A social contract for global health investments in times of resilience (editorial)

Dear reader,

The last year saw the re-emergence of a century-old economic idea, namely that investing in health is (good) value for money. The Lancet Commission on Investing in Health (CIH), prompted by the 20th anniversary of the 1993 World Development Report, has argued that a Grand Convergence in health is possible by the year 2035. Global health 2035: a world converging within a generation, the CIH report, calculated that “for every dollar invested in convergence related interventions, the economic benefits are 9-20 times higher”. 

The notion that investing in health leads to (potentially enormous) economic returns is nothing new, though. By way of example, let’s have a look at excerpts from a medical article from the Dutch Colonial Indies, 1879, modern Indonesia:

”The Deli planters association purpose was to implement unity in the handling of the workforce, and to co-operate with regard to importing workers and organizing work. According to this arrangement, the workers brought in from overseas were obliged to work on the plantation for a fixed wage and under stipulated conditions, while the employer was bound to provide housing, food, and, amongst other things, free medical treatment and medicine. This sort of agreement was of the greatest importance for the viability of the enterprises because of the huge losses which sickness caused to the productivity of the plantations. And a high mortality rate was equally damaging to the company’s good name and could cause problems for recruiting new workers. Humane and economic considerations clearly went hand in hand” (Source: Dutch Medicine in the Malay Archipelago, 1816-1942, p.75).

The Dutch did not call the project “Global health 1890, a convergence within a generation” (generations were considerably shorter then); the colonial administration found the title a tad too revolutionary and just considered it “robust tropical medicine”.

On a more serious note, key questions regarding the ‘Global Health 2035’ agenda are then: Who (really) benefits (most) from the foreseen economic benefits, in the long run, and who (really) benefits (most) from the reduced mortality in LMICs?

National and global political economy discourses and the debate on social justice and health equity come into play here. Global Health 2035 uses the concept of growth in a country’s ‘full income’, which is mainly GDP change adjusted for the value of mortality change (“the income growth measured in national income accounts plus the value of additional life years (VLYs) gained in that period”). But the report doesn’t refer to ‘full income‘ distribution over socio-economic quintiles nor does it take into account negative externalities impacting on health (e.g. natural resource depletion and climate change). The report also fails to fully recognize the massively unequal and unjust social and living conditions that shape the health status of communities, the so-called upstream determinants of health.

The CIH recommendation for progressive universalism as a pro-poor pathway towards Universal Health Coverage is presented as an efficient way towards health and financial protection.  We will not deny it has obvious merits. However, if we really want health inequalities to reduce substantially, UHC must be embedded in broader social protection schemes, both at national and global levels.  So far the thinking on a grand convergence for global health has not included reflections on global social protection mechanisms.  To kickstart this – in our opinion vital – debate in a further globalizing world, the health community could perhaps discuss and frame UHC in the context of ILO’s Social Protection Floor initiative. The example from the Deli Planters Association from more than a century ago demonstrates that a social contract is needed to guarantee both human security and economic objectives.  As the economic case for health investments is nowadays made for many global health topics, such as maternal, neonatal and child health or the health workforce,  we feel there should also be some reflection on how universal and equitable access will be guaranteed to such services as part of the Post -2015 development framework. In short, how can a social contract theory be applied to current investments and governance arrangements in global health?  Is it still national governments that have the main responsibility for guaranteeing their citizens’ rights, or should there be supranational arrangements, involving also non-governmental actors, at the regional (e.g. EU) or at the global level?

The latest episode in the ‘investment for health’ saga is the notion of ‘resilient health systems’. This has become a major lesson of the Ebola outbreak in West-Africa. In the words of Jim Yong Kim, medical doctor by training but more importantly the president of the World Bank group:

“The other main goal of a pandemic facility (by the World Bank) is to promote greater country investments in preparedness, which starts with having a strong, resilient health system. The Ebola crisis lays bare the consequences of inadequate public health capacity, from disease surveillance and laboratory analysis to frontline health services and community health workers: People die; economic growth rates decline; and countries, their neighbors, and the entire world, are put at risk.”

Although still very much in love with UHC, WHO has also rather eagerly embraced the concept of a ‘resilient health system’, so resilience is likely to become a leading theme in the health SDG and broader post-2015 development framework. I am still struggling to fully understand the concept of resilient health systems, its scope and implications from a human rights and health equity perspective. If you already see clearer, please do not hesitate to get in contact.

In the meantime, let us learn from history and think of social contracts fit for this era. It might make the planet and the human species just a tiny bit more resilient.

Remco van de Pas, MMI Board member
ITM Antwerp, rvandepas@itg.be
Editorial also posted in the IHP Blog

MMI Network: Events, news, resources

Network event: Medicus Mundi Switzerland
The Future of the Swiss Engagement against Malaria
Basel, 22 April 2015

Malaria remains an important public health challenge and a main cause of morbidity and mortality in many countries. Therefore it is the major goal of the Swiss Engagement to support research and effective and sustainable interventions and strategies to further reduce malaria prevalence and incidence. The Technical Exchange Event 2015 “The Future of the Swiss Engagement against Malaria” organized by the Swiss TPH and the Swiss Malaria Group provides insights on latest research trends and strategies in the Swiss engagement against Malaria. (The Swiss TPH is a member of Medicus Mundi Switzerland; the Swiss Malaria Group is hosted by MMS).

