## 1. Key Messages - The unacceptable health inequities within and between countries cannot be addressed within the health sector, by technical measures, or at the national level alone, but require global political solutions - Norms, policies, and practices that arise from transnational interaction should be understood as political determinants of health that cause and maintain health inequities - [[Power asymmetry]] and global social norms limit the range of choice and constrain action on health inequity; these limitations are reinforced by systemic global governance dysfunctions and require vigilance across all policy arenas - There should be independent monitoring of progress made in redressing health inequities, and in countering the global political forces that are detrimental to health - State and non-state stakeholders across global policy arenas must be better connected for transparent policy dialogue in decision-making processes that affect health - Global governance for health must be rooted in commitments to global solidarity and shared responsibility; sustainable and healthy development for all requires a global economic and political system that serves a global community of healthy people on a healthy planet ## 2. Executive summary 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 sideeff ects 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. ### Five dysfunctions of the global governance system We identified five dysfunctions of the global governance system that allow adverse effects of global political determinants of health to persist: 1. [[Interesting Phrase]] Participation and representation of some actors, such as civil society, health experts, and marginalised groups, are insufficient in decision-making processes ([[Democratic deficit]]). 2. Inadequate means to constrain power and poor transparency make it difficult to hold actors to account for their actions (weak accountability mechanisms). 3. [[Interesting Phrase]] Norms, rules, and decision-making procedures are often impervious to changing needs and can sustain entrenched power disparities, with adverse effects on the distribution of health ([[Institutional stickiness]]). 4. 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). 5. 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). > The Commission calls for stronger cross-sectoral global action for health. We propose for consideration a [[UN 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 effect 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 affect 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 efforts to address health inequity==. ## 3. The political nature of global health ### 3.1 Global sources of health inequity > “We are challenged to develop a public health approach that responds to the globalised world. The present global health crisis is not primarily one of disease, but of governance...”. — [[Ilona Kickbusch]] > [!NOTE] Panel 1: Global health inequities > 1. About 842 million people worldwide are chronically hungry,2 one in six children in developing countries is underweight,3,4 and more than a third of deaths among children younger than 5 years are attributable to malnutrition. Unequal access to sufficient, safe, and nutritious food persists even though global food production is enough to cover 120% of global dietary needs. > 2. 5 billion people face threats to their physical integrity, their health being undermined not only by direct bodily harm, but also by extreme psychological stress due to fear, loss, and disintegration of the social fabric in areas of chronic insecurity, occupation, and war. > 3. Life expectancy differs by 21 years between the highest-ranking and lowest-ranking countries on the human development index. Even in 18 of the 26 countries with the largest reductions in child deaths during the past decade, the difference in mortality is increasing between the least and most deprived quintiles of children. > 4. More than 80% of the world’s population are not covered by adequate social protection arrangements. At the same time, the number of unemployed workers is soaring. In 2012, global unemployment rose to 197·3 million, 28·4 million higher than in in 2007. Of those who work, 27% (854 million people) attempt to survive on less than US$2 per day. More than 60% of workers in southeast Asia and sub-Saharan Africa earn less than $2 per day. > 5. Many of the 300 million Indigenous people face discrimination, which hinders them from meeting their daily needs and voicing their claims.8 Girls and women face barriers to access education and secure employment compared with boys and men,9 and women worldwide still face inequalities with respect to reproductive and sexual health rights.10 These barriers diminish their control over their own life circumstances. ### 3.2 What do we mean by [[global governance for health]]? #### 3.2.1 The concept of global governance for health Global governance is the complex of formal and informal institutions, mechanisms, relationships, and processes between and among states, markets, citizens, and organisations, both intergovernmental and non-governmental, through which collective interests on the global plane are articulated, rights and obligatins are established, and differences are mediated. [[Governance refers to the web of formal and informal institutions, rules, norms, and expectations which govern behaviour in societies and without which the very idea of a human society is impossible]] #### 3.2.2 [Political determinants of health]([[global political determinants of health]]) Political determinants operate in various ways. 1. First, ==global norms guide societal interaction==; they shape how problems or issues are viewed in global governance, and frame the types of solutions that are proposed, sometimes excluding discussion of alternative options. 2. Second, political determinants such as rules of representation, voting, transparency, and accountability relate to who participates in ==global decision-making processes==, and to how these processes are shaped by actors with different values, interests, and power. 3. Finally, ==the outcomes of governance processes, such as formalised policies and agreements, shape practices at the national level==. [[Open Question]] What's the progress of this code of practice? Do countries adhere to it like FCTC? Or is it not? What's the outlook of healthcare workers migration? [[Insights]] The [[WHO Global Code of Practice on the International Recruitment of Health Personnel]] exemplifies a policy intended to promote health equity. I==t aims to ensure a fairer distribution of health-care workers by limiting resource-rich countries from attracting health personnel away from resource-poor countries with the greatest health needs==. Ultimately, this code, if effective, will contribute to the fairer distribution of health workers and improved access to health services. The political determinants of health are, as such, neither inherently good nor bad; rather the outcomes of these determinants have either positive or adverse effects on people’s health. ### 3.3 The global governance complex #### 3.3.1 Global political organisation Typical explanation and mentions: WTO, UN, IMF, World Bank, ASEAN, African Union, OECD, NATO, ILO, UNEP, but state sovereignty remains. However, in cases, sovereignty can limit the ability to govern globally by impeding the collective action required to respond to transnational challenges, such as [[climate change]], and from regulation of transnational corporations to policing of organised crime networks. On the other hand, a state’s sovereignty can protect its population against global interference that is not rooted in due democratic process, and take action when global governance processes produce harmful outcomes. For example, international agreements often constrain what national governments are permitted to do, and can in some cases tie a government’s hands when it comes to the protection or promotion of health—often referred to as [[shrinking policy space]]. In principle, ==a government could protect its policy space by choosing not to sign a treaty that it believes will be harmful for its population’s health—as a sovereign state it cannot be forced to do so==. In practice, however, other interests can be at stake such that health and social concerns are not given the priority they deserve. #### 3.3.2 [[Power asymmetry]]: the root cause of inequity HICs account for only 16% of global population but 2/3 of global GDP. The military spending of the USA exceeds that of any other country, and constitutes nearly half of total military spending worldwide. [[Three faces of power are layered. First face is domination, second face is agenda-setting, and third face is thought-control]] Although the “one-state, one-vote” decision-making rules of many UN bodies reflect the legal notion that sovereign states are equals in the international system, the choice of five permanent members of the [[UN Security Council (UNSC)]] and the weighting of [[International Monetary Fund (IMF)]] and [[World Bank (WB)]] votes by financial contribution reflect the greater influence of states with the greatest military and economic capacity. > Power asymmetries between countries are also manifest in the relation between donors and recipients of official development assistance. Although transnational corporations can yield enormous benefits by creating jobs, raising incomes, and driving technological advances, they can also harm health through dangerous working conditions, inadequate pay, environmental pollution, or by producing goods that are a threat to health (eg, tobacco). 1. **Conditionality**: Donor countries or institutions may impose conditions on the aid they provide, which can compel recipient countries to align their policies, including health policies, with the donors' preferences or international standards. 2. **Priority Setting**: Donors may earmark funds for specific health initiatives or programs that they deem important, which can shape the health agenda of the recipient country, sometimes at the expense of the country's own identified priorities​​ 3. **Funding Volatility**: The unpredictable and volatile nature of ODA can make it difficult for recipient governments to plan long-term health initiatives confidently. As a result, critical health programs may not be sustained without consistent donor support​​. 4. **Fragmentation of Aid**: The delivery of aid through multiple channels can lead to a fragmented health system in recipient countries, with disparate programs that may not be well-integrated into the national health strategy. 