THE GLOBALISATION OF PUBLIC HEALTH AND GLOBAL HEALTH GOVERNANCE

It is widely recognized that contemporary globalization is having a profound impact on the health of populations everywhere. Although increasing global integration is not an entirely new phenomenon, contemporary globalization has had an unprecedented impact on global public health and is creating new challenges for international law and policy.

Globalization can be broadly understood as a process characterized by changes in a range of social spheres including economic, political, technological, cultural and environmental. These processes of global change are re-structuring human societies, ushering in new patterns of health and disease and reshaping the broad determinants of health. Indeed, the globalization of trade, travel, communication, migration, information and lifestyles has obscured the traditional distinction between national and global health. Increasingly human activities have profound health consequences for people in all parts of the world, and no country can insulate itself from the effects. Members of the world’s community are interdependent and reliant on one another for health security.

The spread of infectious diseases in a changing and interdependent world is to be expected, given increased human migration, congregation and trade. But contemporary globalization has presented other myriad health risks that were not as predictable and are gaining the attention of political leaders. The burden of noncommunicable diseases (NCDs) was once felt disproportionately in industrialized countries, but NCDs are now the major causes of death and disability worldwide and increasingly affect people from resource-poor countries. Chronic diseases (e.g., cardiovascular diseases, cancers and diabetes) are exacerbated by human behaviour, such as consuming high-fat/high-caloric diets, maintaining sedentary lifestyles, smoking cigarettes and drinking alcoholic beverages. The processes of industrialization, urbanization, economic development and increasing food-market globalization lead to harmonization of behaviours. What was once culturally attractive primarily in industrialized countries has gained popularity all over the world.

Multinational corporations, in particular, have significant influence and power over global consumption of food, tobacco, pharmaceuticals, consumer products and health care. The production and delivery of these goods and services pose health hazards that span national borders, but often escape scrutiny under national laws. The global community, therefore, needs to develop effective ways to ensure the quality and safety of goods and services that travel in international commerce. Recent cases of contaminated fish, lead in toys and tainted pet food illustrate the risks from international commerce that are effectively beyond the reach of national regulators.

Globalization profoundly affects healthcare services in multiple ways. International trade and intellectual property laws affect the ability of low and middle income countries to ensure access to essential drugs and vaccines. Access to antiretroviral medications for poor people living with HIV/AIDS offers an illustration of the political and humanitarian implications of robust intellectual property protection. At the same time, through unethical recruitment practices and the ‘push and pull’ of market forces, doctors and nurses are migrating to developed countries, leaving the poor without adequate human resources needed for well-functioning health care systems.

These, and other, forces of globalization have exacerbated health disparities within and among countries. Indeed, some of the most significant impacts of globalization on health can be understood, in part, as perpetrating and deepening global inequity by compelling poor countries to, inter alia, privatize, impose user fees and adopt trade liberalization policies in areas, including health services and pharmaceutical distribution. In this globalized era, the world is more unequal than ever before. The United Nations Development Programme (UNDP) and the World Bank have both issued reports on human development in the past few years that highlight the spiralling problem of inequity. Notably, the UNDP reported ‘unprecedented reversals’ in human development: few countries of the world’s poorest countries registered lower scores on the human development index, a standard measure of well-being. As income is the primary determinant of health in poor countries, today’s massive inequalities present the most critical global health threat of our time.

Globalization has highlighted and considerably complicated the need for effective mechanisms of global health governance. Overall, the increasing integration and the internationalization of the determinants of health have contributed to the rapid decline in the practical capacity of sovereign states to protect the health of their populations through unilateral national action and, thus, intensified the need for international cooperation among states.

The world community’s growing appreciation of the scope and scale of the challenges in global health is reflected in the multiplication of actors in global health since the founding of the United Nations in 1945. In recent years, for example, there has been a proliferation of international institutions active in the domain of health. Within the comprehensive UN system, organization with significant involvement in health include the World Health Organization, the UN Children’s Fund, the UN Food and Agricultural Organization, the UN Environment Programme, the UN Population Fund, the International Labour Organization and the World Bank.

A similar growth of interest in global health is seen within regional institutions and international organizations outside of the comprehensive UN system. Expanding concern about global health has also been fostered by and led to an increasing number of non-state actors. These non-state actors in international health include a wide assortment of foundations, religious organizations, nongovernmental agencies and for-profit organizations —such as the pharmaceutical industry— with a powerful influence on international health policy. Innovative health coalitions, involving diverse global health actors, such as health research networks and, most significantly, public–private partnerships, are also increasingly commonplace and have an important influence on health policy. The need for more effective collective action among governments, businesses, civil society and other actors is also intensifying as health determinants are increasingly affected by a complex web of factors outside of the health sector, including conflict, environmental degradation, trade, investment and criminal activity.

In addition to the proliferation of actors in international health, contemporary global health is characterized by increasing amounts and sources of funding. As a consequence of a tremendous rise in public and private giving, there is more money in global health than ever before. There are now multiple sources of funding in global health, including bilateral assistance, foundation and nongovernmental organization support, regular budgets of international organizations, and new specialized funding mechanisms, such as UNITAID and the International Finance Facility for Immunisation.

It is widely recognized that current system of global health governance is insufficient to meet the wide range of challenges and opportunities brought by globalization. It is also increasingly understood that one necessary means of effective global health governance is a global health legal system, and that establishing such a system will require innovations in international law—of its existing rules, institutional mechanisms and forms of collaboration.