Global Health Europe applies governance lens to EU Global Health Consultation

Global Health Europe was among nearly 100 submissions to the European Commission's consultation on the EU Role in Global Health.  This consultation feeds into the drafting process for an EU framework communication on global health that is expected to adopted in March 2010.  Of the contributions Global Health Europe stands out in its application of a "governance lens" to the questions raised in the consultation.  Many stakeholders focus on specific sub-issues of global health, such as one or a set of diseases, or one sector, for example development cooperation. In contrast Global Health Europe perceives global health as representing a continuum of issues that span multiple sectors of which development and medical research are a part but not the whole.

All the contributions to the consultation can be downloaded: http://ec.europa.eu/development/how/consultation/index.cfm?action=viewcons&id=4765

What follows is Global Health Europe's responses to the consultation. The responses are based on questions raised in an issues paper which can be viewed through the above link or here (PDF)

The EU Role in Global Health: Answers from Global Health Europe

Our responses reflect discussions at the Graduate Institute's international symposium "What is the Role of Regional Organisations in Global Health" held in Geneva on 15th October, online discussions held on the Global Health Europe web site http://www.globalhealtheurope.org/platform/forum, meetings with groups from Oxford and Cambridge Universities, the London School of Hygiene and Tropical Medicine, Chatham House, Medsin and others as well as our reflections on the Nobel Forum Seminar "The European Union as a Global Health Actor" which we jointly hosted with the Swedish Presidency and the Karolinska Institutet on the 3-4th December. They are also informed by papers from the Netherlands Clingendael Institute and the Swedish Institute of International Affairs.

It is important to note that there is a great deal with which we agree in the EC paper, we are delighted that Global Health is not only recognized as an important focus for the European Union's health strategy, "Together for Health" but that as a next step this issue paper has been produced as a cross directorate exercise with engagement of civil society groups. So this is a discussion between colleagues who share the same values and aspirations, that the EU should play as strong a leadership role in global health as it does in climate change and that these challenges will forge a stronger and fairer system of global governance.

Q1 : In your opinion, does the proposed concept "global health" cover the most relevant dimensions? If not, which other essential factors would you suggest?

A: The concept is introduced in sufficiently broad terms but much of the following discussion is focused on Official Development Assistance (ODA) for middle and low income countries, which is only one element required to address this issue.

The definition of global health in our Glossary, as referring to "those health issues which transcend national boundaries and governments and call for actions to influence the global forces that determine the health of people. It requires new forms governance at national and international level which seek to include a wide range of actors." points to the need for action to address the determinants of health, hunger and poverty and to protect global public goods for health and human security in all countries. While this requires action to increase and improve the effectiveness of aid this will not be sufficient unless action is also taken in respect of: trade and investment, agriculture, communications, migration, conflict and inter-generational issues such as climate change, population growth and food and water scarcity.

These challenges demand we address the crucial issues of global and national governance for the health of future generations. The EU and the EC are in a unique position to provide leadership on such strategic global issues but it is also essential to build the foundations for global governance by engaging academic, business and civil society at every stage in this development.

Q 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?

A: We would like to see a stronger focus on the impacts of trade, promotion of products and lifestyles, employment practices and a failure of global and local governance in these fields and in relation to other major challenges such as climate change, population growth and food and water shortages. It is also important to note that globalisation has a particular impact on women. As examples: a majority of migrants are now women, most of the jobs in export processing zones, sweatshop jobs in clothing and jobs in agriculture are taken by women, who are also a key resource for health.

All of these factors impact on every country in an interdependent, interconnected world, yet in most cases it seems that the rich world imposes a growing penalty on the poor. Moreover it is in these fields that collective actions of the EU and specifically the EC can and should add greatest value.

Q 3: Do you consider the health-related MDGs a sufficient framework for a global health approach? If not, what else should also be considered?

A: No - while laudable, MDGs focused on selected health targets do not address underlying determinants of health, hunger and poverty. Thus while the health MDGs and MDGs 1,2 and 3 that address related issues, provide a focus for the actions of various EU Member States and agencies we suggest that collective EU action should be focussed on MDG 8 since it is action in this sphere that provides the political and practical foundation for the attainment of the MDGs.

