PHA-Exch> A synopsis of the full CSDH Report: part 2

[Claudio Schuftan]

From: woodwarddavid at hotmail.com


*What the Report of the Commission on Social Determinants of Health says
about:*

·         *Financing*

·         *Globalisation*

·         *Global Governance*



 *While the Commission makes a number of specific recommendations, these are
constrained by its mandate, and as a result do not include many suggestions
and proposals included in the body of the report, or address specific issues
which are clearly identified as necessary if the Commission's objective of
"closing the gap in a generation" is to be fulfilled. At the same time,
because of the very complex and inter-connected nature of influences on the
social determinants of health, material relevant to a number of key issues
is spread across several sections of the report. The following is an attempt
to draw the material in the report together, in summary form, under a number
of thematic headings, highlighting the Commission's suggestions and
proposals, and the specific needs it identifies, as well as its formal
recommendations.*

* *

*It should be emphasised that this synopsis has no official status, that it
has been compiled entirely independently of the Commission and its
secretariat, and that it should in no way be attributed to them. While the
contents are intended to reflect what the report says on each subject, some
selectivity has been inevitable, and the emphasis undoubtedly reflects the
priorities of the writer.*

*Financing*

The Commission calls for increased public finance for programmes and
policies to support the social determinants of health, including child
development, education, improved living and working conditions and health
care, recognising the failure of markets to supply vital goods and services
equitably. It also calls for a fair allocation of the costs of action on the
social determinants of health, both geographically and across social groups,
through progressive taxation at the national level, a major increase in aid,
improved aid quality and greater debt cancellation.



Tax systems should be progressive, and focus on direct rather than indirect
taxation; and mechanisms should be established to ensure that available tax
funding is allocated between populations and areas according to need. This
requires strengthening tax systems and capacities in many developing
countries.



The Commission finds current levels of aid "grossly inadequate", and the net
financial outflow from many developing countries to richer countries
"alarming". It identifies a "trust deficit" between donors and recipients,
leading to multiple and onerous conditions which increase transaction costs,
strain recipient countries' often weak administrative capacity, and
constrain their freedom to determine their own developmental and financing
priorities. It also highlights problems arising from the volatility and
unpredictability of aid flows.



It calls on donor countries to honour existing commitments by increasing aid
to 0.7% of GDP, to establish predictable long-term funding mechanisms, to
increase aid quality, to reduce tied aid, to increase budgetary support, to
align aid with recipient countries' own development plans, to increase aid
for health (particularly the social determinants of health), and to
coordinate aid use through a social determinants of health framework



The Commission identifies a need for new multilateral institutions for an
expanded, reliable and more coherent system of global aid. Greater emphasis
should be placed on globally pooled funds, multilaterally managed and
transparently governed, multi-year stability of donor inputs, and the
determination of recipients' eligibility and allocations according to agreed
needs and developmental objectives.



The PRSP process has been "something of a missed opportunity", and appears
to have had an adverse impact on national policy space and public spending
on education and health care. The PRSP process should emphasise more
explicitly that it is a process of national cross-sectoral coherence in
decision-making. Donors and national governments should provide more funding
for cross-sectoral work on the social determinants of health; more support
should be provided to Health Ministries in their engagement with Ministries
of Finance; and Medium-Term Expenditure Frameworks should be more flexible,
to allow key recurrent costs to be met.



An urgent need exists for more debt relief, deployed more effectively in
support of social determinants of health, as the considerable weight of
remaining debt continues to draw public resources away from developmental
investments. The Multilateral Debt Relief Initiative should be strengthened
and extended; and there have been calls for a more balanced approach to debt
cancellation and independent arbitration. Consideration of indebtedness
should expand the focus from narrow indicators of economic sustainability
towards a broader concept of 'debt responsibility', including broader
measures of economic vulnerability, and legislative scrutiny of government
borrowing and lending.



