PHA-Exchange> In preparation of PHA 2 (39) Part 3 of 4 about WHO's Commission on Social Determinants of Health

[Claudio]

2.2.3 Identifying allies and political opportunities

 

The level of the Commission's success will depend to a considerable extent on its ability to construct a

network of alliances and partnerships with influential actors at various levels, including: global

institutions, national governments and policymakers, the business sector and civil society organizations.

Fortunately, while the CSDH can expect to encounter resistance from certain influential constituencies

(and must be prepared with appropriate strategies), the Commission will also enjoy distinctive

opportunities. It will work in a political context which, if managed appropriately, offers chances for

success beyond the reach of previous efforts. Arguably, Commissioners' most pivotal responsibility will

be using their personal networks and links to various spheres of influence (political, business, academic,

media, civil society) to build and maintain an expanding web of alliances that will support and publicize

the Commission's work, disseminate its messages, and drive implementation of its policy

recommendations. To be fully effective, this network must be operative on several levels simultaneously.

 

Global actors

Buy-in and ongoing support from major global institutions, including the relevant UN agencies, will be

essential to creating sustained momentum around the SDH agenda and ensuring that it is durably

integrated into international health policy and development models. The history of the PHC vs. SPHC

debate in the 1980s suggests that the increasing divergence in strategy between WHO and UNICEF was a

significant factor in weakening global commitment to the Health for All vision and to comprehensive

PHC, with its intersectoral action component. Fortunately for the Commission, the SDH agenda appears

strongly aligned with the current main thrust of UN and international development policy, built around

the MDGs. Indeed, while certain aspects of the MDG programme are of course criticisable from a health

perspective (absence of noncommunicable diseases, lack of explicit focus on health systems), the overall

MDG framework provides an admirable opportunity both to secure the central place of health in

development work generally and, more particularly, to promote understanding of the linkages between

health outcomes and underlying social/economic/political conditions. Most importantly, the MDGs by

definition constitute a framework for coordinated international action, with commitment from major

players already built in. To the extent the CSDH can align its policy recommendations with the MDGs, it

can capitalize on the momentum of global and national commitment to the goals.

 

The work of the UN Millennium Project, whose final report was published in January 2005, has

highlighted the interwovenness of the broad range of economic, health and environmental issues in

international development under the MDGs8. A renewed sense of the urgent need for coordinated

multisectoral action to improve the lives of the world's most vulnerable citizens has emerged, along with

the model of a "global compact" between developed and developing countries that would dramatically

increase investment in key sectors of direct interest to an SDH agenda, such as poverty and food security,

education, women's empowerment, water and sanitation and living conditions in urban slums, as well as

improved medical services7. The CSDH must give a high priority to positioning itself within the various

international fora and policy processes connected with the MDGs, and to opening channels of dialogue

with key players that can ensure that the CSDH is strongly profiled within these processes. Relevant fora

and institutions would include the UN Economic and Social Council; the advisory teams around the UN

Secretary-General; the Millennium Campaign effort; and the High Level Forum on MDGs; as well as the

various UN specialized agencies contributing to the MDG effort and aligning their work according to

MDG priorities.

The importance of outreach to the major international financial institutions has already been underscored.

Contestation around the policies of the IFIs remains strong. Debates continue concerning the effects of

PRSPs on developing countries' capacity to strengthen their health care systems and to implement social

policies that promote health and health equity. Yet attitudes and practices at the World Bank and some

regional development banks may be changing in ways that could facilitate the uptake of Commission

messages and the implementation of CSDH-recommended policy measures. Importantly, the World Bank

is publicly committed to the MDGscxxxiv, and relations between WHO and the Bank have been

strengthened through collaboration in the High-Level Forum on MDGs. Meanwhile, the World Bank and

IDB have been instrumental in the success of programmes such as Mexico's PROGRESA/Oportunidades.

The profile the World Bank is now giving to equity as a key concern in international developmentcxxxv

presents an opportunity for the CSDH to press its message that if countries and the global community are

serious about attacking health inequities, the most effective way is via SDH.