MDG 8, calls for a Global Partnership for Development, requiring strengthened global and national governance, this is better matched to EU competence and provides a better address to the underlying determinants relevant to global health. MDG 8 sets targets for trade, market access, aid and other fields of cooperation which involve working with academic, business and civil society such as access to essential medicines use of information and communications technology and addressing youth unemployment. This provides a unifying framework for many of the actions that the EU can and should take collectively with regard to global health and requires the leadership and diplomatic strengths of the EC, that have been enhanced by the ratification of the Lisbon Treaty.

Q 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: Health in All Policies is fundamental to global health and failure to apply such policies in practice is a major weakness. This must include policies of European multi national companies and civil society that have a greater impact than aid. As examples, the EU has only recently begun to address the impact of its agriculture and trade policies on health in middle and low income countries and awareness of corporate social responsibility for global health is at an even earlier stage of discussion but no action, yet these are essential drivers of global health. A recent report from Oxfam and HAI notes the discrepancy between EU policies on health aid and its trade negotiations on intellectual property rights for pharmaceuticals. The EU must address these questions, which currently come under the purview of DG Enterprise but in future will in future be handled by DG Sanco. However it is also essential to ensure that all EU Directorates apply Health in All Policy and as we discuss later specifically in EU foreign policy.

Q 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?

A: Global Public-Private Partnerships for Health and bilateral aid from EU Member States focused on specific diseases and programmes have drawn staff and resources away from basic issues of health systems governance, maintenance and innovation. Just as the EC needs to ensure that its economic and social policies are not detrimental to global health, it should also take a strategic view of how its aid policies can be harmful to health systems and public health. The EC should focus its efforts on such systemic issues, through support for health ministries, support for basic infrastructure and staff and sustained support for research, education and training institutes in partner countries.

We note, for example, that there is no comprehensive database of Schools of Public Health, their expertise and competence because the WHO and the relevant international associations have been unable to fund this development. Yet this would provide an essential starting point for improving cooperative research and development in key areas such as health systems improvement, health promotion and disease prevention and application of the International Health Regulations.

Q 6: Do you think that Official Development Assistance (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?

A: Yes - the EU should negotiate with Member State and other countries to ensure they meet their obligation under MDG 8 to provide ODA at 0.7% of GNI. It should also negotiate agreements with recipient countries on their levels of social expenditures and on cross cutting issues such as health governance, including transparency and sustainability.

This could be further supported by the taxation of international financial transactions. There is a growing European consensus on the need for such taxes both as a way of stabilising the financial system and as a means of funding global governance.

Other sources of funding and resources from academic, business and civil society should be encouraged by collective EU action, for example, ensuring appropriate tax treatment of genuine international philanthropy and working with European based multi-national companies that make positive contributions to global health. This should include not only pharmaceutical and information technology based companies but also the many other multi national corporations whose direct or contracted international operations, employment , marketing and products can make a positive impact on health in Europe and globally.

Q 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?

A: The Paris Declaration on Aid Effectiveness set clear principles for improving aid effectiveness and the International Health Partnership and Related Initiatives (IHP +) show how such principles can be applied to develop cohesive sector wide agreements between recipient and donor countries.

It is important to address critics of IHP + to ensure that they develop as an inclusive mechanism recognising the role of civil society and other actors. This requires that EC develop further practical measures to coordinate aid from Member States and other donors with recipient low and middle income countries. While playing a strong and supportive role on cross sector issues the EC must respect the views of the recipient country Ministry of Health and the support role of the WHO country office.

Q 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?

A: The EU should play a crucial role in supporting sector wide development of Health Ministries and research, education and training institutes. As examples, the Africa Health Workforce Observatory notes that many countries lack the capacity or political will to address fundamental issues of pay, training and career structures for health workers.

Agreement on the International Health Regulations (IHR) has been hailed as a success in which EU and Member States played a strong role but its practical application is not evident in many low income countries. EU support and diplomacy is needed to help low income countries to work with the European Centre for Disease Prevention and Control (ECDC) and other agencies to address the requirements of IHR to identify and monitor international health risks - many of which also pose a threat to European health and resources.

Q 9: What are your suggestions for striking the right balance between addressing health priorities and providing support for developing health systems?

A: These should not be alternatives. In too many cases vertical programmes deplete basic health resources. The EU collective role should not be to add further vertical programmes but to work with recipient states and donors to encourage a balanced approach and support sector wide developments on which specific initiatives depend. This includes improving national governance of health systems and reducing corrupt practices.

