Evidence-based civil society advocacy...

At the upcoming 3rd Global Symposium on Health Systems Research in Cape Town, I will actively participate in a satellite session “From human resources for health research to policy change: The role of advocacy” organized by the Health Workforce Advocacy Initiative. I will there talk about “Evidence-based civil society advocacy in the field of international migration of health personnel”. 

The content of that input is not really an issue: I asked some colleagues to provide insights in the making of recent papers on international migration of health personnel and the implementation of the WHO Global Code of Practice, and I will present the results of this little piece of “research”. 

But I am struggling with the words and the concepts. It might look as if policy change in key areas affecting people’s health can be achieved as simply as this:

(1a) There is sound (scientific) evidence that a policy is wrong and needs to change;
(1b) and/or there is scientific evidence on how to do it better;
(2) civil society “advocates” then take up the issue up and push the policy-makers
(3a) to do their job and change the policy;
(3b) eventually after publicly “committing” themselves to doing this;
(4) which again needs to be followed-up by civil society advocates.

Any questions? ...yes, eventually. Being in South Africa: What did it take to overcome Apartheid? What did it take to make HIV/AIDS medicines more accessible and affordable for South African patients? So what evidence is needed for political transformation, and what “advocacy”, what solidarity and support for those who struggle for their right to health, what political action? I hope to get some new answers in Cape Town, mainly also from researchers and policy makers, as the main theme of the Symposium is “science and practice of people centered health systems”.

And regarding the role of international NGOs in policy change and political transformation, I am just reading once again the input “high time to re-politicize NGOs” of my colleague Thomas Gebauer, two years ago, to the MMI workshop, at the People's Health Assembly ... in Cape Town. And it took me a bit longer than initially expected to put aside, after lecture, the angry blog post by Arundhati Roy:

“The NGO-ization of politics threatens to turn resistance into a well-mannered, reasonable, salaried, 9-to-5 job. With a few perks thrown in. Real resistance has real consequences. And no salary.”

Thomas Schwarz, Executive Secretary

Medicus Mundi International. Network Health for All
HWAI working group on migration - HW4All press officer

The World Health Organisation: Towards health-equitable globalisation

Next week, the Executive Board (EB) of the World Health Organization (WHO) gathers for its 134th session in Geneva, Switzerland. An impressive range of issues will be discussed and negotiated during the 6- day meeting. Amongst these issues are policies that are of great importance to global health governance, such as the draft terms of reference for the global coordination mechanism on the prevention and control of non-communicable diseases, a framework for WHO’s engagement with non-state actors and maternal, infant and young child nutrition.  Once again, the People’s Health Movement will have an experienced team of WHO watchers in Geneva, analyzing in detail the Board documents, providing comments and observing the debate at the EB.

WHO is since 2011 involved in yet another process of reform. One can read in the evaluation report of the Second stage evaluation on WHO reform by PwC the following:
“There are concerns from academia and partners that WHO has been weakened with the expansion of global health initiatives, in what has been called ‘the golden era of global health’. Interviews have shown that although WHO is seen as a critical player, and that its intergovernmental nature is valued, it has not addressed with enough vigour the question of its role in global health governance. There is a feeling that WHO is ‘tip-toeing around the essence of the organisation’, as presented by a global health advisor interviewed”.

This mimics a concern I raised after a consultation on WHO’s engagement with non-state actors in October 2013, concluding that the organization still lacked a strategic vision on its  potential role in global health governance. This month several academic articles have been published, which more or less share a common message: they all call for alternative global governance mechanisms for health, an urgent requirement in our 21st century globalized world, they say. John Lidén argues for UN agency heads (from WHO, UNICEF, UNFPA) to come up with bold ideas, vision and leadership. Ilona Kickbush suggests systematically following the flow of money through the global health domain, and the set-up of a high-level independent panel on global health impact. It would analyse and oversee the implementation of the health and other international agreements adopted (such as in trade, the environment, and food) and report regularly to the UN General Assembly and World Health Assembly.  Julio Frenk and colleagues  make in the Lancet the case for a renewed concept of Global health that would be governed by “the construction of a global society, that emerges as a feasible alternative to harness interdependence in a world polity where sovereign nation states coexist with expansive social networks transcending national boundaries”.

In the journal Public Health, Steven Hoffman and John Arne Rottingen provide examples why WHO should be split in two, separating its technical and political stewardship functions into separate entities, with collaboration in areas of overlap. And lastly, Kelley Lee and Tikki Pang  challenge us to go beyond navel gazing, and move the WHO to a truly Global Health Organization, “with a more carefully described mandate and power, yet having a more binding authority, to make its role more meaningful in terms of effectively delivering the essential functions needed to protect and promote health in a globalised world, governed in a ‘cosmopolitan democracy’’”.

