Health is global: proposals for a UK Government-wide strategy

Abstract

Global health enables the harmonisation of international and domestic-health concerns—its outlook is much wider than a development or foreign-assistance perspective alone. Engaging globally in health requires the creation of relevant and effective partnerships to implement solutions for shared or common problems. To build on the UK's achievements and leadership in global health, the central government Department of Health is now leading the development of a UK Government-wide global strategy. This paper describes the rationale and process for developing the new UK Government-wide strategy for global health and highlights some of the issues that must be discussed.

Global health

Worldwide, communicable diseases, maternal health, perinatal conditions, and nutritional deficiencies account for about 30% of all deaths and 39% of ill health. Deaths and illness from chronic diseases are, however, increasingly important. Preventing chronic diseases: a vital investment ¹ highlighted the global burden of heart disease, stroke, cancer, chronic respiratory diseases, and diabetes. Four out of five deaths from chronic disease now occur in low-income and middle-income countries.

Improving the world's health and reducing premature deaths means the underlying determinants of health must be understood and tackled, health systems strengthened, and spending on health care and health research increased. Poverty, social exclusion, and access to safe housing, food, water, and sanitation are all important determinants of health. In 2005, WHO established the Commission on Social Determinants of Health² to draw the attention of governments, civil society, international organisations, and donors to ways of creating better social conditions for health, especially for the world's most vulnerable people.

The effects of climate change, environmental pollution, and degradation of natural resources on a global scale might be some of the biggest hazards to health in the future. Natural disasters and scarce resources can lead to mass population movements and conflict, which are associated with increased mortality and reduced physical and mental health. The causes of climate change and pollution, like their effects, are common to many countries and require shared solutions.

The state of human health in many developing countries continues to decline at a time when the world's funding of biomedical research is increasing. This situation creates the need to promote greater international cooperation in biomedical research that is relevant to such countries.³

The health and wellbeing of populations is also crucially dependent on the performance of the health systems that serve them. Yet the health systems of many poor countries are overburdened and some are on the brink of collapse. The result is large numbers of preventable deaths and disabilities, unnecessary suffering, injustice, inequality, and denial of individuals' basic right to the highest attainable standard of health. Moreover, despite the burgeoning economies of India and China, health systems in those countries are not advancing as quickly as they could. Investment in systems, services, and public health are crucial if these countries are to maximise their economic and human development potential.

Globalisation and health

Globalisation can bring benefits for human health: via improved trade, sharing of medical research, and the pooling of financial, technical, and intellectual resources for solving shared health problems. Globalisation can also pose risks to human health—for example, through unfair trade and its regulation, inequitable distribution of natural resources, and poorly managed migration. The key issue for policymakers is how these benefits can be harnessed while minimising the potential for harm. The Whitehall Permanent Secretaries regularly discuss how the UK government best responds to globalisation. The group promulgates UK action to maximise the opportunities of globalisation in areas such as development, climate change, energy security, trade and industry, science and innovation, education, and global health.

Rationale for a Government-wide strategy

The US Institute of Medicine, in a 1997 report,⁴ made a strong case for why that country would benefit from investing in health abroad. The report identified three pillars: protecting people, enhancing the economy, and advancing international interests. In 1999, the then director general of WHO, Gro Harlem Brundtland, reminded the international community that investing in global health was good politics, good economics, and good for national and international security.⁵

A Lancet Editorial recently described the advantages of using health as an instrument of foreign policy,⁶ such as protecting nations against health threats, social cohesion, strengthened national infrastructure, improving bilateral relations, and encouraging trust across global multilateral agencies. Five key reasons exist for why the UK Government should do more than it does at present to promulgate global health. Engagement with the global health agenda can improve global security and health protection, enhance sustainable development, improve trade by promoting health as a commodity, maximise potential of global public goods, and encourage a human rights approach to health. Potential conflicts exist between them. For example, reconciling UK trade interests (including trade in health commodities) with sound pro-poor development policy and maintenance of international human rights might be difficult. Also, global health should not be seen solely in security terms. That would create a security triage in which health issues that represent security threats are given automatic priority over others. Another potential area of difficulty is where the military is associated with peacekeeping and service delivery. Local populations can be unclear on mandates and non-governmental organisations might have concerns about erosion of humanitarian space.⁷ A coherent UK global-health strategy is important in navigating an economically and ethically acceptable path through these five areas.

