Response from the London School of Hygiene & Tropical Medicine

THE EU ROLE IN GLOBAL HEALTH: QUESTIONNAIRE Response from the London School of Hygiene & Tropical Medicine The School would be willing to host workshops on relevant issues (e.g. evaluation of EU investments, technical innovation, co-ordination of research capacity building) in order to support the Commission in developing its policy in these areas. The School has undertaken work in many of the areas covered by the questions below. A selection of papers are attached to the email. The School s ECOHOST may also be of interest: http://www.lshtm.ac.uk/ecohost/ Question 1: In your opinion, does the proposed concept global health cover the most relevant dimensions? If not, which other essential factors would you suggest? It is not clear what global health encompasses within the document. While 2.1 begins with the statement that Global health is an extensive multi-sectoral domain that links not only the main policy areas of development, humanitarian aid, research and health, but also trade and foreign policy, this falls short of defining the boundaries of the concept. It is this lack of distinct and clear definition which leads the paper to imply a number of definitions, some of which might be disputed as conceptually distinct. In particular, the report places substantial emphasis on health in developing countries (referred to alternately as low-income and the poor ), but this area has formerly been known to many as international health. If the report seeks to set out the EU s role in global health, this implies that global health is somehow different. It would be assumed that the EU already has a policy on its role in international health (which is clearly not new). Overall, the report is vague in its definition of global health, combining health development issues with what might be described as distinctly global health issues (i.e. climate change and health, licit and illicit trade, documented and undocumented population migration, pandemic diseases which circumvent national territorial boundaries etc.). The paper also uses terms such as global health security (varied definitions exist which are contested) and global health system (arguably this does not exist) without similarly defining. Global, by definition, conceives the world as a geographical whole. Health determinants, outcomes and responses that do not conform to national borders, and indeed undermine or circumvent them, tend to fall within what is known as global health. Global health is not, therefore, foremost an issue of aid to the poor but a collective action problem. The paper needs far more conceptual rigour if it is to be a statement of the EU s role in global health. Question 2: Are the effects of globalisation on health, on the spread of diseases (whether communicable or life-style non-communicable) and on equitable access to health care sufficiently described? The paper deals inadequately with the growing epidemic of chronic diseases that is resulting from the spread of unhealthy lifestyles (changing diet, exercise, smoking habits 1

etc) such as problems of increasing obesity, CVD etc. Globalisation influences are heavily implicated in these changes. There is now a substantial amount of evidence on the effects of globalisation on human health, both direct (e.g. migration of people and infectious disease outbreaks) and indirect (e.g. global economic crises and access to health care). The measurement of global health determinants, outcomes and responses, however, remains constrained by data which is organised by individual country (statecentric), as the unit of analysis, or aggregated to the regional or international levels. Global health data is scarce. This is data that allows health determinants, outcomes and responses that do not conform to the national unit of analysis to be described and analysed. For example, the health status of female migrant workers in special economic zones of a particular industrial sector in outsourcing facilities based in different countries is not easy to capture. Another example is the complex patterns and trends in obesity which affect different socioeconomic groups across different countries. How climate change will impact on different population groups, rather than specific countries, also needs better data. What are the effects of globalisation on the health of the poor, regardless of whether they live in a high-, middleor low-income country? All of these core global health issues require improved data sources to better understand the effects of globalisation and the needed responses to them. Question 3: Do you consider the health-related MDGs a sufficient framework for a global health approach? If not, what else should also be considered? Health-related MDGs should also include 1c on nutrition and 7 relating to drugs. The strong focus on the MDGs, in the paper, but also more generally, reflects the point made in Question 1 that global health is somehow equated with health development. While improving health in the developing world is a core part of global health, it is not the whole story. Moreover, the MDGs are selective and target-driven which global health supports a more holistic approach to public health given the interconnectedness of diverse issues. In other words, without addressing trade imbalances, targets to improve maternal and child health will be difficult to achieve. Many of the questions posed in the paper (e.g. Questions 4, 6, 7, 8, 9, 10) are similarly concerned with EU aid policy (notably aid effectiveness) rather than global health per se. Again, while aid is a key part of the EU s role, framing global health in this way only captures part of the agenda. More broadly NCDs need to be considered, and the strengthening of health systems needed to achieve all health-related targets. School staff are undertaking major programme of work on the potential for new targets after the MDG target date of 2015. The outcome of this work will be published in the Lancet medical journal in 2011. If the EU would like to know more about this initiative we would be happy to provide more information. 2