Efforts should be made to ensure that increases in aid and debt relief
support coherent policy-making and action by recipient governments on the
social determinants of health, and performance indicators of health equity
and social determinants of health should be core conditions of recipient
accountability.



*Globalisation*

While the Commission sees potential benefits in globalisation, the process
has been inherently disequalising, concentrating benefits among the better
off and negative effects among the poor. It criticises various aspects of
the recent process of globalisation, market integration and liberalisation
throughout the report as increasing inequity in health between and within
countries; increasing the cost of life-saving drugs; damaging food security;
undermining the ability of governments to collect taxes though tariff
reduction and tax competition; adversely affecting labour and working
conditions and increasing job insecurity; contributing to the double burden
on women of paid and domestic work; increasing the frequency of financial
crises; intensifying the commodification and commercialisation of water,
health care, and electrical power; severely diminishing the role of the
public sector in regulation for health; increasing the availability and
consumption of health-damaging products; and encouraging unhealthy diets.



The Commission emphasises the necessity of changes in the operation of the
global economy and international institutions, including WTO, IMF and World
Bank, for its recommendations on employment and social protection to be
implemented. While it notes that the the design of a new international
economic order is beyond its mandate, it stresses the need for urgency and
innovativation to integrate health, development and environmental concerns.



The Commission sees an urgent need for a global economic system which
supports renewed government leadership to balance public and private sector
interests, and identifies quantifying the impact of supra-national
political, economic, and social systems on health and health inequities
within and between countries as an important research need. It also proposes
that international legislative standards for rich country business relations
with low- and middle-income trading partners should be increased.



The Commission notes that the global financial architecture may have more
influence on health than international assistance for health care,
contributing to large net outflows of resources from poor to rich countries
and increasingly frequent financial crises.

It calls for better international coordination of tax policy and the
establishment of an International Tax Organisation, and highlights the need
for a globally enforceable framework to reduce international tax avoidance
and capital flight, calling for measures to combat the use of offshore
financial centres and curb tax avoidance. It also stressses the need for
effective taxation of transnational corporations, including the avoidance of
tax incentives for export-processing zones. It proposes requirements for
disclosure by companies of all tax, royalty and other payments to
governments and other public entities. It calls on all governments to ratify
and implement the UN Convention against Corruption rapidly.



The Commission also calls for the development of new national and global
public finance mechanisms, ensuring that the resources generated are genuinely
additional to development assistance. It sees a strong argument in favour of
the development of a system of global taxation, possibly including a tax or
solidarity levy on currency transactions.



Health impact assessments are required before international agreements or
policy commitments on trade and investment are finalised. Countries
considering such commitments should exercise due caution. WHO should
re-affirm its global health leadership by initiating a review of trade and
investment agreements, in collaboration with other multilateral agencies,
with a view to institutionalising health equity impact assessment as a
standard part of all future agreements. The flexibility of trade agreements
should be increased to allow signatory countries, after signing, to mitigate
unforeseen negative impacts on health and health equity, possibly including
opt-out provisions where domestic conditions suggest this is necessary.



Implementation of the Commission's recommendations on empoyment requires
improved terms in WTO Agreements, more development-friendly trade policies
in developed countries, reduced dependence on external capital and export
markets in developing countries, and more intra-regional trade. High- and
middle-income countries should not demand further tariff reductions in
bilateral, regional, and world trade negotiations with low-income countries
which still depend on tariffs for public revenue; and low-income countries
should be extremely cautious in agreeing to reduce tariffs before creating
alternative revenue streams to replace them. The report also indicates
support for the development of preferential trade agreements offering
protection to countries attempting to build the capacity to engage viably in
the global marketplace.



While it supports the inclusion of occupational health and safety provisions
in trade agreements, the Commission highlights the need for caution in
seeking to use 'social clauses' in trade agreements to enforce international
labour standards, which may have counterproductive effects, urging instead
the strengthening of the International Labour Organisation, the UN
Environment Programme, the Food and Agriculture Organisation and WHO.