It is essential to ensure that health aid itself does no harm to health systems thus the EC should focus on support for basic health systems maintenance and development and should counter any potential distorting effects of programmes. It has been suggested that the impacts on the total health system of vertical programmes should be recognised as an overhead to the health economy.

Q 10: What are the main opportunities for increasing the level and enhancing the effectiveness of health aid from the EU?

A: Greater citizen engagement from both EU and recipient countries could improve awareness and transparency. Local to local twinning and partnership and civil action on issues such as fair trade and fair health may not be the most efficient ways of delivering aid but are an essential basis for public support for global health aid policies and to encourage shared values of global citizenship. Such links can also build community or village based approaches to health.

It should also raise awareness of the contradictions in EU policies and awareness of the positive and negative impacts of corporate Europe on global health and development which are many times that of aid alone. It is important to help consumers understand the impact of their choices on global health.

Q 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?

A: The importance of health as a focus for foreign policy was recognised in the Oslo Ministerial Declaration on Health and Foreign Policy of 20th March 2007 signed by the Foreign Ministers of Norway, France, Brazil, Indonesia, Senegal South Africa and Thailand, which with the added support of Switzerland and others is to be brought to the UN General Assembly on 10 December 2009

The EU needs to promote its values and beliefs in health, education and human rights including gender equity, as a basis for building trust and democracy and as central tenets of EU global diplomacy. And it also needs to recognise and respect the values and beliefs of partner countries where these are compatible with basic human rights. This is best demonstrated in practice rather than rhetoric, thus EU policies must be shown to support human rights to health as well as providing examples through the action of European based multi national companies and civil society groups and in its aid programmes.

Global health is of special importance in conflict situations. The potential for the use of health agents as weapons of terrorism is already recognised in EC policy. The EC should also play a leading role in developing the practical application of health as a bridge to peace in pre and post conflict situations. And during conflict, consideration of potential health impacts should be a key consideration of any European Union Force. Thus health and peace forms an important dimension of the EU's role in global health.

Q 12: What impact will global crises (climate change, food prices and economic downturn) have on global health and what could be done to help mitigate their ill effects?

A: For the last 50 years technical advances and increased prosperity have ensured continuing improvements in health, but it now seems unlikely this will continue. The underlying problems of population growth, food and water shortage, economic instability, climate change and the impact of HIV/AIDs, anti microbial resistance and faster spread of both infectious and lifestyle diseases all suggest a turning point in health and equity. The consequences for human health and the potential destabilising impact on peace and stability are immense. But the coming crises also raise awareness of global citizenship and hence present the opportunity to rethink the rules of global governance and the importance of mechanisms for funding and managing such global challenges.

The EU should take the lead on these critical long term issues where concerted international action is required. It should support the emergence of a concerted approach to such issues drawing on Member State and academic, business and civil society resources and working with partner states and agencies. It should use its experience and knowledge to promote global governance mechanisms including international law, funding mechanisms and agencies to address these issues at the level and scale necessary.

Q 13: What should be the role of civil society in the health sector, at national and local levels?

A: European civil society is at the forefront in raising understanding and awareness of global health issues. They are also major providers of health resources, through training, company health schemes and service provision. International, regional and national organisations and associations of health professionals and students are also vital to the development of local training and practice and hence the development of health systems.

Health related organisations, patient groups and professional associations engage between 15% and 20% of citizens in many European countries. It is therefore important to draw on these perspectives and resources in developing European wide action for global health. However, many such organisations reflect specific perspectives and concerns so mechanisms to establish balanced and representative views are also necessary at national and European level..

In low income countries, particularly in rural areas, civil society is of fundamental importance to health: the first health advisor is usually a relative, neighbour or traditional health practitioner, their knowledge is crucial to obtaining and using health services and pharmaceuticals. While formal health systems take many years to improve, action through civil society to improve knowledge and mutual aid are essential first steps.

Ghandi said "health comes from the village" and Ethiopia provides a practical model of this philosophy in practice with village health workers and supporting community structures. This shows the potential for innovative health systems not simply in terms formal structures of hospitals and clinics, but also as part of village and community development. It is one of many lessons that Europe can learn from partner countries.

Q 14 : Which actions do you think the EU should take to stem the brain drain of health workers, while respecting their freedom of movement?