5. **Resource Allocation**: The administrative requirements associated with managing multiple streams of aid can divert limited resources away from direct health services and toward compliance and reporting for various donors. Other non-state actors such as foundations also wield substantial economic power. The Bill & Melinda Gates Foundation has become one of the most influential players in global health. [[International NGOs, media, or expert bodies wield normative power to influence and shape beliefs about what is ethical, appropriate, or socially acceptable]] In addition to economic and military power, normative power—the ability to shape beliefs about what is ethical, appropriate, or socially acceptable—has proven influential, even without huge material resources. International nongovernmental organisations (NGOs), such as Oxfam and Médecins Sans Frontières, can wield considerable influence through their global networks, access to media, and public reputations. The media too can exert power to outrage the public and inspire political mobilisation, and through their editorial decisions they can drive issues up or down the global agenda. Scientific or expert bodies such as the Intergovernmental Panel on Climate Change can provide authoritative scientific evidence that puts pressure on governments to act. [[Power asymmetries are a permanent feature of social, political, economic relations, but constellations of power (or places where power concentrates) can change]] In recent years, emerging economies such as BRICS and MIKT (Mexico, Indonesia, South Korea, and Turkey). Some emerging powers have taken more assertive positions in international arenas governing health, trade, climate, and security, or challenged governance arrangements such as decision making at the UN Security Council or voting shares at the IMF. New modes of economic, political, educational, and development cooperation between developing countries are also emerging, challenging traditional dynamics of development aid. ### 3.4 Global social norms that affect global governance for health and health equity #### 3.4.1 Contesting norms [[Global norms can change, and engaging in global norm contestation is a political act that happens in a political stage, for example MDGs were able to achieve norm contestation that extreme poverty is morally unacceptable]] But global norms can change, and people can find unacceptable what they previously perceived as an absolute truth about the world. Women’s suffrage and abolition of slavery show how new norms can contest existing ones, and offer a reminder that engaging in global norm contestation is a political act. Framing an issue so that it is viewed in a particular way is a central strategy for norm entrepreneurs. According to Bøås and McNeill, framing is successful when the entrepreneur draws sufficient attention to an issue to get it on the political agenda. [[Three-stage lifecycle for norm contestation. First, introduce the idea. Second, ideas cross the threshold and socialization period. Third, when the norm settled in and taken-for-granted (internalised)]] Finnemore and Sikkink propose a ==three-stage lifecycle for an idea to evolve into a norm==. In the first phase of norm emergence, norm entrepreneurs attempt to bring attention to an idea and to persuade a critical mass of norm leaders, such as political actors, opinion leaders, and governments, to embrace the idea as a norm. Once a threshold of normative change is reached, a tipping point sets off the second stage, a norm cascade. During this phase, norm leaders attempt to socialise other actors to follow the norm. Finally, when the norm assumes a taken-for-granted quality, it has reached the internalisation stage: the norm is institutionalised and is no longer an issue for public debate. #### 3.4.2 Market dominance > In recent decades, this system has produced unprecedented growth that has increased material prosperity for hundreds of millions of people and greatly improved their health and wellbeing. But this growth has been uneven, both between and within countries. As Sukhamoy Chakravarty argued, that “the market is a bad master, but can be a good servant” [[World market has evolved without institutional underpinnings to better govern markets in the public interest. At national level, governments protect their societies but at the global level such institutions do not exist]] A key challenge for global governance is that the world market has evolved without the institutional underpinnings that have developed at state level to better govern markets in the public interest. At national level, many governments have created institutions and adopted policies aimed at protecting their societies from the most harmful effects of liberalised markets. Such institutions do not exist at the global level: for example, ==there is no global social protection floor, global competition authority, or global drug regulatory authority; nor are there global transparency laws, or global courts to enforce such laws were they to exist==. With the absence of formal institutional mechanisms to regulate global markets, we fail to realise the potential for a fair distribution of the benefits of globalisation #### 3.4.3 The biomedical approach The positive developments of biomedical approach (including mass immunisation program) are plausibly linked to increased domestic and international investment in health, including unprecedented growth in the political attention and resources dedicated to devlopment assistance for health. But health inequities persist, and are in many instances on the rise. [[Biomedical interventions should be accompanied by a broader understanding of health-depriving forces found in the global political economy]]. The deep causes of health inequity cannot be diagnosed and remedied with technical solutions, or by the health sector alone, because ==the causes of health inequity are tied to fairness in the distribution of power and resources rather than to biological variance==. Yet, most international health investments tend to focus on specific diseases or interventions. Indeed, the ==contemporary focus on such solutions can frame global health as a managerial problem, devoid of the conflicting interests and power asymmetries that can distort the underlying mechanisms that determine health inequalities==. Construing socially and politically created health inequities as problems of technocratic or medical management depoliticises social and political ills, and can pave the way for magic-bullet solutions that often deal with symptoms rather than causes. #### 3.4.4 Human rights norms [[Three-stage lifecycle for norm contestation. First, introduce the idea. Second, ideas cross the threshold and socialization period. Third, when the norm settled in and taken-for-granted (internalised)]] The internalisation stage of human right norms, including the right to health, remains weak and woefully incomplete. Although an international system is in place to monitor treaty compliance, both formal (eg, the UN Human Rights Council and other mechanisms such as the independent UN Special Rapporteurs) and informal (eg, reports from civil society and the media), in practice there is little that other states can or will do to compel an unwilling state to adhere to their human rights obligations. #### 3.4.5 Future challenges Global social norms and the economic and political underpinnings of global arrangements and power distribution can change, and ==the global governance system itself is likely to evolve==. New threats to health arise with environmental degradation, [[climate change]], and unprecedented urbanisation. As thoroughly discussed in previous Lancet Commissions, these threats will profoundly change the global health picture. People’s daily living conditions will change and new patterns of morbidity and mortality will emerge. ==New technology, especially within electronic communications, is being developed at an astonishing pace, and could provide new opportunities to combat health inequity==. Important as explorations of these developments are, they are not within the scope of this report. [[Open Question]] What would they write if they knew about [[Artificial Intelligence (AI)]] when they wrote this article? ### 3.4.6 Aims of the Commission > We maintain that it is the responsibility of nation states to respect, protect, and fulfil the right to health of their populations. However, when health is compromised by transnational forces, the response must be in the realm of global governance. The main ambition of this Commission is to add our voice and weight to push this norm towards its tipping point, by urging policy makers across all sectors, as well as international organisations and civil society, to recognise how global political determinants affect health inequities, and to launch a global public debate about how they can be addressed. ## 4. Political determinants at work In this section, we present examples from seven policy intervention areas in which the existing system of global governance has failed to promote or protect health, or to address health inequities—the financial crisis and austerity measures, intellectual property, investment treaties, food, corporate activity, migration, and armed violence. The case analyses show that the way in which global political determinants of health operate is decisive for the present distribution of health. We show how, in the contemporary global governance landscape, power asymmetries between actors with conflicting interests lead to rules, regulations, or practices (political determinants of health) that cause health inequities, and how dysfunctions of the global governance system allow this to happen. The Commission, through a process of informed deliberation, selected cases that involved clear examples in which global policy interventions could reduce health inequity. These cases should be seen as illustrative examples rather than constituting a comprehensive overview of all policy areas in which global governance processes affect health and health equity. ### 4.1 The financial crises, austerity measures, and health #### 4.1.1 The financial crisis and health in Greece Faced with a national financial crisis that created uncertainty about the country’s ability to repay its debts, Greece accepted the bailout packages from the IMF, European Central Bank, and European Commission, including austerity measures that have had disastrous eff ects on the health and wellbeing of Greek citizens. Major cutbacks in government spending in the social sectors (health, welfare, and education) caused hundreds of thousands of public sector workers to lose their jobs or see their salaries frozen or reduced.69 Since young people were hit especially hard, they have been named the crisis generation: in 2012, unemployment for people aged 15–24 years was 55·2% in Greece compared with an OECD average of 16·2%.70 The country reports increased numbers of homeless people, rising crime rates, growing food insecurity, and more family break-ups.69,71 Last but not least, the health sector is buckling in the face of austerity measures, with its budget cut by 40%, resulting in, among other effects, reduced access to drugs and health care.68 #### 4.1.2 Health consequences of austerity policies Contemporary events in many European countries mirror what has been happening in much of the developing world since the early 1980s: international fi nancial institutions conditioned loans on structural adjustment programmes that included not only budget cuts to reduce fiscal deficits, but also a broader range of measures to balance fiscal and trade deficits, deregulate the economy, and privatise state enterprises.71 These programmes involved implementation of the primary tenets of [[neoliberalism]], including promotion of free markets, privatisation of public assets and programmes (including health care), so-called small government, and economic deregulation. Much research has shown that the effects of these programmes have been disastrous for public health. For example, studies have shown that structural adjustment programmes undermined the health of poor people in sub-Saharan Africa through eff ects on employment, incomes, prices, public expenditure, taxation, and access to credit, which in turn translated into negative health outcomes through effects on food security, nutrition, living and working environments, access to health services, education, etc. This pattern was also seen in other countries under loan conditionalities from structural adjustment programmes. #### 4.1.3 Political determinants of health and the question of accountability The Greek government was under pressure from EU leaders and foreign investors, had little leverage in negotiating the bailout packages from the [[International Monetary Fund (IMF)]], European Central Bank, and EU. ==The bailout package was presented to Greek citizens as the only alternative to total collapse==, and despite a series of major strikes and demonstrations against acceptance of the austerity packages, they were passed without any referendum after the Prime Minister had been forced to resign. [[Open Question]] Two central questions are: were the [[Austerity measures|austerity policies]] the only viable path to economic recovery? And were the adverse health effects avoidable by reasonable means? Evidence from past financial and economic crises shows that when fiscal policies that protect health and social welfare are implemented, economies can recover without adverse health outcomes.68,81–84 ==John Maynard Keynes argued that governments should, rather than cut spending, stimulate the economy during times of crises through increased spending, accepting a temporary increase in public debt that would be counterbalanced by surpluses when the economy became stronger.