What strikes me in all these articles related to global health governance and/or global governance for health is that relatively little attention is being paid to global health equity.
But (global health) equity is an essential, too often neglected, aspect of globalization that requires urgent and committed attention, as many actors and institutions now agree, and global health governance debates should center around this concern. The gap between the “globalizers” and the “non-globalizers” is growing, and its impact can be seen in population health outcomes becoming more unequal, both between and within countries. It is hence good to reread the work of Ronald Labonté and colleagues who wrote in 2007 about health-equitable globalisation and the corresponding need for more Rights, Regulation and Redistribution. They provided in this report the framework of three ‘Rs’:

• systematic resource redistribution between countries and within regions and countries to enable poorer countries to meet human needs,
• effective supranational regulation to ensure that there is a social purpose in the global economy, and
• enforceable social rights that enable citizens and residents to seek legal redress”

I will not go into detail what this implies for global governance structures, the report provided some good recommendations in this respect. Bottom line is that before we create new institutions and mechanisms, we should analyze why these three Rs cannot be provided by our current global institutions, including WHO. This is in essence analyzing political and economic injustice, and identifying barriers to a more just world.

I would like to provide one reflection though. The Lancet Commission on  Global Health 2035 as well as the president of the World Bank recently made the plea for more investments and ‘for a Grand Convergence’ in health as collectively we have the financial and technical means to do so.

They argue that Universal Health Coverage will fulfill the human right to health, and that pro-poor investment (progressive universalism) is an appropriate redistribution mechanism on  the pathway towards UHC. What I miss in these, and many other papers, is that there is also an absolute need for binding regulations for health, whether at the national, regional or global level. Regulations are not only needed to guarantee sufficient international financing for health (such as an international transaction tax, or other global taxation mechanism), but  they are also necessary to prioritize health above other global forces, eg trade liberalization, ecological erosion, unhealthy food or the intellectual property regime.  But maybe the Lancet Commission on Global Governance for Health will talk about this in more detail in its report, to be published on 11 February.

Anyhow, regulation will always be hard, as it clashes with our ongoing appetite for liberty and individual freedom…

Remco van de Pas, Wemos. First published in: International Health Policies, 16 January 2014 http://e.itg.be/ihp/archives/world-health-organisation-health-equitable-globalisation

A renewed agenda for HRH, with some grey areas

The Third Global Forum on Human Resources for Health has just concluded, and I have finally arrived at home, quite happy that the issue of human resources for health had a space of renewed attention within the international community, but also that a renewed agenda has been forged and a consensus has emerged in this area (see "Recife Political Declaration on Human Resources for Health"). As often occurs to me when I walk out of large international discussions, however, I left the Forum with a few question marks in my head, related to the actual meaning of the consensus emerged.

Everybody, for example, agreed that there is an established consensus on the fact that political will is essential for HRH development. I always feel lost in this statement, as I keep asking myself  which kind of political will we are referring to? For me the critical question is: if this political will actually existed, would it incorporate the equity dimension? As the equity dimension cannot be assumed as a natural part of any political will, it seems to me that saying that the latter is central leaves the political issue undefined.

In addition, the political will of a Minister of Health can do little when confronted to broader determinants such as the lack of development in rural areas, or a low negotiating power with regards to migration or, even more substantially, fiscal space constraints. Can health systems in low-income countries be expected to do substantial changes out of political will, or should this issue be strongly linked to aid levels and fiscal space discussions (which were not prominent at the Forum)? Or can southern European Health Ministers truly invest in their health workforces in the frame of the constraints posed to them by the Fiscal Compact?

The challenge of the growing health workers migration was also prominent at the Forum and acknowledged as an area of consensus. However I wonder if one can truly say that there is also political consensus on the need to implement the WHO Code of practice on the International Recruitment of Health Personnel: emerging countries committing to Universal Health Coverage are obviously expanding their health services and are therefore, in some cases, hunting - also abroad - for health workers to staff their new facilities (I think of Brazil but the US may go in the same direction). On the contrary, other countries perceive the remittances sent back home by their health workers abroad as crucial (it is the case of Philippines, but also of some African countries), although I am not aware of any conclusive evidence saying that the value of those remittances overweight the negative impact brain drain has on the health system. This leads to a paradoxical situation where Canada, with a nurse/patient ratio of over 8 /1000 affirms that they do not have enough (and look for them in the Philippines, with a bilateral agreement), while the Philippines, with a nurse/patient ratio of 1.7/1000 affirm they have a lot, and are therefore ready to export them, as was suggested in the session dedicated to migration. In this complex political environment, more tricky issues connected with brain drain phenomena - like for example compensation to countries of origin, or the internal brain drain from the public sector by NGOs and by vertical programmes - remain out of the picture.