A: The shortage of health workers is a growing problem for many high, middle and low income countries, clearly migration of health workers increases this problem. But since global trade is fundamental to the EU it would be wrong to attempt to deny the freedom of people with international skills to migrate to countries which reward them at a higher level. Measures are already being taken to encourage high and middle income countries to train enough health workers for their own needs, this could be further supported by creating a mechanism to repay the training costs incurred in respect of health workers migrating from low income countries. This should not be a cost to the employer but as a form of international compensation for the transfer of a global public good.

This problem is compounded by the fact that health workers are often under recognised and rewarded in low income countries, indeed in many cases there is unemployment amongst health workers. The EC should therefore support partner country Ministries of Health and Professional Association in the redesign and restructuring of the roles and career paths of health workers to ensure that health workers are recognised and have career opportunities in their own countries. Further measures could include subsidy of health worker pay as part of an IHR+ agreement for cross sector support. Note that such agreements would need to encompass civil society actors since 40% of health services are delivered by non government agencies in Africa (this ranges from 20-70%).

Other steps might include incentives for health workers to return from training or periods of work in another country and action to reduce the cost of income remittance from EU countries to low income countries.

Q 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?

A: In rural areas of Africa, where 70% of people live, it is common for health services to operate with one nurse per 2,000 people perhaps with a medical assistant trained to prescribe basic drugs for every 10,000 - 20,000 people but less than one doctor per 60,000 people. It will take at least 30- 40 years to increase doctor numbers to a level that could provide basic services in a European model. While the situation is different in other parts of the world access to doctors and recognised health centres is often a problem, for example, in rural Afghanistan village based women's health services supported by information technology are an essential element of health delivery systems.

Thus telemedicine and advice by mobile phone has great potential, not as additional service elements or for access to emergency services but as basic elements of redesigned services with retrained and restructured health workers. The potential for investment in ICT for Africa has led to a major investment programme, the Pan African Network (PAN) supported by the Indian Government in agreement with the African Union. The EU in cooperation with academic business and civil society groups with interests and capabilities in this field could add great value to this development without competing with the benefits to the Indian economy, this requires complex international diplomacy and coordination led by the EC.

Q 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?

A: The most pressing need in many low income countries is for access to affordable essential medicines and health knowledge. This requires continuing work with WHO Country Offices and Ministries of Health and partner country academic business and civil society groups to agree on affordable essential medicines and health knowledge and how they can best be delivered to meet local needs in rural and urban areas. This may require the redesign of both health workforce roles and systems using information and communications technology where appropriate.

There is also a need for training in prescribing by medical assistants and nurses and dispensing and pharmacy skills plus support for the distribution of medicines through local pharmacies at affordable prices. While further support for regulatory agencies is also necessary this must be coupled with other aspects of drug delivery thus a sector wide approach is essential. Working with donor and recipient countries, WHO, UNDP, UNICEF and civil society organisations like Médecins Sans Frontières the EC should offer support for cross sector measures to develop and maintain access to essential medicines.

This approach would not only meet urgent health needs but would also counter the misuse of drugs and the antimicrobial resistance which follows. We wish to stress that action on anti microbial resistance and to address the problem posed by counterfeit drugs must go hand in hand with action to ensure appropriate access to antimicrobials and other essential medicines.

At the same time the EC should negotiate with European and international pharmaceutical and distribution industries, including suppliers of generic medicines (which make up the great majority of the pharmacopoeia in low income countries), to ensure that a range of essential medicines can be provided at affordable costs in low income countries. To achieve this EU funding will be required, coupled with measures to counter parallel re-exportation of products from low to high income countries.

Q 17: What could the EU do to improve the research funding for global health?

A: Global health research is needed in many fields, including studies of fundamental challenges to health such as food and water supply, population growth, climate change and anti microbial resistance. In such fields the role of the EC may be to bring researchers together to draw conclusions for action on issues of global governance and law.

Second, it is essential to gain a greater understanding of the impact of EU policies on health and to develop measures of the health impacts of European companies. This could be supported by a relevant European research institute or agency.

Third research into neglected diseases may be supported by a mix of push and pull incentives such as advanced purchase commitments, tax relief support for basic research and other measures.

Fourth and of greatest potential is the need to fund health systems research to find innovative ways of improving basic health systems and health protection in low income countries. This requires development partnerships to help build local capacity for practical research and training for health systems innovation in middle and low income countries.

We recognise there are many agencies and coordinating mechanisms for such research we nevertheless suggest it would be useful to re-examine this issue.

Q 18: How, in your opinion, could the EU research funding effectively address the systemic weaknesses of health systems worldwide?