== Iceland offers an illustrative example of how investments, rather than cuts, in social sectors offer a viable path to recovery. Although Icelandic banks faced massive losses after the collapse of the US housing market, citizens decided against a government financed bank bailout through a referendum, with 93% of the vote. The government thus chose not to cover the bank’s private losses with public funds, and did not have to seek bailouts from international financial institutions or to adopt the austerity policies attached to them.68 Against the advice of international lenders, the Government—among other measures depreciated its currency, raised selected tariffs on imported goods, invested in social protection and labour-market stimulation, and retained high taxes on alcohol. As a result, the financial crisis has had little effect on the nation’s health, 69 and economic growth has been robust in the ensuing years,86 with unemployment steadily falling, and projected to be less than 5% in 2013.87 The IMF has recognised that investments in Iceland’s social protection programmes have been crucial to the country’s economic recovery and the wellbeing of the population. Despite such evidence, leading international political and financial figures are still promoting austerity as the favoured route to recovery. This position raises questions about [[how much weight is given to people’s health and wellbeing in economic policy making, and how the interests of lenders are weighed against borrowers in economic crises]]. It also raises questions about [[whether adequate mechanisms are available to demand accountability of international policy makers for the health effects of their decisions]]. European leaders have, for example, been raising concerns about the absence of accountability of the powerful European Central Bank, the leaders of which have been making bailouts conditional on austerity measures in several European countries. #### 4.1.4 Emerging reactions: social protection and alternative paths to recovery [[the relationship between paradigms of health changes over time]] The human rights-based approach is getting more tractions. The Commission on Social Determinants of Health identified social protection as one of the most powerful instruments to tackle health inequity at the national level. Indeed, the fundamental importance of social protection is recognised by its inclusion in the Universal Declaration of Human Rights as a basic human right endowed to all individuals.91 However, currently, most of the world’s poor people live, grow, and work without a social safety net. > [!NOTE] Panel 2: The social protection floor > Endorsed by the UN Chief Executive Board and by the heads of state and government at the 2010 Millennium Development Summit, the [[social protection]] floor is defined as “an integrated set of social policies designed to guarantee income security and access to social services for all, paying particular attention to vulnerable groups, and protecting and empowering people across the life cycle”.45 It includes guarantees of: > • Basic income security, in the form of various social transfers (in cash or in kind), such as pensions for elderly people and those with disabilities, child benefits, income support benefits, and employment guarantees and services for unemployed and working poor people. > • Universal access to essential, affordable social services in the areas of health, water and sanitation, education, food security, housing, and others defined by national priorities. The social protection floor is a global concept. It should be the responsibility of each country to design and implement social protection schemes adapted to national circumstances. Similar ideas for health care are also emerging. In an interim report prepared for the UN General Assembly,95 the [[UN Special Rapporteur on the Right to Health]] [[Anand Grover]] presented a framework for an approach to health financing based on the right to health. ==The report noted that the right-to-health obligations require states to cooperate internationally to ensure the availability of sustainable international funding for health.== Rapporteur recommended that steps should be taken to [pool international funding for health]([[Pandemic Fund]]), in the form of single or multiple coordinated pools, with treaty-based compulsory contributions from states. Civil society organisations and movements in Europe and elsewhere have also started to speak out against the adverse effects of austerity policies on health equity. In line with their increasing influence in global financial governance, some developing countries are beginning to organise within the [[World Bank (WB)]] and [[International Monetary Fund (IMF)]] to move away from policies that reward deregulation. Several Latin American governments have also challenged [neoliberal]([[neoliberalism]]) orthodoxies by becoming financiers in their own right; the [[Latin American Reserve Fund]] offers balance-ofpayments support without requiring conditionalities of the sort demanded in structural adjustment programmes.97 Recently, the IMF has recognised some of the limitations of austerity policies in terms of their adverse effects on economic recovery, health, and welfare. #### 4.1.5 Global governance for health: key challenges identified The austerity policies that were the conditions for bailouts from international financial institutions in several European countries are examples of how political determinants of health can flow from global governance processes. Powerful international policy makers are not held accountable for the health effects of their decisions, and adequate policy space is not provided to ensure that health concerns are considered in the design of financial bailout packages. ### 4.2 Knowledge, health, and intellectual property #### 4.2.1 High costs of new drugs [[Intellectual Property Rights (IPR)]] In March, 2013, the Intellectual Property Appellate Board of India upheld the country’s first compulsory licence on a drug, sorafenib, used in the treatment of liver and kidney cancer, which had been issued 1 year earlier. Sorafenib is patented by the German pharmaceutical firm Bayer, which had priced a monthly treatment at about US$5000 in India. Governments can issue compulsory licences to authorise the use of lower-cost generic versions of patented drugs, a safeguard that can protect the public against potential abuse of monopolies granted through the patent system. Even countries that traditionally embrace strong intellectual property rights at times use the threat of a compulsory licence, as the USA did in 2001 for drugs against anthrax. India’s compulsory licence authorised the firm Natco to produce a generic version of the drug and to pay Bayer a royalty of 6–7% of the generic price. Natco’s version of the drug cost about $160 for a monthly treatment, roughly 3% of Bayer’s price. [[democratization of knowledge]] The sorafenib case is not only a story of one drug and one country’s patent law, but also a flashpoint in a longrunning global political contest over how certain types of health-related knowledge are produced, and who benefits. Because knowledge has had such a central role in improving health over the past century, global rules related to knowledge can profoundly affect health. A global community of scientists and scholars produces a huge volume of research on health policies, systems, and practices, as well as biomedical research that can be channelled into the development of technologies to combat disease and other causes of poor health. #### 4.2.2 Effect of globalised [intellectual property rules]([[Intellectual Property Rights (IPR)]]) on health equity One of the main sets of global rules that govern healthrelated knowledge production and access is the [[World Trade Organization (WTO)]] Agreement on [[TRIPS Agreement]] . A central policy objective of protecting intellectual property is to incentivise the creation and disclosure of information and knowledge. TRIPS requires countries to ensure a harmonised minimum level of intellectual property protection, based on the standards in industrialised countries, including: minimum 20-year patents in all areas of technology, including drugs; restrictions on the policy space for states to exclude specific technologies from patentability; and limits on permissible public interest safeguards in patent laws, such as compulsory licences. [[global health governance will increasingly be determined by economic institutions with the principle concern not of health but of market liberalisation]] Before TRIPS, many countries—including those in western Europe—had made special exceptions for food, drugs, agricultural technologies, and education in their national patent and copyright laws. But the introduction of patents on drugs, in many countries for the first time, enabled monopoly pricing for these products, raising concerns about affordability, particularly for poor populations. Although the right to health includes access to essential drugs,103 the adverse effect of patent monopolies on prices and availability of drugs has made it difficult for many countries to comply with their obligations to respect, protect, and fulfil the right to health.104 Additionally, patents alone do not drive sufficient investment to counter diseases that predominantly affect poor people, because they do not offer a sufficiently profitable market; as a result, some diseases—or rather, some populations—are neglected.105 This problem was characterised by the Global Forum for Health Research in the 1990s as the 10/90 gap,106 on the basis of estimates that only 10% of research funding was spent on the major health needs of 90% of the world’s population #### 4.2.3 Political determinants of health and market power TRIPS shows clearly how economic power can shape global rule making, with far-reaching consequences for health. The negotiation of TRIPS in the 1980s and 1990s was driven by the lobbies of a handful of intellectual property-intensive industries in the USA, Europe, and Japan (mainly in pharmaceuticals, information technology, and entertainment). These lobbies persuaded their home governments to push for the inclusion of a binding multilateral treaty on intellectual property within the Uruguay Round of global trade talks. Developing countries were opposed to the inclusion of intellectual property in the package of trade agreements, because owners of intellectual property were predominantly based in rich countries. ==Globalisation of patent rules would create a net transfer of resources from poor countries to rich countries in the form of royalties, while simultaneously restricting access to the knowledge and technologies that could improve health and spur economic development==. Nevertheless, a combination of carrots (concessions on agriculture and textiles) and sticks (bilateral trade pressure from the USA) led to the treaty being signed in 1994. Related: [[@smithTradeHealthTrade2009]] [[@blouinTradeSocialDeterminants2009]] [[Great trade openness was suggested to be good for health (linearly) but turns out, the reevaluation of that widely cited studies that suggested that, the studies were only good to evaluate medium term]] [[Politics vs policy]] Although concerns about the health effects of TRIPS have been widely voiced by civil society and many developing countries,110 the agreement has become increasingly important with the continuing growth of the knowledge economy. TRIPS is nearly impossible to amend because WTO rules require all members to agree on any changes—an unlikely outcome since the more advanced industrialised countries benefit handsomely from these rules. Thus, TRIPS shows how major power disparities shaped the initial rules of the game, and continue to perpetuate such disparity. #### 4.2.4 Emergency of access norms Governments have started to use more aggressively a range of policy approaches to counteract high drug prices, including TRIPS flexibilities such as [[compulsory licensing]]. New collaborative approaches have also been launched, such as the [[Medicines Patent Pool (MPP)]], which negotiates public health-oriented voluntary licences with patent-holding firms to authorise competitive generic production