> http://www.swissmalariagroup.ch/de/meta/agenda/the-future-of-the-swiss-engagement-against-malaria.html


Network event: Medicus Mundi Switzerland
Community Participation in Public Health: What’s the Added Value in Research and Implementation
Basel, 23 April 2015

The Swiss TPH Spring Symposium 2015 will provide a platform to reflect on the added value of community participatory approaches in public health. Starting with an overview of the current major debates in the field, presentations and discussions will then focus on the added value and challenges in putting into practice these approaches. Speakers will present various ways and reasons for involving community members in clinical and social science research, as well as in project implementation. Critical perspectives will be addressed such as the feasibility, sustainability and equity of these approaches and whether these approaches can actually contribute to increasing quality of research and services, stronger accountability within the health system, and ultimately better health outcomes, with a particular focus on the most marginalised and vulnerable populations.

> http://www.swisstph.ch/news-events/symposia/spring-2015.html

Network event: Medicus Mundi Switzerland
HIV/AIDS and vulnerable groups – no one left behind
Berne, 7 May 2015

This year’s annual aidsfocus conference will focus on vulnerable groups such as Sex workers, injecting drug users; migrants or prisoners. In most countries, these groups tend to have a higher prevalence of HIV infection than that of the general population because (i) they engage in behaviours that put them at higher risk of becoming infected and (ii) they are among the most marginalized and discriminated against populations in society. At the same time, the resources devoted to HIV prevention, treatment and care for these populations are not proportional to the HIV prevalence – a serious mismanagement of resources and a failure to respect fundamental human rights. If we want to achieve the ambitious goal to end the AIDS epidemic by 2030 we cannot leave anyone behind. (aidsfocus.ch is a project coordinated by the Network Medicus Mundi Switzerland)

> http://www.aidsfocus.ch/en/agenda/aidsfocus.ch-conference-2015

Network conference report: ACHAP
The role of faith based health services in contributing to universal health coverage in Africa

Nairobi, 23-26 February 2015. The Africa Christian Health Association’s Platform (ACHAP) hosted a successful 7th Biennial Conference of the Africa Christian Health Associations at the Safari Park Hotel, Nairobi in collaboration with ACHAP Secretariat and funding support by various partners. The Conference theme was “The role of the faith based health services in contributing to universal health coverage in Africa”. The conference which attracted 126 delegates from Africa, Europe and USA discussed global commitments and developments towards universal health coverage and the opportunities for faith based health services in scaling up their contribution towards UHC.

> http://africachap.org/en/achap-hosts-7th-biennial-conference-on-universal-health-coverage/

Network report: Health Poverty Action
Casualties of War: How the War on Drugs is harming the world’s poorest

Health Poverty Action has launched a report calling for the global development sector to rethink its approach to the failing War on Drugs. Entitled ‘Casualties of War: How the War on Drugs is harming the world’s poorest’, the report emphasises how drugs policy is very much a development issue: “If, as international NGOs, we are serious about dealing with the root causes of poverty and not just the symptoms, we cannot afford to ignore drug policy. It’s time we recognised the threat that unreformed global drug policy poses to our attempts to tackle poverty worldwide. The sector can no longer be absent from debates on drug policy reform.”

> http://www.healthpovertyaction.org/news/health-poverty-action-launches-new-report-failing-war-drugs/

Network report: Cordaid
Disaster response: Sendai Framework “shows signs of weakness”

“Local communities, especially in fragile areas will get a central role in disaster risk reduction. Governance and programs will be formulated from their perspective. The role of organizations such as Cordaid is also recognized and established.” However, Jeroen Alberts reaction to the Sendai Framework is not merely positive. The Post-2015 framework for Disaster Risk Reduction was adopted this week at the UN WCDRR in Sendai, Japan. As part of a Dutch delegation, headed by Minister Ploumen of Trade and Development Cooperation of The Netherlands, Alberts attended Sendai on behalf of Cordaid. From the 14th until the 18th of March, the conference brought together governments and NGO delegates from around the world to chart the future management of disaster risks.

> https://www.cordaid.org/en/news/sendai-framework-signs-weakness/

Network people: Medicus Mundi International
Get well soon, Nick!

Nick Lorenz, President of the MMI Network, suffered a stroke while he attended a conference in Maputo, Mozambique, at the end of February. Thanks to the immediate action of some colleagues, Nick received prompt and appropriate care through the Instituto do Coracao in Maputo. A week later he was repatriated to Switzerland. After initial care at the University hospital in Basel, he is now undergoing an intensive rehabilitation program in a specialized clinic. Get well soon, capo!


A luta continua! Strengthening or weakening health systems? Geneva, 23 May 2015, MMI Annual Assembly and WHA side event

A luta continua! Strengthening or weakening health systems? Geneva, 23 May 2015, MMI Annual Assembly and WHA side event

The General Assembly of the MMI Network will take place in Geneva, at the end of the first week of the 68th World Health Assembly. A luta continua – the struggle continues – is a good slogan for the adoption of the MMI Network Strategy 2016-20 in the business part of the Assembly, but also for the ongoing need to reflect about the influence of international health cooperation and a globalized health business on national health systems. Based on the movie “A luta continua” (Medicus Mundi Catalunya) and the case of Mozambique, a public workshop linked to the MMI Assembly and considered as civil society side event to the World Health Assembly will provide a good opportunity for the dialogue on what it takes to strengthen – or weaken – a national health system.

Provisional program:
09:30 to 12:00: MMI Assembly
12:00 to 13:30: Lunch
13:30 to 16:00: Movie “a luta continua” and public workshop / WHA side event

There will be a dinner for MMI Network members on Friday evening, 22 May, and as every year, MMI Network members and project representative are welcome to register as members of the MMI delegation at the World Health Assembly. Save the date(s) and start organizing your journey, including your individual hotel reservation!