Another consensus statement which emerged from the Forum relates to the need to strengthen community and mid-level health workers, their full integration within health systems in the frame of task-shifting processes. The prevailing reasoning behind this statement seems to be that lower cadres are more cost effective. Cost effectiveness must of course be a central part of the debate, but not alone, and I wonder if an appropriate addition would be to think how it is also ensured that these cadres become agents of social change. More and more, in fact, these health workers will have a role as promoters of equity, dealing with the prevention of non-communicable diseases and the social determinants of health, and they should be able for example to critically understand the impact of food and tobacco industry on health.

Other "grey areas" for me include the stewardship role of the state in promoting human resources for health for Universal Health Coverage, or the role civil society is called to play in this frame. Question marks remain in my head...

Giulia De Ponte, Amref Italy, advocacy coordinator of the Health workers for all and all for health workers project (HW4ALL), was in Recife at the Third Global Forum on Human Resources for Health. Other voices of HW4ALL project members from Recife: presentations by Linda Mans ("A sustainable health workforce starts at home") and Remco van de Pas ("Towards sustainability in financing HRH"), blog "The Health Worker Crisis" by Nathalie Sharples and blog "Time to blossom? Renewed partnership of WHO and GHWA" by Linda Mans. 

Time to blossom? Renewed partnership of WHO and GHWA

A tough period of engagement between the World Health Organization’s (WHO) Human Resources for Health (HRH) staff and the Global Health Workforce Alliance (GHWA) secretariat over the last halve a year has eventually resulted in a better (defined) marriage. After a sharp decline in financial resources for both of them, the need to rush to the same donors and poor collaboration nearly killed their partnership. GHWA will continue its activities (at least) until 2016. I hope today's GHWA Board meeting will bless yesterday's announced renewed partnership of WHO and GHWA.

Both organizations had very little time to organize this Third Global Forum on Human Resources for Health. And although I am rather frustrated that it was mostly about sending information (I was also spreading messages myself), I am also excited to read that with the Recife Political Declaration on Human Resources for Health government representatives commit themselves again firmly to implementing the WHO Global Code of Practice on the International Recruitment of Health Personnel. Together with our own commitment, we will use the Recife Declaration to hold our governments accountable for developing mechanisms towards improved and equitable access for every person to competent health workers and health services.

Just after the closure session of the Global Forum Marie-Paule Kieny (WHO) and Ruediger Krech (GHWA director a.i.) presented a draft role division within their partnership. GHWA will concentrate itself on advocacy at global level, convening stakeholders and accountability (e.g. monitoring and evaluating commitments made). WHO, with its normative role and technical support, will focus on education and training, equitable access to health workers (e.g. through the WHO Global Code of Practice on the International Recruitment of Health Personnel), and HRH information and planning.

Of the GHWA members and partner participating in the Forum, there were quite a few civil society organizations. As civil society we have put a lot of time and energy in urging for more synergy between WHO/HRH and GHWA. The audience was glad to see that GHWA will continue its activities (at least) until the next Global Forum that will be organized in 2016.

I also encourage WHO headquarters and WHO Regional Offices for more collaboration and information exchange, e.g. on best practices of WHO Code implementation. The audience also clearly stated that the GHWA board should take leadership.

To have this marriage blossoming, WHO and GHWA are currently looking for a new director for both GHWA and the WHO HRH Department that should rather be a good manager with some technical knowledge, than a very technical person with poor management skills. Would that be you?

Linda Mans, Wemos, MMI Network activist and coordinator of the Health workers for all and all for health workers project, was in Recife at the Third Global Forum on Human Resources for Health. Other MMI Network and HW4ALL project voices from Recife: CSO commitment statement "No Progress towards Universal Health without Health Workers", presentations by Linda Mans ("A sustainable health workforce starts at home") and Remco van de Pas ("Towards sustainability in financing HRH"), blog "The Health Worker Crisis" by Nathalie Sharples and blog "A renewed agenda for, with some grey areas" by Giulia De Ponte.

WHO’s engagement with “non-state actors”

On 17 and 18 October 2013 the WHO held an informal consultation regarding its engagement with non-state actors. The discussion paper guiding the consultation reads:  “This paper proposes ways in which engagement with nongovernmental organizations (NGOs) and private entities can be improved, including the strengthening of due diligence, management of risks and conflicts of interest, and increasing the transparency of engagement.”