of HIV-related drugs for use in developing countries. This access norm has extended to other diseases, such as tuberculosis, malaria, and the neglected tropical diseases, as shown by large donor initiatives (such as the [[Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM)]] and UNITAID), pharmaceutical-company donation programmes and price discounts for low-income countries, and a well developed watchdog community of civil society organisations, scholars, and analysts. Research into neglected diseases has also increased sharply in the past decade, growing from almost no projects in 2000 to more than two dozen public-private product-development partnerships and about US$3 billion in investment by 2011. Despite some positive achievements, high prices of new drugs are still the norm (especially in emerging markets), the use of TRIPS flexibilities remains exceptional, and policy space to ensure access to health-related knowledge and to protect health within the trade and intellectual property regimes is under threat. Despite the [[Doha Declaration]], many developing countries have been coming under pressure from intellectual propertyexporting countries to enact or implement even tougher or more restrictive conditions in their patent laws than are required (so-called TRIPS-plus provisions) in bilateral or regional trade negotiations. #### 4.2.5 Global governance for health: key challenges identified A serious disparity in economic power and access to expertise exists between the industries and high-income countries that would benefit from the construction of a stringent intellectual property regime, and the lowerincome countries that would pay higher rents while having their access to knowledge restricted. Such power disparities are reinforced by the institutional rules of the WTO, which create a nearly insurmountable barrier to the amendment of TRIPS. The policy space to address health inequity in trade policy making is narrow, and the absence of transparency and public input into the negotiation of trade agreements that contain intellectual property provisions represent a serious democratic deficit. Finally, there is a dearth of appropriate institutions to ensure that sufficient research activities are directed at the greatest health needs. ### 4.3 Investment treaties and health equity #### 4.3.1 Regulations of cross-border investments [[Bilateral investment treaties could undermine national health policies, particularly because there is a power disparity between powerful firms against resource-poor governments]] Governments sign bilateral investment treaties to attract foreign direct investment and reassure investors that they will be treated fairly in a foreign jurisdiction. The purpose of bilateral investment treaties is to protect monetary flows, and they largely exclude concerns such as health, environment, and labour. Such treaties have recently been used by firms to challenge national health regulations. This development has raised concerns that transnational investment rules will discourage or undermine national health policies, particularly when economically powerful, well resourced firms launch legal challenges against resource-poor governments. #### 4.3.2 Investment treaties constraining tobacco control measures Although smoking rates are falling in some high-income and upper-middleincome countries in response to a suite of tobacco control policies, this downward trend has prompted the ==global tobacco industry to seek new customers by shifting marketing efforts to low-income and middle-income countries, where nearly 80% of the world’s one billion smokers now live==. [[World Health Organization (WHO) has defined tobacco use as a marker of social inequity]], because the health consequences of smoking are disproportionately borne by the most disadvantaged groups in society. > FCTC faced national and international legal challenges as violations of countries' obligations under bilateral, regional, and multilateral trade and investment agreements. After signing the FCTC in 2003, Uruguay started to introduce a range of tobacco control measures. In 2010, however, the tobacco company Philip Morris sued the government over a new regulation that required graphic warning labels on cigarette packs,125 which are believed to be more effective than small, text-only health warnings.126 Rather than bringing the case in Uruguayan national courts, Philip Morris went to the International Centre for the Settlement of Investment Disputes (ICSID), an international tribunal at the World Bank in Washington, DC, USA, established to adjudicate conflicts between private firms and states that have signed investment treaties. A parent company of Philip Morris in Switzerland used the Switzerland–Uruguay bilateral investment treaty to bring the case. Bilateral investment treaties usually include investor–state dispute-settlement provisions that allow foreign firms to legally challenge national regulations that reduce their return on the investment. The Uruguayan case is not isolated. The number of legal disputes brought by companies against states for violation of investment treaties has risen sharply in the past two decades. Many cases related to health and environmental legislation have been brought under bilateral investment treaties and the investment chapters of trade treaties such as the North American Free Trade Agreement (NAFTA).127 Philip Morris also launched a legal challenge to Australia’s regulation requiring plain packaging of cigarettes under a bilateral investment treaty between Hong Kong and Australia. The company also brought a case against Canada in 2001 under NAFTA, responding to a government proposal to prohibit the terms “light” and “mild” on cigarette packs. Tobacco is not the only health-related issue to be raised in investor–state dispute-settlement proceedings. In 2012, the pharmaceutical company Eli Lilly challenged Canada’s patent standards through an investor–state dispute after the government invalidated its patent on a drug.128 The company argued that patents should be regarded as protected investments and has sued the government for US$500 million in compensation. #### 4.3.3 [Political determinants of health]([[global political determinants of health]]) and global governance dysfunctions > Several attempts to create global regulations for foreign direct investment have failed. Most recently, the OECD’s proposed Multilateral Agreement on Investment and proposals for international rules on investment during the WTO Doha round failed, largely because of opposition from developing countries and civil society groups that feared they promoted the rights of investors over those of sovereign states. Furthermore, concerns have been raised that arbitration processes suffer from a serious democratic deficit. The existence of cases, arguments, and ==final decisions can all be kept confidential, such that no public scrutiny of cases is possible, even when they touch on questions of major public concern==. Additionally, questions have been raised about the legitimacy of a system in which three judges—who often come from law firms that also represent clients at such tribunals decide behind closed doors on crucial issues of public policy. In both design and execution, the disputesettlement process of investment agreements reflects major power inequalities between those with financial resources (investors and firms) and governments, particularly governments of developing countries. #### 4.3.4 Challenging existing regulations When Philip Morris first challenged its regulation, the Uruguayan Government initially considered conceding and changing its law. However, the global tobacco control community mobilised to facilitate access to expert legal services to support the government, which is now fi ghting the challenge at ICSID. 132 The normative weight of the FCTC and the strong global civil society networks that have been built to support its implementation provided a counterweight to the investment regime. The Australian Government recently defeated a legal challenge by Philip Morris against its plain-packaging law at the Australian Supreme Court, although the international challenges under the investment treaty and through the WTO are continuing. In 2012, the South African Government announced that it would not renew 13 bilateral investment treaties it had signed with European Union member states, because European firms had used them to challenge its domestic labour laws. #### 4.3.5 Global governance for health: key challenges identified [[Power asymmetry]] | [[The global investment regime shows how public health concerns can be subordinated to the interests of private firms]]. Major power disparities exist between multinational tobacco firms and developing countries in their access to the costly legal expertise required to fight a dispute at an international investment tribunal. Furthermore, firms can reap benefits from the absence of transparency in such proceedings, which shields them from public scrutiny and reputational harm. Several shortcomings of the global governance system contribute to this situation. First, a democratic deficit arises from the confidential nature of dispute-settlement proceedings. Second, whereas strong institutions exist for the protection of investors’ rights, mechanisms to hold investors accountable for the negative health effects that can result from their legal challenges are weak. Finally, investment agreements have proven difficult to reform: despite some progress, calls to substantially increase the transparency of the system have proven difficult to implement. ### 4.4 Food and health equity #### 4.4.1 The political nature of nutrition The conditions of hunger and obesity within a country are subject to various local, national, and global political processes. As [[Amartya Sen]] argued three decades ago, [[nutritional status is not determined solely by the availability of food, but also by political factors such as democracy and political empowerment]]. The politics that generate and distribute political power and resources at local, national, and global levels shape how people live, what they eat, and, ultimately, their health. The global double burden of overnutrition and undernutrition is thus one of serious inequity. #### 4.4.2 Food insecurity and health inequity Changes in the global food system are major drivers of the double burden of malnutrition, wherein obesity paradoxically coexists with hunger and undernutrition.147 Overconsumption of energy-dense fats and sugars leads to obesity, which is now surpassing tobacco as the biggest preventable cause of disease burden in some regions.148 Because highly processed, energy-dense foods are consistently cheaper in terms of energy content for a given price,149 social and economic conditions result in a social gradient of diet quality. #### 4.4.3 Food insecurity in a globalised economy [[trade liberalisation could affect popular diets]] Trade liberalisation has also contributed to the escalating obesity pandemic. The deepening penetration of food markets in middle-income countries by multinational food corporations has been associated with increasing intakes of unhealthy commodities such as soft drinks and processed foods, contributing to rising rates of non-communicable diseases.146,149 This shift in diet patterns and changing nutritional challenges have come about as corporate value chains increasingly integrate production, transport, and distribution of food, with wide reach from farmers to consumers. [[@blouinTradeSocialDeterminants2009]] The global food crisis of 2007–08 increased the political attention paid to the ways in which deficiencies in the governance of food affect global food security, and emphasised the adverse effects of unregulated financial markets. Some commentators have argued that the price hike in food crops reflected changing food demands in emerging economies in favour of meat (necessitating increased production of animal feed) and increased demand for biofuels, leading to a fall in the production of food crops.161 However, research has shown that excessive fi nancial speculation in the world grain market accelerated the crisis.142,162 As investors faced a downturn in