As COVID-19 has laid bare, no one is safe until everyone is safe, making collaborative, collective commitment critical to strengthening the global governance of the determinants of health
The COVID-19 pandemic has dramatically displayed the importance of the underlying, multifaceted determinants of health in saving people’s lives, protecting their well-being and sustaining the economy, society and ecology they need. Thus far the most effective instruments in controlling COVID-19 have come less from biomedical equipment, therapeutics, procedures or vaccines than from simple actions in society at large – handwashing, physical distancing, mask wearing, self-isolating, home working and schooling, and connecting digitally. These social, economic and educational determinants in turn depend critically on having abundant, accessible, affordable clean water and soap, secure jobs and incomes, safe and spacious homes, women serving simultaneously as front-line healthcare workers and caregivers and teachers at home, digital skills and facilities for working, shopping and socialising, caring neighbours and communities, and supportive governments that people trust. They depend on nature to sustain the physical and mental health of individuals, to prevent animals from bringing pandemic pathogens into human settlements and bodies, and to provide the clean water, air and land needed to survive. Indeed, even an effective vaccine against COVID-19 could depend on the bark of a particular tree grown in a few developing countries in the world.
COVID-19 is a global threat from which no one will be safe until everyone is safe. It highlights the critical importance of global governance in addressing and strengthening the determinants of health in a comprehensive, mutually reinforcing and ambitious way. For over a century, countries’ leaders and ministers have come together to create and support several multilateral organisations dedicated to improving some of the key individual determinants of health. Along with the League of Nations, they started with the International Labour Organization in 1919 for workplace safety and labour standards, followed by the International Monetary Fund and World Bank in 1944 for economic stability, growth and development, and the United Nations itself in 1945 with its vision of coordinating all. These historic pillars have been joined by the UN bodies for the environment, climate change, biodiversity and animal health, the regional European Union and African Union, compact informal summit institutions such as the G20, a committed business community, foundations and non-governmental organisations to protect the most vulnerable and help provide essential public goods.
The World Health Organization
At the hub of this growing network governing the determinants of health stands the World Health Organization. Since 1948, the WHO has worked to bring health and well-being to all, by controlling and eliminating individual diseases and addressing the ever-expanding underlying determinants of health. It does so to fulfill its broad constitutional mandate to address the social determinants as well as the biomedical ones. To its inherited, long-standing, recently upgraded legal instrument of the International Health Regulations governing the outbreak of infectious disease, it added the Framework Convention on Tobacco Control, aimed at a key agricultural determinant. These are supplemented by codes on the food and nutritional determinants of health, from breast milk substitutes to sugary beverages. The WHO’s growing concern with preventing and controlling chronic, non-communicable diseases, climate change and gender equity has widened its field of action even more.
The UN and 2030 Agenda’s Sustainable Development Goals
Equally important is the United Nations, constitutionally mandated to address health, as part of its overarching purpose to bring peace and security, economic development and social well-being to all. Since 1990, it has increasingly addressed the determinants of health through global summits: for children in 1990; for the natural environment including climate change, biodiversity and desertification in 1992; for HIV/AIDS, NCDs at recent high-level meetings; and, in September 2019, for universal health coverage as a critical instrument. Its importance was highlighted in the first volume in this series, Health: A Political Choice – Delivering Universal Health Coverage 2030.
A major sustained thrust came with the eight Millennium Development Goals launched in 2000. Three were dedicated to child and maternal health and HIV/AIDS, malaria and other diseases, with the other five to poverty and education, primary education, gender equality, environmental sustainability and global partnership in direct support. Many more determinants and much more ambition were added in the successor 17 Sustainable Development Goals and the 2030 Agenda for Sustainable Development, approved by world leaders at the UN in September 2015. Health has a place of its own as SDG 3, which depends critically and explicitly on progress on the other SDGs, including economic and ecological ones, all now applying to developing and developed countries alike. Yet today, one-third of the way to achieving the SDGs by their deadline of 2030, progress is in retreat and success is in peril. Indeed, 30 years of development have been erased in 30 weeks by the deadly grip of the COVID-19 pandemic. Renewing the advances on the determinants of health in all the SDGs is the central common cause in the difficult decade ahead.
The functional multilateral organisations
The SDG summits in 2015 and 2019, and those to come, add the highest-level political will to the work of the many ministerially led bodies in the UN galaxy that have long worked to improve all the determinants of health. The ILO deals with occupational health and safety, employment and labour standards. UNICEF safeguards children’s health in humanitarian emergencies and beyond. The Food and Agriculture Organization, the World Food Programme and the International Fund for Agricultural Development focus on food and nutritional determinants, including those from fish and forests.