A: Health systems research partnerships could form a virtual Global Health Institute, drawing on the model of the European Observatory on Health Systems and Policies and building on the wide range of partnerships between Universities and Institutes in European and middle and low income countries. It should be led by regional bodies such as the African Union and supported by WHO and other UN bodies with EU support. The virtual institute could also draw in support from ICT companies, pharmaceutical and others with an interest in global health as well as civil society organisations including professional associations.

The Institute's research programme could focus both on finding local solutions to local problems and on examining major alternative approaches to basic health delivery, including uses of ICT and healthy village and community approaches.

Research programmes would need to partner not only with local Universities and Institutes but also with Ministries of Health and professional associations in low and middle income countries. It is envisaged that such programmes would also form WHO Collaborating Centres to include, for example, an African Health Observatory and an Arabic Health Observatory.

Q 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?

A: Many low income countries currently lack the capacity for such research and are unable to attract staff of the level required. They may feel a lack of support from Ministries of Health and professional associations. Indeed it is sometimes felt that Ministries feel constrained to respond to overseas delegations offering models of healthcare delivery as part of an aid package at the expense of consulting local research and professional groups. Academic partnerships and joint working should be encouraged but it must be realised that not withstanding the establishment of a virtual Global Health Institute, as described here, this will take some years to develop.

The EC could play an important role in supporting research and implementation of health system improvement. The leadership provided by WHO and its Country Offices is essential to engage Ministries of Health and professional associations.

Q 20 : Which kinds of global public goods for health should be given priority and how should they be financed and managed?

A: The EU should focus on ensuring equitable access to public goods for health. Specifically, health knowledge and access to essential medicines at affordable prices. In addition, the International Health Regulations could provide a basis for defining local and global priorities for global public goods for health.

The price of access to health knowledge could be reduced in many different ways. For example, the EC could work with WHO Country Offices to improve access to comprehensive knowledge libraries for health ministries and health workers. Health advice services, along the lines of the UK NHS Direct - but reconceived for local needs, could be developed with local entrepreneurs and health professionals.

The price of pharmaceuticals is of course an artificial construct based on the protection of intellectual property, European prices for pharmaceuticals could take into account the need to provide access to low and middle income countries, in exchange for protection from parallel re-importation.

Antimicrobial drugs are global public goods that require special attention, to ensure universal access at affordable prices, to ensure that they are used responsibly, in order to avoid anti microbial resistance and to ensure their continued availability, by investing in the development of new solutions. This field is a special focus for EU joint action with the US and provides a model for early action on a very significant health issue. However, as Hans Rosling pointed out, it would be morally unacceptable to address this issue without also dealing with the loss of lives due to lack of access to antimicrobials as essential medicines.

Q 21 : Which do you think are the priority areas for coherence on global health policies, and how should they be addressed?

A: Health in All Policies provides a broad basis for demanding policy coherence in all fields relevant to health. Specific priorities for action will depend upon the extent of the potential impact on global health, the practical level of agreement that can be achieved between Member States, the European Parliament and other parties and the other agendas of the EU. Thus, as examples: European Parliament comments on the need for policy coherence on the application of TRIPS to pharmaceuticals have been helpful in making this a priority. Equally agreement with the US on joint action on antimicrobial resistance fostered by the Swedish presidency have both built on and ensured this as a priority, though note our previous comments on the need to couple this with action on access to antimicrobials as essential medicines. The current redefinition of the EU structure and process following the ratification of the Lisbon Treaty coupled with other movements to reform the UN provides an opportunity to address global governance and global citizenship issues. The Copenhagen summit on climate change brings as a priority governance and funding measures to adapt to and mitigate its health impacts. And the upcoming review of the Common Agriculture Policy provides an opportunity to address a very significant area of health impact. Further priorities driven by need include support for health systems research and development and measures to address the migration of health workers.

In all the fields noted there have been previous research recommendations and resolutions promoted by presidencies, commission papers and/ or resolutions of the European Parliament. We therefore believe there is a very good basis for agreement and action. However, the competence of the EU for collective action in such cross cutting areas depends upon the ongoing agreement of Member States, the European Parliament, partner countries, international agencies and academic, business and civil society groups. We therefore suggest that the Rotating Presidency and the European Economic and Social Council should be asked to support an ongoing process to establish agreement on community wide actions for global health. We suggest that this would form a European Strategy for Global Health to support the actions of the High Representative for Foreign Affairs and Security Policy and Vice President of the European Commission.