other financial markets, they entered the futures commodity markets on a massive scale.144 Conditions whereby speculation was allowed to occur in essential food commodities largely exacerbated the effect of regular market supply and demand mechanisms. As such, although the promotion of biofuels and changing food demands in emerging economies were catalysts that set off a giant speculative bubble, the increased trade in futures commodity markets was the underlying reason for excessive food-price volatility. #### 4.4.4 Power inequality and diverging interests ==Generally, institutions, agreements, and laws related to finance and trade are more powerful than those that deal with food security==.164,166,167 For example, the ability of host states (ie, the nation state where the investor is registered) to force investors to run their investments in ways that do not violate food security is undermined by overprotection and under-regulation of the investor.168 Furthermore, no supranational mechanisms exist to mediate between the normative orientation of the WTO, where the primary objectives are trade liberalisation and little state intervention, and the UN human rights system, wherein the primary objectives are to obligate states to respect and fulfil human rights (such as the right to food), particularly those of the most vulnerable populations.168 Additionally, reform of existing rules on agricultural trade to better protect health is difficult, in view of the decision-making processes at the WTO requiring consensus among all member countries. [[Smallholders, marginalised communities, and indigenous people participation in the global governance must be increased]] Traditionally, political participation in the global governance of food and agriculture by people affected by agricultural and food policies (eg, smallholder food producers, marginalised communities, and Indigenous people) has been low.169,170 By contrast, market actors such as transnational corporations and financial speculators are increasingly expanding their policy space and influence on global decision-making processes, with no accountability with respect to the international laws protecting vulnerable populations.155,171 The international peasant farmers movement La Vía Campesina argues that smallholder farmers should have a more dominant role in agricultural policies, stating that this enhanced role only can be achieved if local communities have better access to, and control over, productive resources, and more social and political influence in international regulatory processes that affect food security. #### 4.4.5 Reforming the global governance architecture In 2008, the UN Chief Executive Board established a high-level task force on the global food security crisis, involving UN agencies, the World Bank, IMF, OECD, and WTO. The task force produced a Comprehensive Framework of Action on Food Security, calling for two policy tracks: [[social protection]] systems, and policies to stimulate longer-term productive capacity, resilience, and earning opportunities through investments that prioritise the interests of smallholder farmers. #### 4.4.6 Global governance for health: key challenges identified The negative effect of global political determinants on food security shows serious deficiencies within the global governance system: no single global institution has the authority and responsibility to ensure food security; reform of existing rules on agricultural trade to better protect health is difficult; and mechanisms to hold powerful actors accountable for the health-related effects of their decisions do not exist. ### 4.5 Conduct of transnational corporations and health #### 4.5.1 Toxic waste in Côte d’Ivoire—who is responsible? Toxic waste dumping in Abidjan, Côte d’Ivoire, shows clearly how [[under-regulation of transnational firms can negatively affect health]]. On the morning of Aug 20, 2006, residents of the west African city woke to a foul smell. Toxic waste had been dumped in at least 18 places around the city, close to houses, workplaces, schools, and crops. People started to get nausea, headaches, breathing difficulties, abdominal pains, stinging eyes, and burning skin. The situation in Côte d’Ivoire was created by the interplay of global and national determinants: the toxic waste was carried by the ship Probo Koala, leased by the Europe-based commodity trading company Trafigura. The company had sought firms in many countries to process the toxic waste at a price it was willing to pay. Its efforts spanned the Mediterranean, the Netherlands, Estonia, Nigeria, and ultimately Côte d’Ivoire, where it contracted a company that had neither the experience nor the capacity to deal with this type of waste. When the incident occurred, Côte d’Ivoire was emerging from a serious political and military crisis in which institutions of government had been severely disrupted. Health centres and hospitals were soon overwhelmed and international agencies were drafted to help overstretched local medical staff in the subsequent weeks. Less than 2 months later, health centres had registered more than 107 000 people as having been aff ected by the waste. National authorities attributed at least 15 deaths to the exposure.174 No health monitoring or epidemiological studies have been undertaken to assess the medium-term to long-term health effects. Complete information about the composition of the waste has not been made public. Major questions loom: why did this happen where it did, and who should be held to account? #### 4.5.2 Under-regulation of transnational activities and effects on health equity The costs of extractive industry activity are not borne only by workers, but also by communities and their environment. In the case of mining, toxic contaminants such as arsenic, heavy metals, acids, and alkalis can be discarded into the environment, ending up in water, soil, and the food chain. Through industrial activities in agriculture and manufacturing, harmful pollutants can be released directly into the environment. #### 4.5.3 [[Foreign Direct Investment (FDI)]] and policy space [[Trade reforms create winners and losers. Some sectors of the economy might not be able to compete with new imported goods whereas others get access to new markets and opportunities]] Foreign direct investment is widely regarded as an important vehicle to advance economic growth and development.182 Proponents argue that deregulation and foreign direct investment are good for health, because liberalisation leads to economic growth and generates new wealth, which in turn is expected to lift more people out of poverty. However, Anand and Sen warn that the effect could instead be increasing inequality and deterioration of human welfare. A complex system of global rules and regulations has been put in place to protect and promote the flow of capital, but it largely excludes public policy issues such as health, environment, and labour. [[Great trade openness was suggested to be good for health (linearly) but turns out, the reevaluation of that widely cited studies that suggested that, the studies were only good to evaluate medium term]] For host governments, the activity of transnational corporations can be used to help them to advance economic growth, and they might therefore support and encourage firms to expand through fiscal incentives to attract foreign direct investment. Countries have also been seen to deregulate labour and environmental standards, and to limit tax or corporate tax collection. Consequently, they limit their own policy space. Civil society groups, including NGOs, trade unions, local communities, and Indigenous people, have been important critics of the under-regulation of transnational corporations. They have brought attention to and documented the suffering of affected communities, exploitation of natural resources, environmental degradation, and deteriorating labour standards. They have called for increased policy space to pursue legitimate social policies in host countries. They have stressed the need for transparent agreements and the inclusion of environmental and core labour standards in negotiated treaties. #### 4.5.4 International laws, norms, and monitoring initiatives > Traditionally, foreign direct investment treaties protect investments on foreign soil and thereby favour home countries and firms. Binding regulations for compensation for harm done on foreign soil are, however, less developed. National courts can sometimes exert extraterritorial authority to strengthen accountability for harm committed elsewhere. An example is the Alien Tort Claims Act (ATCA) in the USA,191 which has been used by advocates for several decades to bring cases in US courts for harm committed on foreign soil; however, a recent decision of the US Supreme Court has dramatically limited ATCA, raising serious questions about whether it can function as an effective mechanism for transnational accountability.192 At the international level, only a thin patchwork of international courts exists, covering a restricted set of issues, and with very little jurisdiction over corporations. In an effort to move beyond purely voluntary action, schemes for the rating, labelling, and independent monitoring of the activities of transnational corporation have been implemented. [[The Publish What You Pay network is an example of a strategic coalition of civil society organisations pushing for transparency and accountability of extractive industries]]. Other attempts to improve corporate accountability include socially responsible investment, which mobilises financial resources of large institutional investors, thereby influencing the business practices of transnational corporations. #### 4.5.5 Global governance for health: key challenges identified Vast power disparities exist between the multinational firms that make decisions about where to invest or establish production facilities, and the poor countries that seek to attract such investments by offering low costs through, among other methods, lax enforcement of labour, environmental, and social regulations. [[Insights]] This is probably why [[Job Creation Law (UU Cipta Kerja)]] is created. Lax enforcement of labour to attract [[Foreign Direct Investment (FDI)]] The challenge of regulating transnational corporations in a globalised economy shows several dysfunctions in the global governance system, including: the paucity of rules and codes of conduct that reach beyond the voluntary level; weak mechanisms for accountability of transnational corporations to the people whose lives and health are most directly affected by their actions; weak institutions for enforcing international norms, laws, and standards when they are violated by transnational corporations; and the absence of institutions to ensure that competition for foreign direct investment between states does not lead to outcomes contrary to public interest. ### 4.6 Irregular migration and health #### 4.6.1 Failure to protect the health of the most vulnerable An example of an irregular migrant’s experience with Norway’s health system shows clearly how constraints posed by national policies lead to a failure to protect the health of the most vulnerable people.197 A 42-year-old man travelled for hours from a rural refugee reception centre in southern Norway to attend the health clinic for undocumented immigrants in Oslo. The man was HIVpositive, but the complaint that brought him to the clinic was a constant, unbearable hip pain. At the refugee reception centre, a doctor examined him and referred him for an orthopaedic assessment at Oslo University Hospital, where specialists diagnosed joint failure and referred him for hip replacement surgery. However, the hospital’s surgical department refused to do the procedure, because his application for asylum had been turned down, hence he found himself with irregular status. The hospital that refused his surgery was the same one where he received outpatient treatment for HIV, free of charge and irrespective of legal status. HIV treatment falls under Norway’s Communicable Disease Act, which grants access to free medical assessment, diagnosis, and treatment to anyone in the country, irrespective of legal status. Were the