It is interesting how the semantics and debate regarding WHO’s relations with other actors have changed over time. WHO spoke in the 80s and 90s mainly of cooperation with NGOs. Read for instance the excellent consultation report from 1997 “A new global health policy for the 21^st century, an NGO perspective”. This perspective shifted in the first decade of this century to cooperation with NGOs and Civil Society Organisations. The Civil Society Initiative in 2004 contributed to a proposed renewal of a “policy for relations with Non-Governmental Organisations”. This proposal however did not pass the World Health Assembly in 2004, as some countries opposed it.

In 2011 WHO started a process of reform, due to financial, organizational and legitimacy challenges. One part of the reform focuses on governance with external stakeholders. In 2009 already an attempt to create a so-called committee C of the World Health Assembly was blocked by member states. In 2011 a proposal for a world health forum, a multi-stakeholder platform, that would assist in policy shaping for WHOs governing bodies, did not pass either.

And now it is 2013. As NGOs we have had over the years several consultations with WHO how to move forward on this governance matter. During the last Executive Board meeting in May 2013 the represented WHO member states, but not all of them, proposed to develop overarching principles for engagement with non-state actors. Since then the WHO secretariat has reshuffled some of its staff working on this governance matter and appointed a special envoy on the engagement with non-state actors, Prof. Thomas Zeltner, the former head of the Swiss Federal Office for Public Health.

So there I found myself, representing a non-state actor (or a civil society organization, or a non governmental organization, or a stakeholder?) in this consultation last week. Within our constituencies, we have little confidence in this reframing and lumping together of all different actors, as can be read in this statement. Rather than non-state actors, we see ourselves as part of the extended state.

The consultation itself was chaotic. It was too open in its scope and could have been much more guided by the WHO secretariat. It was not a constructive sharing, as civil society, commercial actors and (some) member states all had to defend their points and positions. It felt like being in a zoo, in the middle of a cacophony of different sounds.

Dominant multi-stakeholder paradigm

I believe that there are two crucial issues; the first is that the multi-stakeholder, neoliberal “the-world-is-flat” paradigm has become the dominant form of governance within UN and other multilateral bodies. This model can be best envisaged by the framework proposed below by Julio Frenk and Suerie Moon in an article on Governance Challenges in Global Health (March 2013).

WHO is preparing for (and defending) its role and position in a new global coordination mechanism for NCDs as well as in the new UN Interagency Task Force on the Prevention and Control of NCDs. WHO has to follow this multi-stakeholder approach, because otherwise financial donors (both member states and others) would find another multilateral platform to work on the NCDs. The stakes are simply too high. With the rise of NCDs in low-income countries and emerging economies, and with their relation to food and beverage consumption, there are many interests from governments, transnational companies as well as NGOs to be involved in this global market place. WHO can only follow and try to influence this direction from within (via due diligence, management of risk and transparency procedures) or otherwise risks to be bypassed.

Still lacking vision of WHO’s role in global health governance

This leads to the second issue. While there has been much debate about the finance, governance and organization of WHO, there has been little talk about WHO’s vision and strategy to address public health challenges in a globalized, rapid changing world. Growing health and social inequalities, ecological health erosion, food and water insecurity are enormous challenges for public health in the 21^st century.  Yes, WHO has a new global program of work valid for the coming years, but it hasn’t got a clear strategy how to be engaged and position itself in the global governance around these modern public health challenges. Fair enough, WHO is an intergovernmental organization, and is not allowed this progressive, autonomous, mandate by its member states.

In the late 70’s (comprehensive primary health care and health for all by the year 2000!) and late 90’s (a new global health policy for the 21^st century), it was still evident where WHO wanted to go. This is less the case in 2013. What is the public health value I sign up with if I keep engaging myself the coming years with WHO? After this consultation, I sincerely do not know. Will WHO be open to work with organizations on alternative models to protect public health? The biggest risk for WHO is not that it will be underfunded, but that it will lose further legitimacy as the leading global public health authority.

Remco van de Pas, Wemos Foundation 

First published in International Health Policies, 25 October 2013 

 

First impressions from the WHO consultation on “Non-state actors” relations

Impressions from the first morning of the informal consultation, by Thomas Schwarz, Executive Secretary of the MMI Network.

(1) It is incredible to see how semantics develop and can influence a process. The blurring and simplifying “non-state actors” language introduced by the WHO secretariat before the May EB meeting and used as a title for the current consultation meeting has become mainstream, accepted and used by most of the speakers. Implications for the future process?

