Earlier this week, the report of The Lancet – University of Oslo Commission on Global Governance for Health was published.
I will not try to summarize the report here, as I hope you will read the entire report, not only the summaries and analyses that have started circulating. But it was a forceful analysis of the report that encouraged me to write this editorial: the one by Charles Clift at Chatham House.
Charles hits the nail on its head when he writes that “the analysis could have been briefer and its recommendations stronger”. Ouch!
You will forgive me for not writing an apology on behalf of the Commission – I’m not in a position to do that. Nor will I write an apology on behalf of myself – something like “if I had written this on my own, the recommendations would have been stronger”. I’d rather challenge you to formulate stronger recommendations, after considering the real life constraints as we faced them. If the report can achieve that, I’ll be very proud to have contributed my share to it.
We did spend a lot of time, in meetings and correspondence, analyzing the present reality, and the report reflects that. And it was depressing. Not global health governance in particular, although that was pretty sobering as well, but all of the global governance that affects people’s health. I remember thinking, after our meeting in Arusha: ‘Damn, perhaps Thomas Nagel was right after all.’
Most of you may not be familiar with Nagel’s work. Allow me to introduce you to one of his most famous papers, about The Problem of Global Justice. This is the first paragraph:
“We do not live in a just world. This may be the least controversial claim one could make in political theory. But it is much less clear what, if anything, justice on a world scale might mean, or what the hope for justice should lead us to want in the domain of international or global institutions, and in the policies of states that are in a position to affect the world order.”
Hopefully, you won’t get stuck on the ‘not clear what justice on a world scale might mean’ – that is the least convincing part; at least I can imagine what global justice might mean, simply by imagining what a global democratic government would do better than the global governance we have. We don’t really need to have a global democratic government to be able to imagine what it would do. But if we all agree on the improbability of a global democratic government in the near future – as I presume we do – it is far more difficult to express what we “want in the domain of international or global institutions, and in the policies of states that are in a position to affect the world order.”
After the sobering analysis of present global governance and its impact on health, it was difficult to imagine global institutions that would, at the same time, have the power to make states behave in ways other than they would without such institutions, and remain unaffected by the present power asymmetries.
Allow me to use a suggestion from the Youth Commission on Global Governance for Health to illustrate the dilemma we faced. In its comment, also published by The Lancet, the Youth Commission argues: “In an increasingly interdependent world, the Commission’s concern for diverging interests and power asymmetries requires a more ambitious response if we are to harness opportunities for shared responsibility and global solidarity for health among nation states and non-state actors.” In fairness, there is a recommendation in the report, about shared responsibility: “The Commission believes that there is an urgent need for a framework for international financing that is broader than what is currently defined as official development assistance to ensure the financing of a more universal agenda for socially sustainable development”. The report also mentions “global social protection”, which “would entail appropriate distribution of national and international responsibilities, with mechanisms to collect and redistribute transfers that are both duty-based and rights-based.” But that idea is followed by a kind of warning, not a straightforward recommendation: “these are important questions that need to be further explored and debated.”
Those of you who are familiar with my work know that I am strongly in favor of a global social protection regime. Nonetheless, I support the warning. Why?
About the two principal recommendations of the report – establishing a UN Multistakeholder Platform on Global Governance for Health and an Independent Scientific Monitoring Panel on Global Social and Political Determinants of Health – the Youth Commission argues that they are “likely to be influenced by the same diverging interests and power asymmetries described by the Commission.” Right. And a global social protection regime runs the same risk.
Allow me to return to Thomas Nagel. Here’s the final paragraph of his paper:
“… if we accept the political conception, the global scope of justice will expand only through developments that first increase the injustice of the world by introducing effective but illegitimate institutions to which the standards of justice apply, standards by which we may hope they will eventually be transformed. An example perhaps, of the cunning of history.”
Applied to the suggestion of the Youth Commission, what Thomas Nagel predicts is that any international institution that has the power to impose contributions for shared responsibility and global solidarity would be illegitimate at the start – with an overrepresentation of the most powerful states, and pursuing these countries’ interests first and foremost. Then, slowly, ‘standards of justice’ could be applied, to transform this institution into a legitimate institution. Perhaps the Global Fund to fight AIDS, Tuberculosis and Malaria fits this description: half of the votes of the board were given to ‘donors’, representing 1 out of 7 billion people; the other 6 billion people on this planet have only half of the votes. The Global Fund focuses on infectious disease control rather than on health, and it could be argued that infectious disease control serves the interests of the inhabitants of ‘donor’ countries more than efforts to improve health in a comprehensive way would. But maybe these shortcomings were unavoidable when the Global Fund was created, and because it now exists, standards of justice can be applied to it, and that would – in my opinion – require turning the Global Fund we have into a global fund for health, with a more representative board. This will take time, and more debate.
Charles Clift calls the central proposals of the report “a talking shop and a monitoring mechanism”. True, but I think we need more thinking, talking and monitoring, before states – and peoples – can move beyond their narrow short-term self-interests, towards a better understanding of the many dimensions of global interdependence; towards a global social protection regime, anchored in human rights, for example. Impatient we are, but carefully we must tread.