hospital to treat his hip, however, it would not be reimbursed for the cost. #### 4.6.2 Rights of irregular migrants not respected Often, migrants are disproportionately subject to poor socioeconomic status via their migration status, ethnicity, and processes of social exclusion,203,204 and are vulnerable to exploitative working conditions in which regulations are not enforced.195,205 Furthermore, in many countries undocumented migrants are largely excluded from health care and social services,206 leaving irregular or undocumented migrants with poorer health than migrants with legal status. For example, in the European Union, most countries offer only emergency care to undocumented migrants. Additionally, fear of deportation further limits migrants’ use of health care. A range of complex, interrelated factors, including conflict, environmental disasters, and socioeconomic deprivation, can drive people to leave their countries of origin for unknown territories and jurisdictions. Many such people have been referred to as survival migrants, since they migrate because of desperate economic and social situations, but do not conform to the 1951 Refugee Convention’s definition of a refugee. Since the 1980s, the number of so-called irregular migrants has increased rapidly, with irregular migration becoming one of the fastest-growing forms of migration worldwide. Information from regularisation programmes and other sources suggests that there might be 30–40 million irregular migrants worldwide, or 15–20% of all international migrants. > [!NOTE] Panel 3: Defining irregular migrants > An irregular (or undocumented) migrant is a person who does not have legal status in a transit or host country. The term refers to people who entered the territory of the state without authorisation (eg, through smuggling), and to those who entered the country legally and subsequently lost their permission to remain. Loss of legal status can happen, for example, because the migrant has overstayed a visa or residence permit, been denied refugee status, or because an employer has arbitrarily withdrawn an authorisation to work that is tied to immigration status. #### 4.6.3 Inadequate adoption of human rights norms This situation partly reflects an absence of international guidance about how existing human rights norms should be applied to the situation of vulnerable irregular migrants. Additionally, it reflects the absence of a clear division of responsibility for protecting such migrants among international organisations.196 Although the UN High Commissioner for Refugees (UNHCR) is mandated to safeguard the rights and wellbeing of refugees, no mechanism exists to enforce the application of and respect for international human rights norms by governments—rather, each state is able to interpret their relevance in national policy making. #### 4.6.4 Protection of irregular migrants on the political agenda States have so far been reluctant to commit to new formal multilateral agreements to protect the rights of migrants. The only globally accepted protection framework for migrants that is explicit about irregular migrants (the 2003 UN International Convention on the Protection of the Rights of All Migrant Workers and Members of their Families216) has been ratified by only 47 countries; and no major migrant-receiving country has acknowledged the rights of irregular migrants specified in the convention.208 Rather than signing up to formal multilateral agreements, most migrant-receiving states prefer to develop cooperation on migration through informal regional consultative processes or through bilateral agreements. #### 4.6.5 Global governance for health: key challenges identified Migrants who cross borders in search of better lives often have no democratic representation, globally or nationally. They are disempowered with respect to the host country, which has the power to determine their legal status and their relative degree of social, economic, political, and legal exclusion from society. The difficulty in ensuring protection for the health and human rights of irregular cross-border migrants shows dysfunctions in the global governance system: mechanisms to hold states accountable for their obligations under international human rights and other conventions are weak; only nascent institutions exist to set standards for the treatment of migrants, especially irregular migrants; and institutions to ensure that health is taken into account in the development of migration policy are also weak. ### 4.7 Patterns of armed violence and effects on health #### 4.7.1 Changing patterns of violence With the patterns of armed violence emerging in this century, the global governance regime must confront intrastate instances of armed intergroup conflict, waged along communal, sectarian, or ideological lines, and often strengthened by drives to command territory and resources. Although these organised campaigns of armed violence have numerous causal roots, they often surface as vicious assaults on civilian populations, grave threats to the sovereignty of a state, and abrupt destabilisers of regional hopes for peace. Arguably, wars and armed conflicts more generally are one of the most powerful and enduring threats to human health and wellbeing. #### 4.7.2 Acute effects of armed conflict on civilian morbidity and mortality ==An inevitable result of the deliberate targeting of civilians is forced migration==. When armed groups or armies attack specific neighbourhoods or communal groups, residents flee en masse and, dependent on geographical and security constraints, become either internally displaced or refugees in neighbouring countries. UNHCR estimates that by the end of 2011 there were 42·5 million refugees and internally displaced people worldwide, the highest cumulative total since 1994.233 The average length of protracted refugee situations is approaching 20 years (an increase from 9 years in 1993). #### 4.7.3 Global governance and contemporary armed conflict > [!NOTE] Panel 4: Continuing conflict in the Democratic Republic of the Congo > Despite the official end of the war in the Democratic Republic of the Congo (DRC) in 2002, the internecine violence waged by many groups of armed non-state actors has continued unabated, with devastating effects on civilians. In the country’s eastern regions, recurrent waves of attacks on villages and settlements—often located beyond the reach of health-care services—directly target civilians, including children and elderly people. The many lethal and non-lethal attacks on these civilians have included severe and widespread infliction of individual and gang rapes of women, girls, and boys, and people who have tried to flee have found it impossible to hide or to find safe areas. > > The conflict in eastern DRC has become increasingly criminalised, with warring parties vying for control of land and natural resources. DRC is rich in minerals, including reserves of wolframite (tungsten), diamonds, and gold. It also has supplies of coltan, which is used in mobile phones and other electronic devices, and cassiterite (tin), which is used in food packaging. > The misery of civilian deaths and the horror of sexual violence have caused international outrage. However, regional politics have so far prevented the creation of a stable ceasefire or a process of enduring demobilisation, disarmament, and reintegration. Thousands of Congolese national army troops, together with UN peacekeeping forces, have attempted to restore stability and safety in the region. However, these efforts have been unsuccessful. The formal armed forces remain inadequate to constrain the incessant attacks on civilians by several different rebel groups and outside armed forces. Humanitarian health assistance has been severely restricted by the conflict, and government services in the more contested regions have broken down. > > Priority must be given to ending the reign of armed violence in the region, which will require regional and wider international insistence on the rule of law and adherence to treaty obligations by those nation states implicated in the violence. [[The wars of the present century are more complex because the time and cause of provocations due to innovations in communications technology]] However, the wars of the present century are more complex with respect to time and cause or provocation, and are less likely to be constrained by space, thanks to innovations in communications technologies such as the internet. The combination of political and socioeconomic exclusion, perceived and experienced by people as social injustice, serves to encourage acts of violence and supports larger-scale mobilisation of armed groups. #### 4.7.4 Global governance responses to new patterns of violence With the shift away from interstate war to patterns of violence less concerned with national boundaries, the challenge becomes increasingly about how to protect individuals rather than states. Progress has been made in the development of legal and normative frameworks to condemn attacks on civilians as unlawful in both peace and war—eg, UN conventions, the ICC, the UN framework on the Responsibility to Protect, and the Ottawa Treaty to ban landmines. #### 4.7.5 Global governance for health: key challenges identified 1. First, no institutions have proven effective in guiding the international community in approaching the mix of volatile domestic factors (such as unemployment, income inequality, exclusion, and oppression) and the role of external disrupters (such as global economic instability, the international trade in small arms, and international organised crime) that might aggravate existing or rising internal tensions among groups and classes of people. 2. Second, multilateral institutions such as the UN have contributed to improved security and prosperity in many parts of the world, and international humanitarian law has developed over the past 150 years to protect people from insecurity and violence and to govern the conduct of war and conflict. ## 5. Barriers to [[global governance for health]] ### 5.1 Analyses across policy intervention areas We look across the cases to show how competing norms and priorities can jeopardise achievements in global health, and identify five systemic dysfunctions that impede the realisation of global governance for health. ### 5.2 [[Power asymmetry]] and competing norms Adverse health outcomes systematically affect the most vulnerable people—eg, poor people, those living in conflict situations, and those without adequate legal rights—who often have little or no access to decent health-care services. Furthermore, even with the best of health-care services available, the root causes of these avoidable health outcomes are far out of reach for the health sector to tackle alone. ==The unfairness in the distribution of health risks and health effects, as shown in the case examples, requires global, cross-sectoral policy interventions that reflect the value of human health and welfare.== The case examples show that health and wellbeing are in many instances subordinated to other societal objectives. For example, the case of the financial crisis and austerity shows how people’s health and wellbeing are being compromised as a result of transnational economic policy making. Furthermore, contemporary global governance also allows the profit goals of private actors to displace health and social objectives—eg, the way in which strong international investment treaties and trade rules override social policies, as seen in the case of tobacco and TRIPS. Global norms, we have argued, limit the range of choice and constrain action, but also sometimes provide opportunities. Human rights law is one such opportunity. But ==we have seen that the power of the market often supersedes the power of human rights norms, including the right to health==. Also, governments in stable, resource-rich countries can prioritise other objectives over adherence to internationally agreed-upon human rights norms, as in the case of vulnerable irregular migrants. The Universal Declaration of Human Rights needs to be reinvigorated, and as a norm it could find mutual re-enforcement if combined with the surging public call for a more fair distribution of money, power, and resources than exists at present. We have seen how power asymmetries challenge collective action across a wide range of global policymaking areas and effectively hinder the realisation of [[global governance for health]]. The norms, rules, and practices generated under these circumstances are not adequate to tackle health inequity. However, understanding how these global political determinants of health can arise requires a deeper investigation into where weaknesses in governance arrangements originate. Ultimately, whether global governance has beneficial or harmful effects depends on how it is practised. ### 5.3 Diagnosing systemic weaknesses Five systemic dysfunctions: 1. First, democratic deficit: participation and representation of some actors, such as civil society and health experts, in decision-making processes is insufficient. 