Greater security: protection of the UK population's health

The effect of conflict on health is well known.⁸ Conflict causes death and morbidity from physical injuries, but also results in large population movements, mental illness, malnutrition, and outbreaks of communicable diseases. Improvement of global health and health care helps guard against states failing. Failed states, poor human development, and absence of basic services breed instability, poverty, and inequalities—the sort of environment that can encourage conflict, but also terrorism and illegal trafficking of tobacco, alcohol, drugs, and people. Global security also means food security and includes food safety and continuity of food supply.

Nowadays, improving human security includes tackling communicable diseases. The UK Government Office of Science and Innovation's Foresight Project drew attention to the threat of new infectious agents and their potential for epidemic spread.⁹ It identified the need to strengthen the response to this threat by integrating new and effective public-health control measures within local cultural and governance systems. An influenza pandemic is an obvious example of a global-security threat. HIV and AIDS are inextricably linked with national and global security. AIDS is crippling economies and also compromising the governance, state stability, and military capacities of many African countries.¹⁰ In view of South Africa's international tourism boom and global trade and transport systems, recent emergence of extensively drug-resistant tuberculosis is another example of disease with a global threat.¹¹ Migration brings economic and social benefits. Although many migrants are healthy, some have complex, specific health needs (eg, mental health, communicable disease).¹² People developing communicable disease control policies, such as pre-embarkation screening for tuberculosis and HIV, should do so on the basis of sound public-health evidence.

Contributing to sustainable development

Three of the eight Millennium Development Goals (MDGs) relate directly to health, but health is also an important contributor to several of the other goals.¹³ The WHO Commission on Macroeconomics and Health showed that investing in health makes sound economic sense.¹⁴ Countries with poor health are less likely than those with good health to achieve sustained economic growth and contribute to the global economy. The commission estimated that in developing countries, a basic health-care package of US$34 per person would save 8 million lives a year, which would generate economic benefits of $360 billion. Tactically sound action across government could encourage African countries to implement the Commission for Africa's recommendation that they spend 15% of their national income on health and that resources are used to support health interventions that are proven to be most cost effective.15, 16

The macroeconomic effects of the HIV pandemic are substantial.17, 18 In eastern Europe, 80% of people infected with HIV are of working age. Malaria is slowing African economic growth by up to 1·3% a year, costing more than $12 billion yearly. Controlling endemic malaria in Africa will raise its gross domestic product by 20% over 15 years. Tobacco use results in a yearly global net loss of $200 billion. The $300 million investment in global smallpox eradication returned more than $3 billion in economic benefits.¹⁹ Improvements in health might have contributed to as much as a third of the east Asian economic miracle.²⁰

Health as a commodity

Health services, research, drugs, and medical devices are commodities that contribute to the global and UK economies. Worldwide, the health-care industry is worth more than US$3 trillion yearly.²¹ The estimated value of health-care products and services exported from the UK in 2005 was £14 billion. Pharmaceutical industry exports are estimated at £12·2 billion, creating a trade surplus of £3·4 billion. The UK's medical device market is the fourth largest in Europe, with an estimated value of £4 billion. Globally, the industry is an attractive target for abuse. According to Transparency International the medical sector is seen as being more corrupt than the military sector.²²

Enhancing the effect of industry on global health requires greater focus on access for the poorest people in the world than exists at present. Increasing the number of public–private partnerships that include commercial drug and biotechnology companies is one way to do this. A second approach is fairer regulation of international trade. The Trade-Related Aspects of Intellectual Property Rights (TRIPs) agreement is designed to protect the rights of patent holders over knowledge systems or products including, for example, drugs. In 2003, World Trade Organisation (WTO) members agreed that developing countries with insufficient manufacturing capacity in the pharmaceutical sector could make effective use of the compulsory licensing provisions contained in the TRIPs agreement, which was amended in 2005. These changes are designed to make it easier for poor countries to import cheaper generic medicines if they are unable to manufacture them. Developed countries have an obligation to help poor countries make the most of these flexibilities with the aid for trade approach.²³ The General Agreement on Trade in Services is the first multilateral trade agreement to cover trade and investment in services. It constitutes the legal framework through which WTO members progressively liberalise trade in services, including, where members wish, health-related services. The Codex Alimentarius Commission, a UN Food and Agriculture Organization and WHO body, sets standards, codes of practice, guidelines, and other recommendations for food quality and safety to protect consumers from food-borne illness from home-grown and imported food and ensure fair trade practices in the food trade.

Health as a global public-health good

Public goods are goods that benefit society as a whole. In an increasingly interdependent world, more attention than ever before is being paid to global public goods. These address issues in which the international community has a common interest, although some might be especially important to certain countries. Public-health interventions, such as effective therapy for a disease, epidemic control, or dissemination of research, are global public goods that address problems irrespective of national borders. The UK's contribution to the polio-eradication initiative or the containment of the severe acute respiratory syndrome outbreak in 2003 are examples of its contribution to global-public health goods—shared protection of health worldwide.