The economic and development determinants of health since 1944 have been significantly shaped by the IMF and World Bank, which acquired a major role when the World Bank adopted health as a priority in the 1990s. The IMF in 2005, at the behest of the G8’s Gleneagles Summit, produced its multilateral debt relief initiative for the world’s poorest countries, on condition that the freed-up funds go to health and education. These Bretton Woods bodies have been assisted by the Organisation for Economic Co-operation and Development, the United Nations Development Programme, the World Trade Organization and regional bodies such as the European Union, the African Development Bank and the Caribbean Community.
Since the 1970s, new UN bodies have arisen to address the ecological determinants of health: the United Nations Environmental Programme, UN Climate and UN Biodiversity. The UN Fund for Population Activities and UN Women have advanced the gender equality determinants of health. The UN Human Rights Council and Commissioner for Human Rights have long focused on key political determinants.
Important additions to this galaxy have come from the newer health bodies of UNAIDS the Global Fund to Fight AIDS, Tuberculosis and Malaria, GAVI, the Vaccine Alliance and the Coalition for Epidemic Preparedness Innovations, regional bodies such as the Caribbean Public Health Agency, and non-governmental agencies such as the International Federation of Red Cross and Red Crescent Societies, and many more.
Many of these old and newer players have formed partnerships. The WHO has done so with the World Organisation for Animal Health and in a trilateral alliance that includes the FAO. And the OIE has incorporated the SDGs as the framework for its 2021 strategic plan. This is a model worthy of attention and adoption by all.
The central comprehensive global governance summit institutions with a compact membership have long addressed the determinants of health and, more recently, health itself. The G20, created among finance ministers and central bank governors in 1999, has always focused on the financial, economic, development and trade determinants of health. Since rising to the leaders’ level in 2008, it has added employment, climate change, gender equality, crime and corruption, and more. It started to focus explicitly on health in 2014, responding to the deadly Ebola outbreak. Its scheduled summits have made 75 commitments on health, which members have complied with at a level of 69%, close to the all-subject average of 72%, according to the G20 Research Group and its partners. To counter the COVID-19 crisis, G20 leaders met virtually on 26 March 2020 and made 22 commitments on health. Two months later, G20 members had complied with them at a level of 69%. There remains far to go in G20 commitments and compliance to meet today’s proliferating global health needs.
The current challenge
Much more is also clearly needed to expand the capacity and cooperation of all the deeply committed institutions and actors to address the current pandemic, the other diseases that continue to kill so many and those diseases yet to come. Yet the pandemic has simultaneously catalysed new actions on a more comprehensive, far-reaching and innovative scale, both to counter the current disease and to act on the underlying determinants of health for all. The contributors to this publication present some of the pioneering advances, a frank assessment of the challenges that await, and compelling and creative solutions to meeting them.
In the first section, the leaders of the leading UN institutions centred in New York and Dr Tedros Adhanom Ghebreyesus as the director general of the WHO outline the overall vision and priorities that drive their work to defeat the pandemic and strengthen the determinants of health as a whole.
Next, the leaders of countries and international organisations from key regions of the world speak out about how they are mobilising the many health determinants to foster well-being. These include the security subjects of armed conflict and foreign policy, and the political determinants of patient and stakeholder participation in decision-making, human rights, non-discrimination and media.
Leaders of key international organisations and countries and experts address the economic and employment determinants. These drivers embrace economic growth and development, poverty reduction, employment and workers’ rights, transportation, travel, tourism, trade, tax, infrastructure, entrepreneurship, business and the pharmaceutical industry.
Several global leaders show how healthy people need a healthy planet. These ecological determinants include the entire integrated natural environment, containing agriculture, food, nutrition, water, sanitation, hygiene, natural disasters, climate, outdoors and indoor pollution, biodiversity, animal health and extreme weather events such as hurricanes.
On vulnerable people and gender, global leaders discuss the critical social determinants of health, which include children and childcare, migration and shelter, education and human capital, demography, ageing, youth, gender equality and sexual orientation.
On digitalisation and innovation, leaders deal with the digital determinants of health – suddenly all the more important as COVID-19 catapults so many, so quickly, in so many ways, into the digital age. They write on science, technology, innovation, connectivity, and the scientists and digital firms that lie behind these subjects.
This collection concludes with an overview of the past achievements, present challenges and future possibilities for improving these and other key determinants of health, amid today’s many crises. The leaders of the multi-stakeholder World Health Summit and the author of the landmark report on the social determinants of health reflect on the advances we have made, the new challenges that have arisen and the many tasks that remain.