• see WHO discussion paper http://www.who.int
• see DGH statement of concern http://www.medicusmundi.org

(2) Very interesting feedback by WHO DG’s special envoy Thomas Zeltner from his consultations with the private industry: “They are not interested to directly participate in the meetings of the WHO governing bodies, because they are already there, represented by their associations which are registered as NGOs.” – How will WHO handle this situation and prevent undue industry influence in its normative and regulatory work if not with a very specific private sector policy including their business associations?

(3) It is also interesting how countries such as Finland and Brazil now refer to their experiences with dialogue with the private sector. What are their rules for this? I would also be interested to know more about the composition of country delegations at the WHO governing body meetings, mainly regarding parliament, civil society members, academia – and lobbyists.

(4) The whole consultation focuses on the WHO Secretariat level. But all WHO member states need to define policies and instruments for engaging civil society not only in their domestic health policies, but also in the making of their positions on global (health) issues. We are advocating for a WHO in which the normative processes for global health policy are led by countries, based on coherent positions resulting from a democratic political process at the domestic level. True global health democracy (and related accountability) starts at home. There is no shortcut nor quick fix for it at a global level. 

• see MMI editorial: www.medicusmundi.org

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Consultation Meeting website: www.who.int/about/who_reform
MMI thematic guide on WHO reform: www.bit.ly/whoreformguide

Europe concerned about the mobility of health personnel

How can European countries, the Netherlands included, contribute to the creation of a sustainable health workforce worldwide? What can we do within our own borders, and how can we help ensure countries beyond Europe have the qualified health providers they need to build up their public health systems? But beyond that, how should we address the growing inequality in access to health providers in Europe? These are thought-provoking questions, and the first two are my particular focus at Wemos – but the third one is emerging.

By Linda Mans*

Access to a health provider is an essential criterion of Universal Health Coverage (UHC), a concept (and term) formulated by the World Health Organization (WHO) and defined as access to health care (prevention, health promotion, treatment, rehabilitation and palliative care) for all people without financial risk to themselves. It will also be the theme of the third Global Forum on Human Resources for Health (HRH), held in November 2013. Organized by the WHO and the Global Health Workforce Alliance (GHWA) to highlight the urgency of UHC, the Forum will concentrate particularly on what national and regional parties can do to build a sustainable and fair global health workforce.

The Oslo Consultation on Human Resources for Health for high income countries

A first step in this direction was taken on 4 and 5 September 2013, when representatives of 14 European countries convened in Oslo. Among those attending were WHO, GHWA, WHO/Europe, policy makers, researchers, professional organizations and civil society organizations such as Wemos. As the coordinator responsible for the European Health workers for all and all for health workers (HW4ALL) project, I had been invited to shed light on the role of civil society organizations. In the HW4ALL project, Wemos and organizations from eight other European countries have partnered to raise awareness about the WHO Code of Practice for the International Recruitment of Health Personnel. Efforts include translation of the WHO Code for practitioners and the facilitation of dialogue between the actors involved in training, recruiting, retaining and deploying health care workers. By working together to identify opportunities and avenues for promoting a sustainable and fair national health personnel policy, this multi-stakeholder approach has enabled us to join forces and pool our professional expertise to stimulate policy and activities keyed to this objective.

During the Oslo conference, the central question was how the migration and mobility of health personnel in Europe – which exploded on the back of the economic recession – is impacting the availability of qualified health providers for European citizens. Notably, participants steered clear of any discussion of European funding distribution policy, apparently feeling that financial debates about how public funds should be spent and how much money is needed to support a sound and adequately staffed public health system ought to be left a national affair. However, I doubt whether a discussion limited to purely practical aspects, with no consideration of budgetary responsibilities, will get us very far.

The Finnish delegation explained that a future-proof national health plan will only come within reach if different ministries (health, employment, finance and foreign affairs) can all be brought to the same table. This would enable countries to stake out health personnel policies that are only minimally dependent on international influx, that are geared towards the welfare of an ageing population and that will not crack under austerity measures.

