UUnniivveerrssiittyy ooff LLoouuiissvviillllee TThhiinnkkIIRR:: TThhee UUnniivveerrssiittyy ooff LLoouuiissvviillllee''ss IInnssttiittuuttiioonnaall RReeppoossiittoorryy College of Arts & Sciences Senior Honors College of Arts & Sciences Theses 5-2013 GGlloobbaall--hheeaalltthh ddiipplloommaaccyy :: tthhee ssoocciiaall ddeetteerrmmiinnaannttss ppeerrssppeeccttiivvee ooff hheeaalltthh aapppprrooaacchh aanndd tthhee ffuuttuurree gglloobbaall ppoolliiccyy aaggeennddaa.. Naseem Ansari University of Louisville Follow this and additional works at: https://ir.library.louisville.edu/honors Part of the Health and Medical Administration Commons, and the International Public Health Commons RReeccoommmmeennddeedd CCiittaattiioonn Ansari, Naseem, "Global-health diplomacy : the social determinants perspective of health approach and the future global policy agenda." (2013). College of Arts & Sciences Senior Honors Theses. Paper 4. http://doi.org/10.18297/honors/4 This Senior Honors Thesis is brought to you for free and open access by the College of Arts & Sciences at ThinkIR: The University of Louisville's Institutional Repository. It has been accepted for inclusion in College of Arts & Sciences Senior Honors Theses by an authorized administrator of ThinkIR: The University of Louisville's Institutional Repository. This title appears here courtesy of the author, who has retained all other copyrights. For more information, please contact [email protected]. Global-Health Diplomacy: The Social Determinants Perspective of Health Approach and the Future Global Policy Agenda By: Naseem Ansari Submitted in partial fulfillment of the requirements for Graduation magna cum laude University of Louisville March, 2013 Ansari 2 Introduction: Within the last two decades, the international community has made significant strides in developing global-health goals. Regional organizations, such as the Organization of American States (OAS) and international organizations, primarily the United Nations, have taken steps to clearly outline the most pressing health-related needs in the developing world, global-health standards, and a variety of policies aimed at encouraging countries to strive to reach basic health thresholds. In addition, a wide array of non-governmental organizations (NGOs), public and private, have stepped forward to provide funding for a broad variety of health initiatives, primarily in the developing world. Despite these sweeping and far-reaching efforts, global-health policies have had a minimum effect on developing countries. Over the last couple of decades, intellectuals and health-care experts have offered up a variety of mixed assessments of these policies. Nevertheless, perhaps because this is a relatively new subject, very few full development analyses have appeared to examine and assess completely this international health-care approach to addressing the concerns of developing countries. This paper investigates global-health policies and seeks to determine the political determinants that shape their design and implementation and the factors that ultimately contribute to their success or failure in developing countries. Questions to be answered include: How has global-health policy evolved over time? What are past global- health policy successes and failures? What does the future of global-health policy hold and what changes should be made to the system in order to ensure the most improvements? Global-health policy primarily targets a general international audience, and since global- health policy are essentially a set of best-practices ideas, they have not developed into a body of international law. Rather, they offer broad one-size-fits-all guidelines to participating countries Ansari 3 who are seeking assistance in an effort to improve overall health indicators. Many economically weak countries lack both the resources and the knowledge to develop their own set of health policies. Instead, they turn to regional and international organizations for expertise in identifying critical needs, drawing up a budget, applying for international assistance for NGOs and international lending institutions, and setting priorities. Scholars and health-care experts, however, have broadly criticized the new global-health approach. They argue that broad international policies, highly centralized and bureaucratized, have not been easily applied universally. They contend that a centralized international organization cannot devise a set of policy goals and procedures that can apply to the majority of the world's developing countries. While some scholars and many non-governmental organizations (NGOs) have wholly supported global health-policy goals, others argue that health policies, like all policies, must be locally designed in order to address the particular concerns and needs of the community. From this perspective, health policy cannot actually be “global.” Instead, it must be focused and individualized according to the demands of specifically local ethnic, national, or religious groups. This group of academic skeptics point to problems related to corruption and accountability, drug abuse, and internal ethnic, racial, religious, and culture cleavages. As a recent New York Times article stated, “Sadly, WHO [World Health Organization] has promised much and delivered little.”1 The issue has demanded and entertained increasing levels of media attention to the unfolding threats created by bioterrorism and the question of national health security risks, which have further been the topic of national foreign policy discussions and legislation. International conferences that are devoted to the delivery and mission of maintaining peace and security, 1 New York Times, May 23, 2006 at www.nytimes.com/2006/05/23/opinion. Ansari 4 encouraging friendly relations between states, and resolving international problems of economic, social, cultural or humanitarian nature also generate a great amount of publicity, pushing health policy closer and closer to the forefront of the international political agenda. Accordingly, controversies surrounding the use of public funding for health