European capability in global health would be further enhanced by measures to develop international diplomatic and technical skills in this field within the European External Action Service and through ECDC. We note the experience of the USA in this field, which has dedicated health experts within its Foreign Service and 280 global health experts from CDC located in 54 countries.

Q 22 : How could the legitimacy and efficiency of the present global health governance be improved and which role should the EU play in this?

A: The EU should bring European perspectives, including academic business and civil society voices to global health fora: (UN, World Health Assembly, G20), based on European values of solidarity, universality equity and quality. It should ensure that the many different mechanisms for global health governance are themselves more cohesive. This requires that the many agencies involved should work better together by recognising the nature of the distributed leadership of actions for global health within the overall leadership of the UN and WHO.

In practice this means that agencies should each focus on the fields in which they can add most value. Mechanisms such as G20 can be helpful in bringing agreements to the UN system, but if they are seen as an alternative this will undermine the authority of the UN. Notwithstanding this, there is scope to improve the mechanisms and agencies of the UN. At national level the strengthening of WHO and other UN local offices in "one UN" provides a basis for local leadership that should be supported by the EU. This should help to reduce the burden of multi agency visits and conflicting advice to low and middle income country Ministries of Health.

The EU can also enhance the legitimacy of its role in global health governance by supporting other regional groups in acting collectively on health and related issues. This require support for groups such as the African Union and the Arab League, drawing on lessons from the experience of the New Partnership for Africa's Development and respecting the huge diversity of global regions.

Within Europe the EU should enact legal instruments to support Health in All Policy. EC should lead and define common policy and help coordinate subsidiary actions by Member State agencies. It should work closely with WHO Euro and major agencies in this field to establish a common agenda and joint working programmes where possible, recognising that the agencies have different responsibilities and constituencies but often share common goals and values. It would be helpful to define a procedure for agreeing such a shared agenda for policy, technical and operational consideration and for consultations with civil society with WHO Euro and the other major agencies and groups involved in global health. Recent developments in WHO Euro suggest that it would be very timely to introduce such a process.

Q 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?

A: The EU should support WHO and its country offices in working with national governments to define and monitor national standards and establish realistic plans to achieve them. EU may need to define the essential medicines for which it will provide support but should seek to work with WHO and recipient countries on this, it should not seek to impose yet another set of standards.

Q 24: What, in your opinion, should be the main principles guiding equitable social protection for health?

A: Equitable social protection requires first that global and national governance should do no harm. For EU this means ensuring trade and other policies are not detrimental to health. This requires the legal enactment of Health in All Policies and mechanisms for the regular assessment of health impacts for EU policy and in relation to the actions of European multi national companies. For recipients this means no discrimination or corruption. The EC should work with WHO and donor programmes to ensure these requirements are vigorously pursued.

Pursuit of equity, broadly defined as overcoming barriers to human rights to health raises the question, "when does inequality amount to inequity." This is a moral question in which the EU should engage many different civil society and national voices to develop public awareness of global citizenship and its obligations.

Q 25 : Which fair financing principles and mechanisms should apply to health system financing to ensure equitable and universal coverage of basic health care?

A: In low income countries most health costs are met by individual citizens, the first priority of basic health services financing should be to empower and enable citizens to get safe, effective services and drugs for the money they spend. A frank recognition of these costs to users who pay for services provided by health systems would provide a more realistic basis for considering their financing. It would open up profitable markets such as the provision of telephone health advice and local pharmacy services, which currently exist as unregulated and sometimes illegal activities to regulation and improvement.

Current mechanisms for informal finance - for example borrowing from neighbours to finance a trip to a source of medicines - can also be improved by community micro finance mechanisms. These local approaches are in many cases more realistic than plans to introduce social insurance principles or tax funded services.

Q 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?

A: Civil society does not offer an alternative to the representation of democratic local or national government in Europe, but does offer different perspectives often based on specific experience and interests. Moreover civil society engagement is essential to create a sense of European identity and common values through engagement with the decision making processes on global health. It is important to listen to both representative and interest groups. No single organisation or mechanism can represent the collective views of civil society or even all patients because in most cases there is no common view. The European Parliament can play an important role in bringing together different views and positions informed by a range of diverse views.