WHO Code of Practice for the International Recruitment of Health Personnel

Representatives from Norway and Ireland demonstrated that the WHO Code of Practice for the International Recruitment of Health Personnel can provide an anchor for a coherent health workforce policy. Both countries have implemented national measures to ascertain how many doctors and nurses need to be trained and in which specializations. In making these countries less dependent on foreign health personnel, these measures also ensure they won’t be exacerbating the global and regional brain drain. Alongside this focus on education and training, these countries are also looking at how to retain their own health personnel, for example through education programmes and salary provisions. And if an injection of foreign health personnel is needed, they make agreements with the countries of origin regarding the duration of stay, employment conditions, training options and workers’ return. Additionally, Norway and Ireland have both adopted foreign policies that aim to help low-income countries strengthen their own health systems, including measures and investments keyed to health personnel. These two member states have played an active role in promoting this topic at the WHO. At home, regular meetings on global public health issues between officials from the respective ministries of health and foreign affairs enable them to coordinate with each other and thus ensure the coherence of their policy interventions.

These examples dovetail with the next step of the HW4ALL project, which will shortly be presenting an online platform where policy-makers at different ministries and health professionals will be able to share examples and experiences of good practices with each other. For example, the retention of health personnel and achieving an equal workforce distribution are a key priority for various European countries. In particular, they are concerned that people living outside urban areas will no longer be able to find doctors as these have all moved to the cities or abroad. Denmark has introduced a system in which during their internship medical specialists are deployed to a particular region for a certain period, giving them a look behind the scenes at different institutions and assuring Danish citizens access to good care. The online platform will offer a space for sharing and discussing measures and interventions like these and for different disciplines and countries to learn from each other.

Fundamental debates on the future of welfare and health care are essential

At Wemos, one of the main questions we are looking at is how we can ensure that everyone in the Netherlands and, indeed, all of Europe, continues to have access to a qualified health provider even in these times of government cutbacks. Already, some European researchers have been sounding the alarm. At the European Public Health Alliance (EPHA) conference that also took place during the first week of September in Brussels, the Romanian State Secretary of Health related how the conditions dictated by the International Monetary Fund (IMF) and the European Commission in 2009 have led to the disappearance of many clinics in rural Romania. What’s more, following salary cuts in 2011, more than 2,000 doctors registered for international recognition of their credentials in order to be able to immigrate and work in Western Europe.

Besides learning from one another’s health personnel policies, Wemos believes financial choices have to be made that reinforce governments’ obligation to provide good health care, both at national level and throughout Europe. This calls for fundamental debates about the future of welfare and health care, centring on the need for solidarity and equal access to care. Crucially, it will also require a coherent approach by the European Commission and EU, and the national ministries of Health, Welfare and Sport, Economic Affairs, and Foreign Affairs. And this is precisely what Wemos is working to achieve.

*Linda Mans, Wemos, project coordinator of ‘Health workers for all and all for health workers’
linda.mans@wemos.nl, www.wemos.nl, www.healthworkers4all.eu/

Economic governance for European health

Governance for (global) health starts at the national level. This concept is elaborated by the WHO in its publication Governance for health in the 21st century. The new governance for health is strongly rooted in concepts like Health in all Policies, multi-stakeholder approaches and democratic decision making for health. But aren’t we fooling ourselves with these trendy approaches? In a sense political philosopher Antonio Gramsci already promoted this governance model when he wrote about an ‘extended state’ that consists of media, civil organizations and labor unions exerting their influence on policy makers and politicians. Extended state actors are crucial in shaping the ‘cultural hegemony’, the social, cultural and political values, that shape society and state governments.  To be clear, the cultural hegemony is not something that emerges by consensus. No, it is shaped by political thinking, debate and ‘sometimes’ bitter fights.

And this is where the comparison between  ‘depoliticized’ multi-stakeholder approaches and Gramsci’s concept of a ‘political society’ diverges. Do the new governance for health and health-in-all-policies concepts allow for the strengthening of political societies for health or is its ‘the-world-is-flat” notion merely a form of dominant hegemonic leadership?

I wonder what Antonio Gramsci would have thought of current governance for health at the European level. Last week, the European state of public health was discussed at the 4th annual conference of the European Public Health Alliance. The title’ Brave new world, inclusive growth and well-being or vested interests and lost generations’ describes perfectly what is at stake. The first day (with an impressive line-up of presenters) focused mainly on health systems reform in European member states, protecting access to services during austerity measures, addressing inefficiencies in health systems, and at the same time investing in sustainable long term (public) health programs. It is the second day that I like to highlight, as here the impact of the current EU economic framework for health has been discussed. This reform of the European economic governance, part of the EU 2020 growth strategy and also known as the European semester, has a thorough and structural impact on public health and health care in all member states. The entire process and mechanisms of this new economic framework and EU macro-economic surveillance can be found in this excellent EPHA briefing from April 2013.