literacy, disease eradication, and other related health programming measures being instituted in countries worldwide has raised questions about the value and relevance of international health-care policies. Above all, highly centralized global-health governance and international efforts at problem-solving all tend to confront the same obstacles: lack of coordination among contributing and executing partners, fragmentation and duplication in a system that both fails to delineate procedures measuring accountability and produce reliable data needed for the analysis of outcomes and success, and a notable contrast in the ratio of capital resource allocation versus human resource allocation during implementation and delivery of health initiatives. Some scholars have asked: Is the “global” approach the best, most effective approach? The global approach is increasingly becoming the approach of choice both in the United States and around the world and is widely attributed as the reason for both health successes, such as the small pox eradication campaign, and notorious failures, such as the HIV/AIDS health programming in the region of Sub-Saharan Africa. Yet, the question to be answered now is whether or not states are investing considerable time into a discipline whose very framework is fundamentally flawed. The first part of this paper will discuss broadly the evolution of past global-health diplomacy and policy. I introduce the history of global-health diplomacy as it has evolved from its beginnings to modern times. Then, I critique the Millennium Development Goals as the primary policy goal and overarching mission of global health agenda in the 21st century by examining their specific achievements and relaying significant criticisms. Next, I detail the Ansari 5 progress being made in the development of a more comprehensive, holistic global health model, which is now known as the social determinants of health perspective. The second part of this paper will analyze the development and impact of three current sociopolitical health frameworks on the international level: health as a matter of security, health in the context of development, and health as a human right. These three frameworks are the ones most frequently utilized to both collect funding for global-health programs and to explain the basis of foreign-policy choices. Each framework has its own strengths and weaknesses and may serve to predict the likelihood of success of the new social determinants of health perspective on the future global-health policy agenda. Finally, I argue that the conflicts created by the different global-health sociopolitical frameworks and the lack of accountability and legitimacy imposed by an unclear structural hierarchy in global health governance could potentially impede the success of the social determinants of health perspective and ultimately prevent long-lasting improvement. Moreover, I assert that progress is dependent on more participation from communities and accountability from the recipients of aid. I also assert that public sector actors should look to the evaluation standards and performance models of successful private sector organizations such as the Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria and the Bill and Melinda Gates Foundation to formulate mechanisms for generating an environment of increased accountability and incentivized resource allocation disbursal. Finally, I assert the need for a different organization to process, evaluate, and analyze the data generated by public sector organizations because of the inherent conflict that arises when the same entity designs, implements, and measures the progress of its own creation. Part 1: A Brief History of Global-Health Diplomacy Ansari 6 Beginnings: The Necessity of a Global System of Governance Global-health diplomacy traces roots to the regional discussions that occurred during the International Sanitary Conference in 1851 among European states as they attempted to resolve a means of cooperation to handle cholera, plague, and yellow-fever epidemics. Debates ensued that addressed the need for "international regimes capable of responding to global threats of public health." 2 The states participating agreed to continue convening the International Sanitary Conference and utilize the forum as a venue for collaboration in specific health initiatives and the resolution of critical health obstacles. These international conferences and regional meetings became the precursors to the modern International Health Regulations of 2005, "a multilateral agreement that outlines countries’ obligations and responsibilities for detecting, reporting, and responding to health events of international concern such as disease epidemics and pandemics." 3 The evolution of scientific theory, specifically in relation to the work by Pasteur and Koch on germ theory in the 1860s, helped to encourage international cooperation as it contributed to the understanding of the transmission of disease and provided a multitude of supporting evidence for the environmental and social factors that influenced health. Pasteur and Koch explained that specific factors, such as unclean water sources and overcrowding in urban areas, promoted the spread of epidemics such as cholera and yellow-fever. Movement along the arc of theory development and acceptance of the need for international governance in the realm of health and politics was driven by an ever-increasing level of globalization and its impacts. Ronald Labonte, in his article on the connections between 2 Fidler, David, "The globalization of public health: the first 100 years of international health diplomacy," The World Health Organization, 2001 at http://cdrwww.who.int/bulletin/archives/79(9)842.pdf. 3 The Henry J. Kaiser Family Foundation, "Raising the profile in the U.S. Global Health Response: A Backgrounder on Global Health Diplomacy," September 1, 2012 at http://www.kff.org/globalhealth/upload/8360.pdf. Ansari 7 globalization, health, and development, defined globalization as a network of "processes by which nations, businesses, and people become more connected and interdependent via increased economic integration and communication exchange, cultural diffusion, and travel." 