Countries should avoid making any commitments in binding trade treaties (eg
the WTO's General Agreement on Trade in Services) which affect their ability
to regulate health services effectively until they have demonstrated that
they can regulate private health services in ways that increase health
equity. It is not clear that any country has yet done so.



Food-related trade agreements should concentrate on the three key aspects of
nutrition and health equity – availability, accessibility and acceptability.
Trade policy that actively encourages the production and consumption of
foods high in fats and sugars to the detriment of fruit and vegetable
production is contradictory to health policy. It is important to ensure that
local agriculture is not threatened by international trade agreements and
agriculture protection in rich countries. National and local government
policies and programmes should focus on agricultural development and
fairness in international trade arrangements, and protect the livelihoods of
farming communities exposed to cost and competition pressures through
agricultural trade agreements.



The Commission calls on international agencies, donors and national
governments to address the "brain drain" of health human resources, focusing
on investment in increasing health human resources, and bilateral agreements
to regulate gains and losses. It also calls for more effective policy and
financing mechanisms to support refugees and internally displaced
populations; and greater global cooperation on the establishment of
'portable rights' accruing to all cross-border migrants, to be honoured by
all host countries.



*Global Governance*

The nature of global systems and the requirements of good global governance
have changed considerably since the current multilateral system was
established some 60 years ago. Poor democratic function and inequality of
influence are widely prevalent. The institutional processes and democratic
credentials of the World Bank and IMF are questionable; trade and investment
agreements have often been characterised by asymmetrical participation and
inequalities in bargaining power among signatory countries; and participation
and representation on the Codex Alimentarius Commission are inequitable and
biased, resulting in an imbalance between the goals of trade and consumer
protection. Agreements are often entered into without adequate assessment of
the full scale of the social risks; and the profound disempowerment of some
countries through their lack of resources and unequal capacity leads to
treaties and agreements that do not necessarily serve their best interests.



The Commission argues for stronger global management of integrated economic
activity and social development as a more coherent way to ensure fairer
distribution of globalisation's costs and benefits. It sees the entrenched
interests of some social groups and countries as "barriers to common global
flourishing", and expresses concern about the increasing influence of
transnational companies, which it argues should be accountable to the public
good as well as to private profit.



The Commission highlights the need for new, strengthened and more democratic
forms of global governance, considering it imperative that the international
community recommit to a multilateral system in which all countries have an
equitable voice. A system of global governance which places fairness in
health at the heart of the development agenda and genuine equity of
influence in the centre of its decision-making is indispensable to the
realisation of the right to health. The Commission calls for reform of
Security Council, for example through strengthened regional representation;
and for support to governments and other stakeholders to allow their
equitable participation in global policy-making fora.



Multilateral agencies should work more coherently to a common set of
overarching objectives, underpinned by a common vision of issues to be
addressed, and shared indicators by which to measure the impact of their
actions. Representation of public health in domestic and international
economic policy negotiations should be ensured and strengthened; and the public
sector should take a leadership role in national and international
regulation to protect health and reduce health inequities.



The 'thick' global governance on economic, trade, finance and investment
relations, is in marked contrast with 'thin' governance on health and social
equity, and global roles relating to social determinants of health are
fragmented between numerous competing actors. The Commission proposes
revising existing global development frameworks to incorporate health equity
and social determinants of health indicators more coherently, and the adopting
health equity as a core global development goal, with appropriate indicators
to monitor progress both within and between countries. The MDGs should be
reconsidered, advancing equity as a core marker of achievement,



The Commission strongly supports WHO in renewing its leadership in global
health and its stewardship role across the multilateral system, and urges an
increase in WHO's capacity, and its institutional renewal through the
establishment of a social determinants of health approach across its
programmes and departments. It also proposes the creation of inter-agency
thematic working groups on different aspects of the social determinants of
health, the appointment of a Special Envoy for Global Health Equity, and a
Permanent Special Rapporteur on the Right to Health.

David Woodward


woodwarddavid at hotmail.com
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