institutionalised through an Independent Scientific Monitoring Panel and mandated health equity impact assessments within international organisations. The Commission also calls for measures to better harness the global political determinants of health. We call for strengthened use of human rights instruments for health, such as the Special Rapporteurs, and stronger sanctions against a broader range of violations by nonstate actors through the international judicial system. We recognise that global governance for health must be rooted in commitments to global solidarity and shared responsibility through rights-based approaches and new frameworks for international financing that go beyond traditional development assistance, such as for research and social protection. We want to send a strong message to the international community and to all actors that exert influence in processes of global governance: we must no longer regard health only as a technical biomedical issue, but acknowledge the need for global cross-sectoral action and justice in our eff orts to address health inequity.
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U2 - 10.1016/S0140-6736(13)62407-1
DO - 10.1016/S0140-6736(13)62407-1
M3 - Review article
C2 - 24524782
AN - SCOPUS:84893823818
VL - 383
SP - 630
EP - 667
JO - The Lancet
JF - The Lancet
SN - 0140-6736
IS - 9917
ER -