2. Second, weak accountability mechanisms: the means by which power can be constrained and made responsive to the people that it affects are weak and insufficiently supported by transparent governance processes. 3. Third, institutional stickiness: norms, rules, and decision-making procedures are inflexible and difficult to reform (especially when they maintain entrenched interests), and thereby reinforce harmful health effects and inequities. 4. Fourth, inadequate policy space across sectors: the means by which health can be protected both nationally and globally are inadequate, meaning that in global policy-making arenas outside of the health sector, health can be subordinated to other objectives, such as economic or security goals. 5. Finally, missing or nascent institutions: international institutions (eg, treaties, funds, courts, and softer forms of regulation such as norms and guidelines) to protect and promote health are either totally or nearly absent. ![[CleanShot 2024-01-02 at [email protected]]] ### 5.4 [[Democratic deficit]] Beyond the nation state, we are far from anything resembling global democracy, since international decision-making processes do not operate on the principle of “one person, one vote”. Rather, the main principles are based on “one nation state, one vote” or, in some arenas and for the more powerful, “one nation state, many votes”. In the [[International Monetary Fund (IMF)]] and [[World Bank (WB)]], the wealthiest countries have far greater influence over policy making than do less wealthy countries. They thus have greater ability to promote their interests and values through the international financial institutions than do less powerful countries, whose citizens are often the most likely to be directly affected by the policies that result. The democratic deficit is even greater outside of multilateral institutions. For example, in regional or bilateral negotiations over trade or investment agreements, no fixed rules exist for voting, participation, or transparency. [[Non-state actors]] such as civil society organisations, marginalised groups, and health experts are also inadequately included in international decision-making processes. The potential for the engagement of non-state actors in global governance processes has been shown by progressive changes over the past 20 years. For example, civil society and a group of mostly small and mediumsized countries mobilised to make the Ottawa Treaty to ban landmines a reality. Furthermore, the Rome Statute in 1998 that led to the formation of the ICC as a permanent institution was the result of a group of 60 countries and a 700-member [[NGO]] coalition, which succeeded despite opposition from permanent members of the [[UN Security Council (UNSC)]]. Into the 21st century, the push for participation has gained further momentum, as shown by engagement from civil society and individual citizens through social media during intergovernmental meetings such as the [[World Health Assembly (WHA)]]. At the UN, open online consultations have become increasingly common, such as the World We Want process, which allowed individuals and civil society organisations to submit proposals linked to negotiations over the post-2015 development agenda, alongside states and multilateral organisations. Dialogues and partnership arrangements with civil society and the private sector are expanding throughout the multilateral system. The ILO’s tripartite structure is one of the most inclusive within the UN system. The Committee on World Food Security enables meaningful participation by both states and non-state actors, and the [[World Trade Organization (WTO)]] and [[UN Security Council]] have been under pressure to allow more participation by other state and non-state actors. The WTO allows civil society actors to attend ministerial meetings and regular briefings, and public access to official WTO documents has improved. Nevertheless, opportunities for civil society to influence the deliberation processes are generally poor and detached from the WTO’s regular policy-making processes. By comparison, industry can have more privileged access to national delegates, who can bring their proposals to the negotiating table. Despite progress towards more inclusive global governance processes, the democratic deficit remains a central feature of most global governance processes. ### 5.5 Weak accountability mechanisms and poor transparency Accountability can be understood as “a means to constrain power and make it responsive to the people that it affects, especially people who tend otherwise to be marginalised and silenced” In the present global governance complex, consisting of a range of state and non-state actors, however, linking accountability directly to a single decision-making process or a specific actor is difficult. Accountability for the health effects of rules, norms, and policies that emanate from global governance processes can lie with a range of different actors, rather than with any one in isolation. At the transnational level, the means by which accountability can be ensured are weak. No single global political authority exists to hold states accountable when they violate or fail to comply with internationally agreed upon rules, norms, and standards, as was noted in the case of migration. Nor do adequate accountability mechanisms exist for non-state actors such as transnational firms that can move between jurisdisctions with relative ease and are often more powerful and better resourced than the governments that should regulate them, as was seen with the example of Trafigura in Côte d'Ivore. Policies of international financial institutions, such as the European Central Bank and the IMF, can have substantial and widespread effects on health, as noted in the case of austerity in Greece, the lines of accountability between such institutions and the citizens they affect are tenuous at best. [[Broader participation and transparency to enhance accountability must be followed by participation in decision-making, be it to challenge or to remedy issues]] Although broader participation and transparency in global governance can indeed enhance accountability, information is not enough when few means exist to then shape decision making. A means by which decisions can be challenged or issues remedied, traditionally done at the national level through courts, must therefore be central to accountability. For example, during its first 10 years of existence, the ICC heard only ten cases and convicted only one person. > In the contemporary governance complex, we still do not have adequate means to ensure the accountability of states and non-state actors for the health consequences of their actions. ### 5.6 [[Institutional stickiness]] > The ability of international institutions to adapt to changing environments while remaining resilient against opportunistic reforms by actors seeking undue influence is crucial for institutions to remain legitimate and effective. However, [[once international institutions are created, power can also become entrenched, and those with power will often resist surrendering it]]. This institutional stickiness makes it difficult to reform institutions to evolve with the times, and means that those disadvantaged by established rules will face daunting challenges when seeking to change them. A range of other examples also exist, such as the difficulties in reforming the UN Economic and Social Council and the reluctance to open the governance of [[World Health Organization (WHO)]] to a wider range of stakeholders. Institutional stickiness can drive some actors to seek alternative strategies or to create new institutions entirely. A tendency in the new millennium has been a growing pluralism of governance, with countries turning, for example, to regional arenas, new groupings based on common interests, multipartner initiatives, and voluntary standards. Similarly, the [[BRICS]] countries recently announced that they aim to establish a new development bank, ==signalling a dissatisfaction with the governance of existing multilateral banks==. ### 5.7 Inadequate policy space for health [[Interesting Phrase]] International rule making has proliferated, with the number of international bodies, conferences, and multilateral treaties growing from about 2900 in 1981 to 4900 in 2003. This trend has produced a system of overlapping, conflicting, and nested sets of rules (sometimes called [[regime complexity]]), which can blur obligations and responsibilities, and complicate accountability. Some global standards, such as [[Framework Convention on Tobacco Control]] and treaties that govern trade in toxins, can increase government policy space for the protection of health, other global standards can reduce this policy space. Major weakness of the system is that health concerns are too often subordinated to other objectives, such as economic growth or national security. The struggle to carve out policy space for health is clearly shown by the example of investment rules tying the hands of governments' attempts to regulate tobacco. Even existing policy space is threatened as actors seek new rules that were beyond reach in multilateral arenas, such as TRIPS-plus provisions in regional trade agreements that limit the safeguards contained in TRIPS. [[Open Question]] How do we achieve the win-win-win? For public health, for the government, and for the pharma company? Can pandemic be the entry point? National policy-making processes, such as negotiations between ministries of health and trade, can be as important as global processes for the protection of policy space for health across sectors. The [[Health in All Policies]] approach builds on what health ministries can do to advocate for health across government ministries at the national level. However, making this approach operational and effective at the level of global governance is more difficult. For example, [[Insights]] [[World Health Organization (WHO)]] has so far not been able to open up space and arenas for policy dialogue inclusive of other relevant intergovernmental organisations, governments, and nonstate actors. The intergovernmental membership, represented by the health ministries, prevents sufficient engagement with a broader set of actors to address complex challenges such as the social determinants of health, the growing challenges of non-communicable diseases, and the health security threats of pandemics, climate change, violence, and humanitarian crises. This situation has limited the effectiveness of WHO, making it unable to coordinate a coherent approach that unites political and public will and private sector readiness to act on necessary policies and regulations. > Weak institutions to protect health in other sectors, especially politically powerful sectors such as trade and security—thus remain a major weakness of the global governance system, and such weakness must be addressed both globally and nationally. ### 5.8 Missing or nascent institutions Economic globalisation has outpaced political globalisation—ie, the development of institutions that could govern the global market effectively and protect societies against market failures. Sometimes norms or rules can be agreed upon, but mechanisms for enforcement remain weak. For example, [[migration of health workers from poor to rich countries is governed by the