The UK Government global-health strategy can look at how to build on existing global public goods, including the work that the International Task Force on Global Public Goods has been doing on infectious diseases, climate change, and ensuring that the public good benefits of, for example, the uptake of new vaccines are distributed as widely as possible.²⁴

Health is a human right

Examples of international human rights instruments that are binding on the UK include the UN's Universal Declaration of Human Rights, International Covenant on Economic, Social and Cultural Rights, Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, Convention on Elimination of all forms of Discrimination Against Women, and Convention on the Rights of the Child. In 2002, the UN Commission on Human Rights created a Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, which reports on a yearly basis.²⁵ Achieving a balance between respecting the rights of the individual and the population is crucial. Compulsory as opposed to voluntary vaccination, and whether involuntary detention should be used to contain extensively drug-resistant tuberculosis, are examples of some of the difficult judgments to be made.²⁶

Consistency of purpose across Government

The UK Government has much to build on. The growth of an international social movement that recognises health as a shared global value that comes from vibrant non-governmental organisations and academic institutions has been important. The UK has been at the forefront of multilateral initiatives, such as cancelling debt from poor countries, increasing access to medicines, and establishing global initiatives such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Global Alliance for Vaccines and Immunisations, the World Alliance for Patient Safety, and the WHO Commission for Social Determinants. The UK Government Department for International Development is seen by many development specialists as one of the most effective bilateral development agencies. Frameworks and initiatives across the UK Government have the potential to improve global health (webtable).

The 2005 UK presidency of the Group of 8 wealthiest nations (G8) drew attention to global health, climate change, investment in health systems, and partnerships with governments of developing countries. The UK Prime Minister's Commission for Africa gives the UK a leading role to end poverty and tackle health inequality in Africa, tackle HIV/AIDS, and meet the 2015 MDG targets. These and other frameworks reinforce the importance of a multisector approach to achieving health outcomes. European Union engagement provides opportunities to drive the global-health agenda forward.

The UK Government's support to the UN and other global-health agencies and partnerships places it in a strong position to encourage the UN and others towards reform—eg, implementation of the recommendations of the High-Level Panel on System-Wide Coherence.²⁷

WHO's International Health Regulations show how concerted global action can provide the framework for national measures to address a health threat.²⁸ The UK has worked with others to implement these in a way that avoids unnecessary interference with international traffic and trade. After Sept 11, 2001, the G7 countries, European Commission, and Mexico established the Global Health Security Initiative with WHO as a technical adviser. This initiative is an informal, international partnership of like-minded countries to strengthen health preparedness and response globally to threats of biological, chemical, and radio-nuclear terrorism and pandemic influenza.²⁹

The UK has several internationally respected non-governmental agencies and academic institutions as well as the NHS and specialist agencies (eg, Health Protection Agency and National Centre for Health and Clinical Excellence [NICE]) that can help central Government develop and implement global health policy. The UK is also a global leader in the biotechnology sector, which is the largest in Europe and second only to the USA. The central government Department of Trade and Industry and UK Trade and Investment are important in identifying new international markets and attracting foreign investment.

Challenges and tough questions

The global-health strategy could have a number of functions. First, it could give additional legitimacy for individual government departments and non-governmental agencies to invest in and take action on global health. Second, it could be an accountability mechanism for government delivery on existing frameworks that affect global health. Third, it could help to prioritise areas for action. A global-health strategy provides the opportunity for individual Government departments and agencies to ask themselves whether their engagement in global health is sufficient. For example, many of the central government Department of Health's objectives and targets under its Public Service Agreement (reducing adult smoking rates and halting the rise in obesity in children younger than 11 years) have a global dimension and require global engagement.

In the wake of the Stern Review,³⁰ Stott and Godlee challenged citizens and governments to take effective action in responding to the challenge of climate change,³¹ an area in which a Government department such as the Department of Health can show leadership.

In 2002, the UK Government published a strategy for combating infectious diseases,³² which made clear that the prevention and control of infectious disease in England must be set in a global context. The separation of domestic and international health problems is less relevant than it used to be as people and goods travel across continents. The strategy also widened the traditional infectious-disease control functions to encompass health protection—including combating chemical, environmental, and radiation hazards. The value of this approach was shown in the response to the poisoning of Alexander Litvinenko, a former Russian intelligence officer, with polonium.³³

WHO, for example, often struggles to get professionals working in the UK health system released to work on global health priorities. In February, 2007, the ex-Chief Executive of the NHS, Lord Crisp, published a report commissioned by the Prime Minister on how the UK and the NHS can do more to strengthen the health capacity of developing countries. This report provides an opportunity for UK development partners to think about engaging more strategically in this area.³⁴

Independent of the priorities that arise from the global-health strategy, Government departments can work together more effectively. The UK Government should speak with a clear and unified voice on the role and mandate of WHO and other multilateral agencies with an interest in health. Many of the Government's health targets need international solutions that can only be tackled through the input of a number of domestic Government departments. The human-rights agreements to which the UK Government has signed up encompass availability of health care, health promotion and protection, safe water, adequate sanitation, and occupational and environmental conditions conducive to good health.

