Global Health Equity: The Challenge of a Just Globalisation

1
Global Health Equity The Challenge of a Just
Globalisation

• Ronald Labonte
• Canada Research Chair
• Globalization/Health Equity
• Institute of Population Health
• University of Ottawa

2
Four Global Contexts

• Slowing of health gains, reversal in Africa and
  former Soviet Union
• Major health determinants are now inherently
  global (Labonte Spiegel, BMJ, 2003)
• Retreat from social justice
• Development costs of global security

3
The debate on globalization is fast becoming a
debate on democracy and social justice in a
global economy.World Commission on the Social
Dimensions of GlobalizationInternational Labour
Organization2003
4
Deaths by Terror, Inequality, Invasion and
Occupation
5
Millennium Development Goals, by 2015

• Cut poverty by half (1/day)
• Universal Primary Education
• Gender equality in education
• Cut IMR and lt5 MR 2/3rds
• Reduce maternal MR 75
• Reduce HIV/AIDS malaria
• Implement full sustainable development strategies
  

6
Number of Heavily Indebted Poor Countries and
Selected MDG Targets
Source Pettifor and Greenhill, 2003
7
A Quick Comparison

• Global anti-terrorist 2003 551 billion
• Millennium Development Goals 600 billion
• (one-time, health goals 1-5)
• One year Iraq pacification 87 billion
• Millennium Development Goals 70 billion
• (annual)
• Anti-terrorist, US, 2003 57 billion
• Anti-terrorist, Canada, 2003-07 7
  billion
• Development assistance 2003 69 billion
• Aid to AIDS, 2000 2002 annual
• average 2 billion

8
Globalizationa process by which nations,
businesses and people are becoming more connected
and interdependent across the globe through
increased economic integration and communication
exchange, cultural diffusion and travel
9

• A Global Village or
• A Global Market?
• increasing cross-border flow of capital, goods
  and services
• scale of such movement
• binding rules
• size of trans-national companies
• commitment of most countries to continue global
  economic integration through increased
  liberalization
• no where to move displaced workers

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Pro-Globalization ArgumentLiberalizatio
n ? Increases Growth Increased Growth ?
Increases WealthIncreased Wealth ? Decreases
PovertyDecreased Poverty ? Increases
HealthIncreased Health ? Increases Growth
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• Globalizations Counter-Arguments
• Rapid spread resistant diseases, pandemic of
  Western lifestyles
• Tariff reductions hardest on poor countries,
  reducing revenues for health/social spending
• Growth for some, not for others
• Poverty reduction not automatic and even
  contentious
• Inequalities on the rapid rise

12
Some global food trends

• Growth in global food trade now 11 of all
  trade
• Consolidation in oligopoly of transnational
  corporations
• Overproduction by rich countries leading to
  dumping into global markets, developing
  countries and value-adding through addition of
  sugar, salt, fats and oils
• Global pandemic of obesity and diabetes

13

• Globalizations Counter-Arguments
• Rapid spread resistant diseases, pandemic of
  Western lifestyles
• Tariff reductions hardest on poor countries,
  reducing revenues for health/social spending
• Growth for some, not for others
• Poverty reduction not automatic and even
  contentious
• Inequalities on the rapid rise

14

• Globalizations Counter-Arguments
• Rapid spread resistant diseases, pandemic of
  Western lifestyles
• Tariff reductions hardest on poor countries,
  reducing revenues for health/social spending
• Growth for some, not for others
• Poverty reduction not automatic and even
  contentious
• Inequalities on the rapid rise

15
Currently wealthy/healthy countries never grew
their economies using neo-liberal (free) trade
policies.They used state intervention/support,
infant industry protection and copied technology,
now WTO prohibited.Ha-Joon Chang, 2002
Kicking Away the Ladder?
16

• Globalizations Counter-Arguments
• Rapid spread resistant diseases, pandemic of
  Western lifestyles
• Tariff reductions hardest on poor countries,
  reducing revenues for health/social spending
• Growth for some, not for others
• Poverty reduction not automatic and even
  contentious
• Inequalities on the rapid rise

17

• Globalizations Counter-Arguments
• Rapid spread resistant diseases, pandemic of
  Western lifestyles
• Tariff reductions hardest on poor countries,
  reducing revenues for health/social spending
• Growth for some, not for others
• Poverty reduction not automatic and even
  contentious
• Inequalities on the rapid rise

18
Growing Income Inequalities

• Inequalities decrease
• Poverty reduction
• Rate of economic growth
• And increase
• Rates of suicide homicide
• Conflict
• Costs of policing and security
• South Africa 2001
• Police budget - 1.96 billion
• Health budget - 1.56 billion