A key strategic advantage for the CSDH, in comparison with efforts to promote intersectoral action on

health determinants during the 1990s, is the strong and visible commitment to the SDH agenda from top

leadership at WHO, including the Director-General. This high-level institutional buy-in within WHO

increases the chances that an SDH approach to health policy design can be "mainstreamed" within WHO

during the life of the Commission and can become a permanent dimension of the Organization's technical

work and policy dialogue with Member States. On the other hand, across the global health community

and even within WHO itself, some constituencies will certainly greet an SDH approach with scepticism.

The architecture of the Commission and its Knowledge Networks, including special focus on health

systems and diseases of public health priority, is designed to provide maximum chances to bring

traditionally more biomedical constituencies "on board" with SDH, showing them how SDH approaches

can improve results within their own programmes and contribute to the strengthening of integrated,

sustainable health systems. A high-level WHO Reference Group linked to the Commission will develop a

specific WHO-internal action agenda to incorporate the Commission's key recommendations into WHO

policy and programming in a durable way.

International fora such as the G-8, regional bodies and more or less formalized political alliances around

specific issues such as global hunger will also be key potential linkages for the Commission. The concern

of the G-8 nations with economic and health inequalities offers an important entry point for the CSDH,

which the Commissioners and their support staff should work to capitalize upon. African-led

development initiatives such as NEPAD, though criticized in some quarters as excessively influenced by

neoliberal models, signal creativity and fresh commitment to a comprehensive development approach that

could offer opportunities for action on SDH. Development initiatives such as the global alliance against

hunger recently launched by the Presidents of Brazil, Chile, France and Spain relate directly to Commission themes and may enable synergies. The recent proposals by the UK on debt cancellation and

a possible "Marshall Plan" for Africa also underscore the degree to which at least some sectors of the

global policy and development community are willing to envisage new strategies and to weigh bold

innovations.

 

National actors

At national level, the Commission begins its work at a time when, as noted above, momentum for

concerted action on SDH is building. A number of politically and economically influential countries have

enacted bold policies on SDH, and others may soon be ready to act. The problem of socially-conditioned

health inequalities has emerged as an important political issue in an increasing number of jurisdictions88.

The most substantial policy advances have so far been made in high-income countries, but as the

Oportunidades example shows, some developing countries are also introducing pioneering programmes.

At the January 2005 session of the WHO Executive Board, strong endorsements of the CSDH were

expressed by developing countries currently represented on the Board, including Bolivia, Ghana, Lesotho

and Thailand. Many developing countries appear ready to consider serious, pragmatic proposals for

policies and interventions that can reduce health inequality gaps through action on social factors.

A close relationship to country-level processes and the policymakers involved in them will be vital for

the Commission's success. Here again, Commissioners will make maximal use of their personal networks

and will play a role that is above all political. An important function for the Commission will be

brokering policy dialogue and knowledge-sharing between countries on the "leading edge" that have

already enacted health policies addressing SDH and countries that want to implement such policies but

have not yet done so and are seeking practical advice and insights on how to proceed.

 

The private sector

We have already discussed the challenge that may be posed to the CSDH by possible tensions between its

messages and the interests of influential private sector actors, in particular transnational corporations.

Clearly, finding appropriate modes of engagement with the business sector will be a major strategic

concern for the Commission. Recommendations for structural change to reduce social inequality through

large-scale, government-led redistribution of resources are unlikely to find favour with the business

community. However, certain intermediate-level policies and interventions aimed to improve health

through action on SDH may indeed be appealing to private sector actors, and may enable the Commission

to bring some industries and firms "on board" with CSDH proposals. The recent ILO-sponsored World

Commission on the Social Dimension of Globalization, which included Taizo Nishimuro, Chairman of

the Board of Toshiba Corporation, may provide lessonscxxxvi. Some policies and interventions

recommended by the Commission can be cast as "business friendly". For example, investment in early

child development and in education is highly advantageous for creating the healthier, more skilled, more

adaptable workforce required by many modern industries in the technology and service sectors. Likewise,

housing improvement projects in urban slums could mean profits for the construction industry. Two

recent reports on national business competitiveness (by the World Economic Forum and World Bank)

have found Nordic countries to be among the world's most competitive economies. These countries'

strong investments in social equity and programmes addressing SDH do not hinder their ability to

compete in the global economy. On the contrary, according to an author of the World Bank study, "We

found that social protection is good for business, it takes the burden off of businesses for health care costs

and ensures a well-trained and educated work force''cxxxvii. Such findings may open up useful lines of

argument for the CSDH.