Question 4: In your opinion, which are the main strengths and weaknesses of the current EU policy on health and development cooperation, and which dimensions should be given greater attention in order to face the challenges ahead? A key weakness is that standard programmes last for three years, and there needs to be longer-term approaches. There also needs to be more rigorous evaluation of the impact of EU funding on health outcomes. We suggest there should be more emphasis on reducing inequalities and a European-wide policy co-ordinating health aid to recipient countries. Question 5: Could you identify health problems that have been neglected by the EU and international health research agenda and propose the best means to support innovation to address them, especially in low- and middle-income countries? NCDs are a neglected problem. Greater investment in health systems research is required to address problems. Also population issues are not addressed by the paper Question 6: Do you think that ODA commitments for health should increase, and how do you think that other sources of financing could contribute to addressing global health and universal access? Donor countries should live up to the commitments they have already made before making additional commitments. Equally vital is that developing countries be supported to develop national financing systems with much higher levels of risk pooling. Question 7: How do you think fragmentation of aid for health could be reduced, with a view to increasing aid effectiveness and preventing detrimental health spending? Current funders need to work together far more. Streams of funding need to come together at country level in support of country strategies. Very careful thought needs to be given to how best to co-ordinate streams of funding for health systems strengthening agencies like Global Fund and GAVI should not be in the lead given their specific disease/programme focus and lack of health systems expertise. We suggest there is a role for the EU in co-ordinating donor countries. Question 8: In the context of aid effectiveness and alignment of financing to national priorities, what can be done to make sure that adequate attention is paid to health priorities and to strengthening health systems? Countries with competent government should be setting their own priorities, rather than influenced by the developed world s view of disease priorities. There needs to be greater discussion about the different approaches required for different countries, as a one-sizefits-all approach is inappropriate. 3

Countries usually recognise the importance of the system. However, dialogue will be needed to ensure resources are focussed on building up as a priority the primary care and local hospital network. Evaluation to demonstrate value for money should be built into aid policies Question 9: What are your suggestions for striking the right balance between addressing health priorities and providing support for developing health systems? It is a false dichotomy to view health priorities as somehow different from health systems they need integrating. Question 10: What are the main opportunities for increasing the level and enhancing the effectiveness of health aid from the EU? It is essential that evaluative research is built into large scale health programmes such as those funded by the EU, the Global Fund to Fight AIDS TB and Malaria and GAVI. This is necessary in order to ensure not only that the resources spent achieve the intended goals but also that lessons are learnt about the most appropriate ways of organising and delivering services and addressing the cross cutting health system constraints of human and financial resources and weak governance and regulation. Question 11: In your opinion, what are the links between health, governance, democracy, stability and security and how could the right to health be put into operation? Question 12: What impact will the global crisis (climate change, food prices and economic downturn) have on global health and what could be done to help mitigate their ill effects? This is one of the few questions that gets to the heart of the global health agenda. The various crises described reflects a weakness in the governance of the emerging global political economy. Weak or non-existent regulation, and the absence of institutional authority to ensure social and environmental protections, lies at the heart of the current crises. Allowing the market to define the globalisation process, and framing social and environmental protections as somehow hindrances to be minimised, has proven shortsighted. A fundamental rethink of global institutional frameworks, similar to the policy debates after the Second World War that led to the creation of the Bretton Woods Institutions, is needed. The EU might lead on this process. The EU might also reflect on how it has contributed to the various crises faced through unfair trade policies (e.g. subsidies, IP protections), levels of carbon emissions, and the Common Agricultural Policy. More emphasis needs to be given to policies that can address environmental priorities such as climate changes and achieve co-benefits for health 4

Question 13: What should be the role of civil society in the health sector, at national and local levels? Civil society can play a critical role in helping hold governments to account for provision of health services. Question 14: Which action do you think the EU should take to stem the brain drain of health workers, while respecting their freedom of movement? There is a balance between stemming the brain drain and allowing freedom of movement; however, we suggest that stemming the brain drain should be a priority. There are a number of ways in which the EU could help to offset the costs of losing health workers. For health workers who have trained in Europe, contracts could be implemented to retain them in their home country. The EU could also encourage members to ensure that training programmes recruiting students from low income countries are tailored to support health workers returning to and working in the home country. Question 15: What role do you see for new technologies (including telemedicine) in enabling developing countries to provide access to care even in remote areas and to allow better sharing of knowledge and expertise between health professionals, and how can the EU support this? Question 16: What are the keys to ensuring equitable access to medicine and how could the EU help to do more on this, including by supporting innovation and management of intellectual property rights? Question 17: What could the EU do to improve the research funding for global health? Simplify procedures and ensure evaluation is built into aid programmes. There is an abundance of research funding for certain types of global health research but very little for that which intellectually challenges current paradigms. Many funders define global health in terms of biomedical research, focusing on the creation of new drugs, vaccines and health technologies targeted at selected diseases or conditions. This paper, in places, suggests it takes a similar approach to research (e.g. discussion of effective tools in 2.1.3 and product development in 2.2.3). Research on the bigger picture, such as how to effectively institutionalise such interventions, how to democratise global health institutions, how to restructure the health sector aid system, and how to embed global health issues with foreign policy/security policy agendas remain enduring issues. These types of issues are intimately linked to how we might make globalisation work for the greatest good. Such higher order questions require engagement with a broader community of scholars and thinkers beyond the health 5