A way forward

Health is global: proposals for a UK Government-wide strategy³⁵ makes the case and provides a framework for the development of a global-health strategy. The document creates the opportunity for a wide discussion on what the current global-health priorities are, what the UK should focus on, and what the global-health strategy should include. During the first part of 2007 a UK Government-wide steering group will lead the collaborative process of developing the strategy. This group will consult widely—both within Government and with the non-governmental sector, the professions, industry, academia, and partners abroad. In moving from these proposals to a full strategy, criteria will need to be agreed the steering group after consultation that determine what the priorities should be (panel 1 ) and several questions must be addressed (panel 2 ).

Panel 1. Potential criteria for assessment of Government-wide strategic priorities in global health.

• •Global-health risks that threaten health of UK population (eg, communicable diseases (such as HIV, tuberculosis, severe acute respiratory syndrome, and pandemic influenza) and food-borne disease, bioterrorism, and climate change)
• •Global-health solutions in which UK has particular expertise (eg, global-disease surveillance, workforce planning, standards and training)
• •Global-health opportunities that benefit UK (eg, sharing knowledge and learning lessons from other countries, improving UK health and health services)
• •Global-health problems that UK action can help solve (eg, our work on an ethical code for international recruitment of health-care professionals or work to support UN reform)
• •Achievable but challenging goals can be set
• •Specific, measurable, and time-bound outcomes possible
• •Cuts across several Government departments, particularly when one department leads but is frustrated by insufficient engagement of others

Panel 2. Examples of questions that UK Government and its partners need to debate during development of Government-wide global-health strategy.

Health and foreign policy

What is the best way of integrating global health into UK foreign policy?

How can awareness be raised of the effect of non-communicable and communicable diseases, and policy levers to tackle them, among those working in and with the Foreign and Commonwealth Office?

How can G8, G7, and other international and regional forums tackle global health more systematically?

How can a more systematic and rapid contribution of health expertise to conflict and post-conflict situations be developed (eg, role of public health in the Post-Conflict Reconstruction Unit)?

How can consideration of globalisation and global health in EU policies outside health be best promoted (eg, social, food security, economic regeneration, trade and market regulation)?

Health and development

How can the Department of Health, NHS, and other UK Government departments and agencies support the Department for International Development's goal of achieving the MDGs?

How can internationally coordinated action be best promoted at European Union and global levels to address the push and pull factors leading to migration of health staff?

Is there more that the Department of International Development, Department of Health, and other Government departments and agencies can do to improve their joint responses in relief and development?

How to work most effectively with developing countries on the emerging epidemics of chronic and non-communicable diseases?

Health and the UK economy, including trade

How can the effects of trade liberalisation on global health, including on affordable medicines and the delivery of health care throughout the world, be better examined?

How can trade liberalisation be harnessed to promote global health?

How can we ensure that international trade rules take into account global-health objectives?

How to achieve greater coherence between the UK's trade and health policies?

Global threats to UK health

What can be done to predict and mitigate the health effects of climate change?

How can the Department of Health, its agencies, and NHS best use their expertise (eg, in epidemiology, toxicology, and health protection) to inform the Government's international environmental policies?

How can the challenges described in the Foresight Project on infectious diseases be best responded to?

How can the communication of health-intelligence and horizon-scanning systems to monitor and predict new threats to global health be improved?

What more can be done to promote and protect health of asylum seekers and immigrants?

The range of international resources (both financial and services in kind) needed for global health, what is currently available from Governmental and other organisations, and how they are spent, must be better understood. Although estimates exist for amounts of development assistance that countries, such as those in the Organisation for Economic Co-operation and Development, should aspire to, much less information is available about the right amount to invest in other aspects of global health. The strategy provides the opportunity to bring together the UK's foreign, international development, and trade and investment policies that affect global health. The outcome should be a strategy that is challenging and achievable, that will improve health and wellbeing in the UK and elsewhere, and that allows Government to be held to account.

Web Extra Material

Webtable

Examples of UK strategies and initiatives that effect global health, by Government department