Alongside this European semester, a number of countries (Greece, Portugal, Spain, Ireland) receive financial assistance (bailout funding) from the Troika (being the European Commission, European Central Bank and International Monetary Fund). These countries are subject to specific reforms of their public expenditure and fiscal frameworks. This is typically done under an MoU between a countries government and the Troika. The (first) effects of the economic crisis and related austerity measures on public health outcomes in these and other European countries has been presented in in the Lancet earlier this year, as well as by WHO EURO.

Rita Baeten from the European Social Observatory explained during the conference clearly how the EU macro-economic surveillance has profound impact on the development of national health care systems, without Ministries of Health being involved so far!  It is eventually the European ministries of finance, that within the Economic and Financial affairs (ECOFIN) council ‘recommend’ on the macro-economic structural reforms and fiscal consolidation of countries state budgets. Each year in November an Annual Growth Survey (AGS) is published that gives general guidance for EU member states for measures to ‘ensure financial stability, fiscal consolidation and action to foster growth’. Regarding health care the AGS 2013 mentions “reforms of health care systems should be undertaken to ensure cost-effectiveness and sustainability, assessing the performance of these systems against the twin aim of a more efficient use of public resources and access to high quality healthcare.” Although there is mention that social protection systems should be protected and strengthened, there is no reference to (health) inequalities. Seemingly the principle of reducing social inequalities has to be sacrificed in the times of financial crisis.  

Since 2011 the EC and Council produce Country Specific Recommendations (CSR) on macro-economic sustainability. In 2013, 16 CRS have been made. E.g. for the Netherlands, related to its health system, the following recommendation was made: “Implement the planned reform of the long-term care system to ensure its cost-effectiveness and complement it with further measures to contain the increase in costs, with a view to ensure sustainability. While the plans entails substantial budgetary savings, additional measures are likely to be necessary to fully restore the long-term sustainability of public finances.” An overview of the CSRs and its relation to health can be found in this EPHA policy analysis from Sept. 2013.

 

So, some key questions can be asked about the governance of the European Semester in relation to health:

• What is the legitimacy of Ministers of Finance to “strongly recommend” on the content and reform of the health system at national levels?
• Is the treaty of Europe not breached here; as health systems ought to be under national competency and responsibility of member states, not that of the EU. The treaty on the functioning of the European Union mentions in article 168 the responsibilities of the member states and the EU in protecting and improving public health.
• There seems hence to be a contradiction between different EU policies “fostering sustainable growth” and creating “social cohesion and protection”.
• The transparency of the process is unclear. Where do these recommendations come from? It seems mainly from the EC, probably influenced by the thousands of corporate lobbyists in Brussels, in addition to a selected group of people in and around the ECOFIN council (in which the EUROGROUP is currently chaired by the Dutch Minister of Finance). The European Parliament, national ministers of social and health affairs and civil society groups have had so far little influence in its directions. Partly because the EU economic framework evolves with fast changing targets. Especially the fact that the European Parliament has so little power in relation to the European Semester indicates the “democratic deficit” existing in current Europe.

The European Public Health Alliance has since 2013 analyzed these developments and does it best to be engaged and influence this process. Other European bodies, such as the Social Protection Committee and the Employment, Social, Health and Consumers affairs (EPSCO) Council also have a role in co-legislating the AGS and CSR. More transparency by these bodies and involvement of civil society organizations has occurred, but impact so far has been negligible. Thorough coordination and cooperation between social movements is required as decisions take place both at national and European level. 

Rita Baeten made it clear in her final remarks: “The house of Europe is built on the basis of liberal economic principles such as fiscal consolidation, GDP growth, small public expenditures and an internal open market as to be competitive with other emerging economies”.  In times of economic crisis, we see the true face of the current European Union and its decision makers. It values its economic interests simply higher than social cohesion by and for European citizens (and those that live undocumented in the region).  Moreover, didn’t some economist say ”never let a good crisis go to waste”? We see an assault by those with commercial interests on our social systems, and, at the EU level, we lack the true democratic possibilities to address this. We must demand our national governments and health ministries not only to fulfill their responsibilities in public health and access to health care but also to reform the governance model of the EU, and challenges this structural democratic deficit. The current EC and EU structures favor economic goals over societies’ goals.  How much longer will the European people accept this? The current European cultural hegemony is in crisis. Is there enough mass for an alternative hegemony?

Remco van de Pas, Wemos foundation
remco.van.de.pas@wemos.nl

Salt, Sugar, Fat: addictive stuff

In this blog post, Remco van de Pas reflects on a recent WHO-Euro conference on nutrition and Non-Communicable Diseases (NCDs).