On the other hand, deeper methodological and ethical questions underlie the issue of relations with the

business sector and with governments anxious about the financial "bottom line". The Commission must

consider if and how to use cost-savings and cost-effectiveness arguments to promote health policies that

embrace SDH. Recourse to such arguments could of course be quite advantageous when promoting SDH 

approaches to political decision-makers. As one senior policy adviser remarked in a recent workshop on

evidence-based policymaking: "What makes evidence talk? Definitely financial impact.. What is the

best argument for getting government to listen? Answer: Money!"cxxxviii As we have noted, the impact of

the Commission on Macroeconomics and Health owed much to the CMH's decision to justify its policy

recommendations primarily in terms of economic gains, rather than via ethical arguments. Similarly,

cost-savings arguments have been advanced by partisans of SDH policy approaches in a number of

countries that have begun to implement or at least consider public health strategies oriented towards

health determinants. Yet the scientific robustness of these arguments may be questionable. (Extending the

lives of people over 50 will not necessarily result in substantial long-term savings for health systems;

much of course depends on the type and quantity of health care and other services people require over

their longer life-spans.). Is it economically credible to present SDH policies as tools that will enable

governments and health systems to save money? Is it morally right to do so? The Commission will need

to reflect carefully about how possible economic arguments for SDH policies relate to arguments based

on equity, social justice and/or human rights.

 

Civil society

Since the pre-Alma-Ata era of community based health programmes, the active participation of civil

society groups has regularly been cited as a key success factor, in cases where intersectoral policy on

health determinants has worked well at local and national levels14,27,42. Since the CSDH aims to generate

results and not just words, it must take this correlation seriously and shape its strategies accordingly.

The CSDH may benefit from the evolving role of civil society at global, national and local levels. The

influence of civil society organizations has grown in many parts of the world, as has the ability of such

organizations to gather and share knowledge and to support each other's efforts, increasingly linking

across political and spatial boundaries through the use of new communications technologiescxxxix, , cxl cxli.

Civil society mobilization has been a crucial factor in some of the key political processes of recent years

(from the toppling of apartheid to the "Orange Revolution" in Ukraine). In health, the impact of the

Bangladesh Rural Advancement Committee (BRAC), South Africa's Treatment Action Campaign and

other civil society organizations has transformed traditional relationships between the medical

establishment, government, industry interests and communities.

Several major international NGOs have expressed strong support for a SDH agenda, indeed some did so

well before the announcement of the Commissioncxlii. If the CSDH does engage civil society groups as

active partners in the various phases of its work, the Commission can hope to harvest strength from the

growing voice and influence of civil society in leveraging policy change and ensuring the translation of

good ideas into concrete results. Recognizing the strategic importance of this issue, the CSDH secretariat

is developing a comprehensive strategy for partnership with civil society organizations that will ensure

space for civil society participation in all aspects of the CSDH process, including partner countries and

Knowledge Networks. CSDH presence at the upcoming Second People's Health Assembly in Cuenca,

Ecuador, in June 2005, is one important step in opening a substantive dialogue.

 

Main strategic questions:

. How can the CSDH most effectively position itself within the global and

national processes connected to the Millennium Development Goals (MDGs)?

. Is it scientifically credible, strategically desirable and/or ethically acceptable for

the CSDH to argue that health policies tackling social determinants are a wise

investment that will "pay off" in terms of enhanced economic performance

and/or cost savings to health systems down the line?

. Can the CSDH operate strategically to get "buy-in" from the business

community, without losing credibility with other key constituencies, including

civil society? How will potential conflicts among these interests be mediated

within the Commission as its work proceeds?

...final tomorrow.
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