Five Steps to Improving Global Governance for Health

The first decade of this new century will be remembered for a number of things, but one that will certainly stand out is the dramatic leap forward in global health.

Between 2000 and 2010, a number of worrying – and sometimes catastrophic – trends in global health were arrested and reversed. For example, the child mortality rate, which had stuck at 12 million per year in the 1990s, was reduced by more than a third to 7.6 million in 2010 thanks to improved vaccination rates, and a dramatic improvement in malaria control and AIDS treatment and prevention.

Over the past few years, enhanced efforts to improve maternal mortality have also had an impact on the ground. From barely budging for decades, the number of maternal deaths has shown a significant decrease in the past couple of years.

And these are only some of the positive figures that are showing up in health statistics.

Most of this progress has been achieved through an increase in health investments: partly as a side effect of economic growth (particularly among middle-income countries), and partly due to a deliberate scaling up of health investments through aid.

In absolute terms, the increases have been modest: a single-digit billion dollar investment per year spread over nearly 150 countries. The fact that this funding has caused such a dramatic leap in lives saved shows just how cost-effective health investments are. 

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As so often, however, addressing one problem – in this case by increasing global health investments – uncovers other challenges. Increased global health investments and increased focus on health outcomes have placed tremendous strain on developing country health systems and have highlighted the complex and often detrimental effects of health worker migration.

It has also become clear that most health problems today are international in character, which means that national health systems and governments often have limited means of controlling health outcomes in their country.

Moreover, the interconnectedness between other factors and health, such as trade policies, global warming, armed conflicts, the legal, social and economic status of women and vulnerable groups, and inequity within and between countries, has also been brought to the fore.

In fact, the interdependence between health and other factors is one of the most striking effects of globalisation.

There are two sides to this interconnectedness: political and corporate leaders need to understand how crucial health is to economic and social development; and those working inside the health sector need to understand how health outcomes are often dependent on decisions taken outside the sector.  Altogether, there is a need for better understanding of how improving health helps to reduce glaring inequities, foster economic growth, reduce workforce costs, and even promote stability and security.

The progress of the past decade has created a tremendous momentum for positive change. Today, well into the next decade, there is a danger that this momentum could be lost.  We are now hearing calls for austerity, the view that health improvements are a “nice-to-have” luxury the world can no longer afford, that a job half done is a job well done, and that the money that has gone into health can now be directed to other areas. This is cause for serious concern. 

We need to fight such complacency and short-sightedness. But we also need to use the momentum built up over the past decade to develop a more sophisticated structure for dealing with global health problems and to better exploit the opportunities for improving health outcomes through decisions taken outside the health sector. 

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I see five steps to driving forward such an agenda:

First, we need better advocacy to focus attention on the interconnectedness of health and foreign policy. Experts within these areas should come together to identify the evidence and develop the language and arguments needed to help decision-makers fully understand the foreign policy implications of global health security.

Second, we need to build support for political initiatives that promote an interconnected global response to health issues.

The UN Millennium Development Goals, although not perfect, are making made a huge difference. The G8 commitment to child and maternal health is another excellent example, as is the UN Secretary-General’s global strategy for women’s and children’s health.

We need to look beyond the MDGs and start planning how to continue to work towards ambitious goals after 2015.  Moreover, much more needs to be done to mobilise efforts against the slow tide of lifestyle diseases that will kill millions and drain state budgets in the years to come.

The WHO Framework Convention on Tobacco Control is an inspiration in this area, as was the UN General Assembly’s Special Session on Non-Communicable Diseases last year.

Third, with the many initiatives taken – both inside and outside the UN family – we need to take a closer look at the institutional global health architecture. We must improve our understand of how decisions made in one area, such as water management, climate change or trade policy, affect health, and we need to plug into these decision-making processes in a coordinated and effective manner.

Fourth, we need to engage. My colleagues from Brazil, France, Indonesia, Senegal, South Africa and Thailand and I continue to collaborate through the Foreign Policy and Global Health Initiative. In 2007, we adopted the Oslo Ministerial Declaration and action plan on global health. It identified 10 key areas where we believe the international community needs to better understand the health implications of foreign policy. Six of these areas have been the subject of debates and resolutions in the UN General Assembly. This year we are working together on relevant aspects of the Rio+20 Agenda.

Fifth, we need more knowledge and better documentation. We also need an interconnected research model that can provide the necessary evidence base and support our efforts.

To this end, Norway and the Foreign Policy Health Initiative are supporting the new Commission on Global Governance for Health. This commission – a collaboration between Harvard University, the University of Oslo and the medical journal The Lancet – will examine the impact of various foreign policy domains on health, and seek to identify what methods we should use to promote global health in international politics.

If the impressive progress of the past decade is to continue in the coming years, investments in health need to be accompanied by more sophisticated decision-making and cross-sector collaboration. It is a challenge I believe we can meet.