community. In this sense, the EU should support research on global health which is truly multidisciplinary. See also the answer to Q 10 above. Health research should be integrated with large scale delivery programmes with a small proportion of the total funds allocated to evaluative research. Question 18: How, in your opinion, could the EU research funding effectively address the systemic weaknesses of health systems worldwide? By greatly increasing funding available for health system and policy research, and including for evaluation of reforms. Question 19: How do you think national capacity and local scientists in low-income countries could be empowered to conduct research relevant to their countries priorities? The paper should address building research infrastructure in low income countries. We suggest a key role for the EU is co-ordinating capacity building initiatives through developing links across sectors and co-ordinating national governments. It is also important to support local institutions develop career structures and to support long term partnerships with institutions in low and middle income countries.. Question 20: Which kinds of global public goods for health should be given priority and how should they be financed and managed? Question 21: Which do you think are the priority areas for coherence on global health policies, and how should they be addressed? Health systems strengthening different donor countries should not be pushing different policies on countries. Question 22: How could the legitimacy and efficiency of the present global health governance be improved and which role should the EU play in this? This is perhaps the most challenging question posed in the questionnaire, and many leading scholars (including a major European Research Council-funded project at LSHTM) are addressing this key issue. There is no global health governance at present. It might be argued that we are in a period of transition, from international to global health governance. The picture is extremely messy, in terms of the collective institutional dysfunction that has emerged, yet opportune in the clear commitment by states, markets and civil society for an effectively functioning system. Research and policy to tackle this subject head-on is needed. However, with a few exceptions, funding for research on this subject can be largely donor-driven, rather than funded by research councils, which influences the type of research undertaken (e.g. timeframe, consultancies rather than longer term studies) focused on aid effectiveness. Many funders, such as the Gates Foundation, do not fund research on this subject. Despite this, there have been many 6

studies and initiatives over the past 10-15 years analysing selected global health institutions, many of them carried out by individuals and institutions within EU member states. A useful exercise would be to take stock of these initiatives, in terms of their key questions and findings, as a first step towards a major new research and policy agenda to tackle the challenges faced in transitioning to global health governance. This might be tied to existing initiatives, such as the Oslo Declaration on health and foreign policy. Question 23: Do you think a definition of a universal minimum health service package would facilitate a rights approach and progress towards more equitable coverage of services? If so, how could such a universal minimum standard be defined? No goals for health services need to be set at country level in the light of local preferences and resources. Question 24: What, in your opinion, should be the main principles guiding equitable social protection for health? The paper emphasises the importance of equitable and universal access to good quality health care. However it also notes that the main determinants of health and health inequalities lie outside the health sector, and these include poor nutrition, unsafe water and sanitation, unsafe sexual relations, household and workplace conditions, poverty, exclusion and poor education [which] are the main causes of ill health. (paragraph 3.1, page 8). Despite this statement about the importance of the social determinants of health, the main focus of the paper is on access to health care. One of the main principles should therefore be that all policies - and not just health policies have a central role in improving health and reducing inequalities. Implicit in this statement is the necessity for all policies to be evaluated as to their effects on health and health inequalities, and for the negative effects to be mitigated where necessary. Question 25: Which fair financing principles and mechanisms should apply to health system financing to ensure equitable and universal coverage of basic health care? Health protection may be achieved through social insurance or general taxation, but should be adapted to each country setting. Question 26: What is the role of civil society in global and national health governance and how can potential conflicts of interest between advocacy and service provision be avoided? Question 27: What, in your view, is the main added value offered by the EU in the field of global health? The EU, given its process of regional integration over the past half century or so, could be the source of many lessons for global health. These lessons might be health sector specific, such as the achievement of standardisation across national health systems of language, legislation, practices, standards, etc.; the migration of patients and health 7

workers; health research collaborations; and the regulation of health-related flows of trade (goods and services) across member states. Beyond the health sector, the EU offers interesting lessons regarding the political processes (from local engagement to high-level global health diplomacy) of achieving consensus across member states on what is seen as a domestic policy area. The EU policy on public health is still relatively new and underdeveloped, but might be a source of broader lessons beyond the EU for tackling global health issues. Beyond the institutions of the EU, many of the world s leading research scholars and institutions concerned with global health are located within EU member states. These are not yet captured by the current EU initiatives on global health, which are policy driven. A forum for closer engagement between the research and policy communities on this subject would be critical. In our view the proposed coordination of the global health activities of European academic public health institutions under the auspices of the Association of Schools of Public Health in the European Region (ASPHER) should bring real added value to the EU by providing a point of contact with the relevant expertise within the Europe. Question 28: Do you think that an EU social model could inspire global health equity? The EU social model has many variants. It should be of interest to low income countries, but they should also be free to explore models from other settings and cultures. 8