4 Colonial expansion, the fervor that revolutionized missionary efforts, the socioeconomic and political reflections of two world wars among leading intellectual centers of the time, the necessity for regulation in the international trade of narcotics such as opium and alcohol, and imperial countries fostering post-colonial guilt, are all factors that shaped the founding of a number of international health institutions. At the 1903 International Sanitary Conference, European representatives supported the need for a permanent international health bureau. Nevertheless, the US had already created their own International Sanitary Bureau in 1902, which was later renamed the Pan American Sanitary Bureau. The result of a 1907 meeting in Rome was the establishment in Paris of an Office International d'Hygiène Publique (OHIP), which boasted a permanent, full-time secretariat and a committee of senior public health officials from participating governments. Other international ventures included the International Opium Convention in 1912, which led to the 1925 Agreement Concerning the Manufacture of, Internal Trade In, and Use of Prepared Opium. This agreement sought to both restrict and guide economic interests and garner support for the marginalized populations in Africa and the Native American groups in the Americas. The International Labor Organization of 1919, which mandated regulation of occupational health-safety standards, also profoundly impacted the development of global-health policy. Perhaps the most notable of these ventures was the design and founding of the League of Nations Health Organization in 1924. The League of Nations specifically acknowledged its "endeavor to take steps in matters of international concern for the 4 Labonte, Ronald and Renee Torgerson, "Interrogating globalization, health, and development: towards a comprehensive framework for research, policy, and political action," Critical Public Health, 15(2): 2005 Ansari 8 prevention and control of disease".5 Significantly, controversy and fragmentation in global health attribute their beginnings to the uncertainty and divergence surrounding the incorporation of the OHIP within the administrative jurisdiction of the League. The United States, a prominent member of the OHIP, but not of the League, undermined the possibility of this inclusion and international cohesion. Therefore, the "years between the two World Wars, two independent international health organizations co-existed in Europe - the OIHP and the Health Organization of the League of Nations".5 The OHIP, the League of Nations, and the Pan-American Sanitary Bureau collectively interacted to develop and execute global-health policy during this time. Simultaneously, private organizations such as the Rockefeller Organization and the International Union Against Tuberculosis improved global-health policy and strengthened international cooperation in designing political, economic, and social policy. World Health Organization: The Administration of Global-Health Policy The ultimate apex of global-health diplomacy in the twentieth century was the establishment of the World Health Organization (WHO) in 1948 as a part of the United Nations (UN), which formed in 1944 in the post-World War II era. Brazilian and Chinese UN conference representatives proposed that an international health organization be founded; consequently, a conference to frame this new organization's constitution was summoned as a result of instructions given the UN Secretary General by the Economic and Social Council. Conference members revised and adopted a constitution for a WHO, which was endorsed by representatives of 51 UN member states and ten additional states. WHO would be a specialized organization of the United Nations as dictated by both the preamble and Article 69 of the WHO constitution. Because of the necessary member signatures needed for the ratification of the constitution, WHO 5 United Nations History http://www.who.int/global_health_histories/background/en/index.html Ansari 9 did not officially become an operating entity until April 1948. During the interim years that unfolded during the delayed ratification of the constitution, the Health Division of the UN Relief and Rehabilitation Administration (UNRRA) and the Interim Commission of WHO assumed the temporary responsibility for the operative duties of the organization. This interim commission also absorbed responsibility for the international sanitary conventions and for international epidemiological reporting data, which was collected through the management of the International Classification of Disease and similar programs.5 WHO became the focal point for global diplomatic activity regarding health at the international level throughout the rest of the twentieth century and into the twenty first century. In the course of the creation of conventions such as the World Health Assembly (WHA), in which international health discussions were held and policy negotiated annually by representatives of all member states, WHO maintained a forum that addressed international health concerns, gathered support in the form of monetary donations, and encouraged promises of advocacy within individual states and groups of states. These new initiatives, brought on through consensus-building and international compromise, marked a significant achievement in the history of global-health diplomacy. The role of global-health evolved increasingly as technology developed and medical discoveries enabled WHO and its counterparts to make considerable achievements in the eradication of infectious diseases. The Global Yaws Program, once fully operational, used penicillin injections to cure inflicted persons of yaws, a crippling, disfiguring disease that affected millions; the program succeeded in reducing the global prevalence of the disease by more than 95 percent between 1952 and 1964, examining more than 300 million people in 46 countries. Between 1967 and 1979, WHO's campaign to fight smallpox resulted in the