non-binding WHO Global Code of Practice on the International Recruitment of Health Personnel, but this system does not have enforcement mechanisms]]. In other cases, regulations remain incomplete. Despite recent progress on regulation of trade in harmful chemicals, exemplified by the 2013 Minamata Convention on Mercury, only 22 of thousands of potentially harmful chemicals are subject to international treaties that govern cross-border movements. ## 6. Tackling political determinants of health ### 6.1 Harnessing the power of norms, knowledge, and responsive institutions Power imbalances will remain a central feature of global governance, but more open and equitable processes for the generation and dissemination of knowledge would allow the status quo to be challenged. ### 6.2 Agenda for change: convening, informing, and monitoring Any proposal for reforming new global institutions is likely to face the same barriers and dysfunctions that have been identified in this report, such as [[Power asymmetry]], [[Democratic deficit]], and [[Institutional stickiness]]. Proposals from the Commission: #### 6.2.1 A [[UN Multistakeholder Platform on Governance for Health]] ![[CleanShot 2023-12-28 at 13.34.59.png]] To enable global policies for health and sustainable wellbeing, the Commission proposes that a Multistakeholder Platform on Global Governance for Health should be considered. ==Drawing lessons from the FAO’s Committee on Food Security,== such a platform would engage governments, intergovernmental organisations (in the areas of finance, trade, labour, food, environment, human rights, migration, and peace and security), and non-state actors including civil society, academic experts, and business. This approach is largely compatible with the proposals by the UN Secretary General on fostering renewed global partnerships. [[Question]] How will the [[UN Multistakeholder Platform on Governance for Health]]answer the systemic dysfunction of [[global governance for health]]? 1. Derived its legitimacy from UN and serve as a policy forum with representations (diverse stakeholders) to frame issues, set agendas, examine and debate policies. It will share and review information, influence norms and opinions, and shape action by making recommendations to the decision-making bodies of participating stakeholders. 2. the Platform can respond to the challenge of weak accountability mechanisms at the global level by creating a public arena in which actors are expected to be answerable for the health consequences of their actions. 3. The Platform will combat institutional stickiness by providing recommendations that are fully transparent, with open access to all information about the policy forum deliberations and their inputs and outcomes, including specific policy advice presented to the participating stakeholders and their governance bodies. 4. The process to shape the post-2015 development agenda is expected to underline the need for review and reform of the architecture of global multilateral institutions, aiming towards a more interconnected, inclusive, and simplified system of global governance. Governance for health and sustainable wellbeing will require such reforms, and the proposed UN Multistakeholder Platform would represent a step in this direction, enabling more inclusive, better integrated, and more coherent policy dialogue across institutions and arenas. 5. The Platform would be independent of the regular health governance processes of WHO and its partners in the health architecture (such as the public-private partnerships for health), but would include WHO in its membership and benefit from the normative guidance and leadership that WHO can provide as the UN agency responsible for health. 6. ==The Platform would take on policy dialogue that involves issues and actors far beyond the health sector==, and thereby complement and strengthen the ability of WHO to serve in its mandated function in [[global health governance]]. Such an approach would lend support to WHO in its work on multidisciplinary policy responses to non-communicable diseases and add strength to promotion of the universal health coverage agenda and initiatives to address the social determinants of health. > [!NOTE] Panel 5: Issues to be worked out in establishing the UN Multistakeholder Platform > Some of the issues that would have to be worked out in a broad and open consultative process include: > 1. Formal connection to the UN and participating intergovernmental agencies > 2. Location of a small secretariat in an accessible and affordable location > 3. Ways to link to established mechanisms for inclusive participation in the engaged intergovernmental agencies, as well as to social movements and popular struggles against institutions and corporations that violate the right to health > 4. Representation of major groups of non-state actors, governments, and regional groups, with rotating membership and special opportunities for low-income countries and other weak or disadvantaged stakeholders #### 6.2.2 An [[Independent Scientific Monitoring Panel on Global Social and Political Determinants of Health]] Grounded in a network of academic institutions and centres of excellence across all world regions. The Panel will call for, receive, assess, analyse, debate, and communicate multiple lines of independent evidenceacross disciplines—and provide independent and transparent strategic information to the UN and other actors that affect global governance for health. The Panel should make full use of right-to-information policies so that its monitoring activities can inform decisions before they are made, as well as tracking the eff ects of such decisions. Data need to be generated that complement existing systems of information about biomedical outcomes and health systems, focusing also on a political analysis of the social and political determinants of health. This type of research will raise additional challenges, both in terms of defining indicators and ensuring independence. #### 6.2.3 Health equity impact assessments As more independent, evidence-based research into the social and political determinants of health is being fed into the global governance system, international institutions could be mandated to do health equity impact assessments of all their policies and practices. Such assessments could call attention to health threats, provide much-needed evidence to decision makers, and change views on policy, especially when combined with political mobilisation. For example, the IMF, World Bank, WTO, WHO, and the UN Department for Peacekeeping Operations could all be required to assess their advice and policies with respect to their effects on the social determinants of health, drawing on coordination and advice from the Independent Scientific Monitoring Panel and the UN Multistakeholder Platform. ### 6.3 Strengthening existing mechanisms #### 6.3.1 Proposals for immediate action Changing the processes and practices of global governance into a system that better harnesses the global political determinants of health will take time. We therefore also propose some immediate actions that are intended, not to root out the very causes of persistent health inequities, but to remedy the effects of the inequitable distribution of health through improved sanctions and security. #### 6.3.2 Strengthen the use of human rights instruments for health The report of the UN Secretary General, A life of dignity for all,58 highlights the growing emphasis on a rightsbased agenda for sustainable development, noting that “people across the world are demanding more responsive governments and better governance based on rights”. The Commission underlines the importance of building on this momentum. #### 6.3.3 Strengthen mechanisms for sanctions To strengthen weak accountability at the transnational level, stronger mechanisms for sanctions are needed. Sanctions can lead to punishment of those actors who violate agreed-upon standards, or to remedy for harms committed, whether in the form of an apology, commitment not to repeat, policy changes, or reparations. In view of the many global power imbalances that can limit the effectiveness of national courts, the international judicial system is an important backstop to national systems and could offer a useful mechanism for strengthened transnational accountability. The existing patchwork of international courts has wide gaps, especially for cases in which non-state actors are potential plaintiffs or defendants. For example, the [[ICC]] does not accept cases brought by non-state actors such as minority groups or civil society organisations, and transnational corporations cannot be brought before the ICC, since its mandate is restricted to prosecuting human beings. Furthermore, the ICC covers only a short list of violations. ==An expansion of eligible violations could involve standards directly related to the social determinants of health==, such as environmental pollution, corruption, abuse of labour rights, and collusion in gross human rights violations. Recognising the many challenges involved in broadening the formal mandate of the ICC, we suggest as a first step the creation of a regularly scheduled forum at which civil society organisations could present reports on alleged violations requiring greater attention from the court. #### 6.3.4 Strengthen and transform mechanisms for global solidarity and shared responsibility [[Power asymmetry]] and the unpredictability in the present OECD-based bilateral and multilateral regimes of international development assistance need particular attention. 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. We also note the need for further attention to binding instruments and compulsory, assessed contributions from all states according to ability to pay, as proposed by the Special Rapporteur on the Right to Health, Anand Grover.89 In this context, the financing of health-related global public goods also requires renewed attention. [[Question]] How to ensure sufficient investment in health-related research and development in areas for which market incentives are insufficient? Proposals have been tabled by many actors, including the [[WHO Consultative Expert Working Group on Research and Development]], to ensure sufficient investment in health-related research and development in areas for which market incentives are insufficient. One of the options is a treaty under which countries would commit to finance research and development in accordance with their ability to pay, while the research would be oriented towards the most important global public health needs. This proposal would have the eff ect of mandatory financial transfers—albeit indirect—from wealthy countries to poorer countries (which would benefit most from the research). If a binding treaty is not politically feasible, an alternative model could be the non-binding assessed contribution scheme used for the replenishments of the International Development Association (the arm of the World Bank that provides grants and soft loans to low-income countries), contributions to which are roughly proportional to a country’s share of the global economy. ## 7. Conclusion The overarching message of the Commission on Global Governance for Health is that ==grave health inequity is morally unacceptable, and ensuring that transnational activity does not hinder people from attaining their full health potential is a global political responsibility==. [[The deep causes of health inequity are not of a technical character, devoid of conflicting interests and power asymmetries, but tied to fairness and justice rather than biological variance]]. Health equity should be a crosssectoral political concern, since the health sector cannot address these challenges alone. A particular responsibility rests with national governments. We urge policy makers across all sectors, as well as international organisations and civil society, to recognise how global political determinants affect health inequities, and to launch a global public debate about how they can be addressed. Health is a precondition, outcome, and indicator of a sustainable society, and should be adopted as a universal value and a shared social and political objective for all.