Last week, the WHO-Euro conference on nutrition and NCDs in the context of Health 2020 took place in Vienna. The purpose of this meeting was to identify policies for the prevention and control of diet-related NCDs. Within the European region there is a dramatic rise in childhood obesity and an increasing incidence of diet-related NCDs. The conference was attended by health ministers and national delegations. Some intergovernmental organizations and NGOs, including ourselves, were invited as observers.

Malnutrition (both under- and overnutrition) is a major risk factor for the high burden of NCDs worldwide, and Europe is no exception. Key presentations at the conference by João Breda, Philip James and Carlos Monteiro indicated very clearly the problem. In 2010 1 in every 3 children aged 6-9 was obese or overweight in the European region (coming from 1 in 4 in 2008). The prevalence of overweight and obesity among the adult population is now over 50% and 15% respectively, in a majority of the European countries. Moreover, this prevalence is expected to grow, see the figure below.

Limited breastfeeding practices, childhood stunting (20-30% in some rural areas of Europe) and poor maternal nutritional status during pregnancy (20%) are also observed. A major reason for the rise in obesity is the increased consumption of trans-fatty acids, salt and sugar in ultra-processed ready-to-eat foods and soda. This has led to an increased energy intake per person/day (see the figure below). As Europeans on average have also become physically less active, the biological reaction of the human body is to “store” the extra energy, hence leading to overweight and obesity.

Within the public health and health policy community, there is now an intense debate going on about how to address this worrying trend. WHO’s DG Margaret Chan, put it like this in her forceful speech at the 8^th global conference on health promotion, last month in Helsinki.
“Today, the tables are turned. Instead of diseases vanishing as living conditions improve, socioeconomic progress is actually creating the conditions that favor the rise of NCDs. Economic growth, modernization, and urbanization have opened wide the entry point for the spread of unhealthy lifestyles. The globalization of unhealthy lifestyles is by no means just a technical issue for public health. It is a political issue. It is a trade issue. And it is an issue for foreign affairs.

As the new publication makes clear, it is not just Big Tobacco anymore. Public health must also contend with Big Food, Big Soda, and Big Alcohol. All of these industries fear regulation, and protect themselves by using the same tactics. Market power readily translates into political power. Few governments prioritize health over big business. As we learned from experience with the tobacco industry, a powerful corporation can sell the public just about anything. When industry is involved in policy-making, rest assured that the most effective control measures will be downplayed or left out entirely. In the view of WHO, the formulation of health policies must be protected from distortion by commercial or vested interests.”

The conference in Vienna showed that some countries such as Denmark, France Austria and Hungary have taken regulatory measures to reduce trans-fatty acids in products. They also imposed taxes on soda and (some) ultra-processed foods. Most other countries rely on self-regulatory measures taken by the food industry, as well as a mix of multi-sectorial approaches such as healthy food subsidies for school canteens, promotion of physical activity, urban planning, supporting healthy choices and marketing restrictions for children of unhealthy food. During lunch sessions, the journalist Michael Moss provided insights from his book Salt, Sugar, Fat, while Eve Heyn of GBC Health, a global coalition of over 200 private sector companies working to improve global health, spoke of the role of the private sector. The NCD Free campaign was able to show their online campaign to the conference participants.

The 53 European region countries eventually agreed upon the Vienna declaration, which promotes decisive and urgent action by governments on the topics mentioned in this blog, while carefully avoiding language about the need to address the causes of the causes of diet-related NCDs.

We have interesting times ahead of us. In most of the countries, as well as at the EU and global level, there will be further research, policy dialogue, strong lobbying and heated political debate about the required policies, and whether or not to engage Big Food and Big Soda in these actions. What is relatively missing from the public health debate so far, is the dialogue with economic, agricultural, veterinary actors and food investors. How to safeguard public health in relation to these powerful interests?

Behind these questions lie deeper individual and societal choices. Do we really need all these different kinds of processed food and beverages, even if they are reformulated to contain less sugar, salt and fat? Do we really need to eat all these saturated fats and proteins from the intensified meat producing industry? Are local food products not available or affordable anymore? Do people still take time to prepare their own food?

Via continuous and clever marketing strategies, we have increasingly become hooked on this pattern of consumption in a 24-hour economy. For ourselves and our children it’s better that we detoxify ourselves, as this consumption pattern is not only unhealthy but also highly unsustainable. If not, we and the planet risk a cold turkey in the not too distant future.
PS: An excellent parallel twitter conference took place on the sidelines of the formal conference, and can be read in full via #NCDVienna . Gauden Galea from WHO Euro has provided an analysis of this twitter conference via his blog.

Correspondence to: remco.van.de.pas@wemos.nl
First pubished in: IHP newsletter