Sources Labonte Torgerson, 2004 Small Arms
Survey, 2003
Source UNDP 1999
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Liberalization and the Environment

• Indonesian de-regulated logging gt 1 million
  hectares lost annually, burning leads to
  respiratory disease (short term), ecosystem loss
  (long term)
• Argentina fisheries exports gt 5-fold increase in
  catches 1985 - 95 foreign companies earned 1.6
  billion, depletion of stocks cost locals over
  500 million

• Uganda privatization fisheries over-fishing
  Nile perch, degradation of Lake Victoria
  ecosystem
• Post NAFTA pull on Mexican forestry, illegal
  logging increasingly widespread
• Mauritania No fish for markets, factory fish
  for the rich

Sources UNEP 2003, NAFTA CEC 2001,
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Greenhouse Gassing The Dirtiest Dozen
Italics indicate Kyoto ratifiers
21
Globalization drivers/mitigators

• Macroeconomic policies structural adjustment
  loan conditions
• Debt overhang of developing countries, forcing
  an economic subservience to the interests of
  wealthier nations
• Global, regional and bilateral free trade and
  investment agreements
• Development assistance
• Global public goods

22
SAPs General Requirements (neo-liberal economic
assumptions)

• Liberalization Open markets work best
• Privatization States shouldnt own profitable
  sectors
• Enhance private sector States should open
  programs/services to private competition
• De-regulation Few rules on private sector
• State minimalism Reduce public spending
  taxation, implement cost-recovery
• adapted from Milward, 2000, What is structural
  adjustment, In Mohan, G., Brown, E., Milward, B.
  and Zack-Williams, A.B. Structural adjustment
  Theory, practice and impacts, London and New
  York Routledge.

23
SAPs and Health Determinants

• Erode labour market institutions
• Financial market liberalization worsens income
  inequalities
• Shifts in taxation policies (less progressive)
• Reduced public spending (on education, health,
  environmental protection) 
• Exacerbate inequalities between rural and urban
  populations, indigenous and dominant cultural
  groups 
• Cornia, A.C. 2001 (ed) Inequality, Growth and
  Poverty in an era of
• Liberalization and Globalization, UNW/WIDER.

24
Globalization drivers/mitigators

• Macroeconomic policies structural adjustment
  loan conditions
• Debt overhang of developing countries, forcing
  an economic subservience to the interests of
  wealthier nations
• Global, regional and bilateral free trade and
  investment agreements
• Development assistance
• Global public goods

25
Debt relief HIPC and its limitations

• Initiative has demonstrably increased funds
  available for health, education in many eligible
  countries, but
• Sustainable debt defined with reference to
  (volatile) export earnings, rather than cost of
  meeting basic needs and
• Funds for HIPC were at the expense of development
  assistance flows of other kinds and
• Debt relief subject to neo-liberal
  conditionalities and
• Most of the worlds poor do not live in HIPC
  countries

26
Debt relief crucial to meeting basic needs
27
Debt Cancellation/Relief Options

• Debt sustainability by need, not export earnings
• Debt cancellation not counted as development
  assistance
• Present multilateral debt proposals
• UK pay debt servicing 20 42 HIPCs to World
  Bank for 10 years, sell IMF gold
• US cancel World Bank debt outright, all new
  disbursements lending as grants not loans
• Canada pay debt servicing 20 HIPCs to World
  Bank and principal servicing to IMF for 10 years
• France institute global taxes, starting with
  jet fuel
• EURODAD
• sell IMF gold reserves to cancel all debt for 40
  60 indebted countries
• cancel World Bank debt by using loan reserves and
  profits from its non-concessional branch that
  lends at market rates to middle-income countries

28
Globalization drivers/mitigators

• Macroeconomic policies structural adjustment
  loan conditions
• Debt overhang of developing countries, forcing
  an economic subservience to the interests of
  wealthier nations
• Global, regional and bilateral free trade and
  investment agreements
• Development assistance
• Global public goods

29
WTO Agreements and Loss of Health Equity Policy
Space

• TRIMS No equity requirements on foreign
  investors
• AGP Public contracts to lowest bidder
  regardless of where in the world
• TBT All domestic regulations must be least
  trade restrictive
• AoA Slow removal of rich world agricultural
  subsidies cost millions on poor world export
  earnings

30
Trade policy Contrast betweenrhetoric and
reality

• Sustained economic growth world-wide requires a
  renewed commitment to free trade (G8, 2001,
  pledging commitment to a new round of
  multilateral trade negotiations)
• The worlds poor face tariffs that are, on
  average, roughly twice as high as those imposed
  on the non-poor (World Bank, 2002a 37)

31
Would it be better to born a Japanese cow than
an African citizen?
32
GATS private health care

• GATS does not cause privatization, but locks it
  in and promotes it over time via progressive
  liberalization.
• Private health care is less efficient and always
  more inequitable than public, risk-pooling
  programs.
• Parallel private systems erode public support for
  universal public programs.
• Private health care in developing countries is
  less effective in monitoring, reporting and
  treating infectious diseases such as tuberculosis.