The development of cross government and cross sector strategies or mechanisms for improving cohesion on global health policies and research as in Switzerland, UK, Norway, Sweden, France, Brazil, Eire and Thailand and also the USA and Canada is a very helpful starting point for civil society engagement in this issue. European organisations representing academic, business and civil society interests and perspectives can similarly be engaged in an ongoing European Strategy for Global Health alongside national representatives, partner countries and international agencies.

In many low and middle income countries the mechanisms for democratic government are poorly developed or non existent, it is therefore useful to develop other mechanisms for public engagement. Civil society organisations can provide the impetus to improve health as it is a critical area in which citizens judge the performance of local and national government, as has been shown by the People's Health Movement in India. International civil society organisations such as Transparency International or Women's Health Movements also play a vital role in raising awareness and stimulating action for good governance and health.

Q 27: What, in your view, is the main added value offered by the EU in the field of global health?

A: EC has convening power, leadership of common policy in health and can establish and support operational agencies to implement such policy. However its competence in this field depends upon the agreement of Member States and others on the need for joint action. Thus an important starting point for EU policy is to establish a process for ongoing agreement on policies and actions. Such a process to develop a European Strategy for Global Health should engage not only Member States but also partner countries and international and regional organisations. Most importantly it must also engage with pan European academic business and civil society groups, since European action requires their support, not only in developing social awareness but also in delivering practical action for global health.
The EU must focus its collective action on strategic issues where its role is essential to promote joint action and should avoid over extending its role in fields which may be better led by the WHO or Member States and other parts of the system. In short, it should focus on strategic issues of governance. We suggest that a focus on MDG 8 provides a clear framework for action on the long term determinants of health and health systems development and cross cutting areas of policy such as health and trade and health and peace.
Specifically as noted elsewhere in this response the EU should undertake the following actions which have been set in order of priority as dictated by practical considerations and urgency of need :

- Clarify the leadership of global health within the EU system as a cross cutting issue, we suggest at the level of the High Representative and begin to strengthen diplomatic and technical skills and representation in this field.

- Take forward action on the protection of antimicrobial agents in partnership with the US and in parallel with action to ensure access to antimicrobials as essential medicines.

- Ensure policy coherence in the application of TRIPS agreement to EU pharmaceutical pricing agreements.

- Address the health impacts of climate change and support collective EU action to mitigate its impact both in Europe and in partner countries.

- Agree a procedure to establish a common agenda for action on global health by WHO Euro and other relevant international agencies.

- Lead the development of an ongoing European Strategy for Global Health.

- Enact European legislation based on this strategy and Health in All Policy.

- Promote responsible action for health by European multi-national businesses.

- Promote safe access to essential medicines by a range of practical measures to improve the delivery of medicines and health knowledge and address drug pricing and parallel imports affecting drugs produced by European companies.

- Examine the impact of Common Agriculture Policy on global health as an aspect of the review of CAP.

- Form a Global Health Institute based on international partnership for research, education and training for innovations in health systems.

- Support WHO country offices in working with low income countries to define access to essential health care, knowledge and medicines.

- Support and develop awareness of global citizenship including action fair trade, fair health and gender equity as European values.

- Develop a policy framework for health and peace in conflict situations and in relation to pre and post conflict initiatives, linked to EU health security policy.

- Coordinate EU research on global health governance, funding and threats including climate change, population growth and food and water scarcity.

- Improve global governance for health by ensuring that regional actors such as EU and other groups such as G20 work through the UN system.

- Extend the use of coordination mechanisms in working relationships between EU donor countries and partner countries.

- Promote global funding mechanisms for global public goods for health, both within the EU and in global health governance meetings.


Q 28 : Do you think that an EU social model could inspire global health equity?

A: The EU encompasses many different social models of health care, but with shared values of solidarity, universality, equity and quality. These values should be promoted by global health diplomacy, engaging civil society actors in this process and taking global leadership on the practical application of MDG 8, to develop a global partnership for development. However, as Nelson Sewankambo reminds us, it is a mistake to promote a set of values without recognising and respecting the values of others.

Global health is a major opportunity for the definition of European values and its contribution to global governance and democracy. But it can only aspire to moral leadership in this field if it draws on and influences all levels of European society in defining such common values and actions.

It must also live by its values. Thus a European wide strategy for global health engaging European and partner governments, academic, business and civil society groups and legal enactment and routine monitoring of Health in All Policy are essential foundations for European leadership in global health.

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