33
Public provision not a guarantee of equity, but a
potential for equity
Benefits or share of public health spending by
quintiles
Source Carr, 2004 Improving the Health of the
Worlds Poorest
34
Impact of GATS liberalization

• Should a country ever be in a position to
  adequately fund and administer its public system,
  and so reverse the current trend away from
  privatization, its GATS commitments would trigger
  trade penalties.
• Once a service sector has been liberalized under
  GATS, there is no cost-free way of reversing it.

35
Fair trade through

• End agricultural export and production subsidies,
  high-income countries
• Removal of tariffs, high-income countries to
  developing world exports
• Strengthen and extend special differential
  treatment, developing countries (mandated by Doha
  but not supported by high-income countries in
  ongoing WTO negotiations)
• Reduce the reach of intellectual property rights
• General exemption for purposes of human
  rights/MDGs, and/or exemption for public services
  essential to the right to health

36
Globalization drivers/mitigators

• Macroeconomic policies structural adjustment
  loan conditions
• Debt overhang of developing countries, forcing
  an economic subservience to the interests of
  wealthier nations
• Global, regional and bilateral free trade and
  investment agreements
• Development assistance
• Global public goods

37
Development assistance as of Gross National
Income
Anglo-American
Source OECD/DAC Annual Report 2004
38
Annual cost of meeting the 0.7 percent of GNI ODA
target, in Big Macs/capita
Based on 2002 ODA figures from OECD, Big Mac
prices from The Economist, April 25, 2002
39
ODA policy options 1

• UK proposal
• International Finance Facility
• Bonds based on future ODA pledges
• Assumes future pledges
• Could be at expense of future aid
• Rewards bond holders with US220 billion in
  interest of 780 billion raised
• Achieve 0.7 target
• Would reach the MDG-based estimates of required
  additional assistance (UN Millennium Project,
  2005)
• Almost half of all donor countries have already,
  or have scheduled commitments to, reach this
  objective
• Includes France (2012) and the UK (2013) but not
  other major donors (Canada, US, Australia,
  Germany)

40
ODA policy options 2

• Remove macroeconomic conditionalities
• Aid goes to where intended, makes a difference in
  peoples lives
• Adjust currency exchange mechanisms to avoid
  Dutch disease
• Eliminate IMF medium term expenditure ceilings on
  public spending
• Pool aid funds to strengthen budget support
• Multiple donors, accountability requirements and
  top-down programs carry huge opportunity costs to
  recipient countries
• Aid as cash, not as kind
• And untied from purchases from donor countries

41
Comparative costs, aid and tax cuts, Canada 2000
2005, millions of C
Source OECD Development Assistance Committee,
Development Co-operation 2004 Report, DAC Journal
20056(1)full issue and earlier years Canada
Department of Finance, The Budget Plan 2003,
Table A1.9
42
The global context need vs. greed
43
Alternative Global Taxes

• Arms trade up to 20 billion annually
• Carbon tax up to 125 billion annually
• Currency tax up to 170 billion annually
• Single tax number for MNEs and global citizens
• Withholding tax (40) on profits/capital flight
• Close tax havens (costing US 20 billion a year
  in corporate taxes alone, UK up to 85 billion a
  year)

44
Globalization drivers/mitigators

• Macroeconomic policies structural adjustment
  loan conditions
• Debt overhang of developing countries, forcing
  an economic subservience to the interests of
  wealthier nations
• Global, regional and bilateral free trade and
  investment agreements
• Development assistance
• Global public goods

45
Global Public Goods for Health

• Public good Non-excludable and non-rivalrous
• Global public good A good which is inherently
  global, rather than national or regional a good
  in itself, or a means of preventing a global
  public bad.

46
Seven Basic GPGs for Health

• cure for disease
• new treatment regime for disease
• control of air and water pollution emissions
• uncovering basic research findings
• monitoring disease
• disseminating research findings
• curbing epidemics
• (Sandler and Arce, 2000)

47
Estimates of Annual Need for Additional Donor
Funding (including Global Fund contributions
Labonte et al, 2004, web-site updates)
48
Shift in rights discourse

• Potential of rights discourse as alternative to
  market-based development?
• From development as need and assistance as
  charity to
• Development as right (freedom/capacity) and
  assistance as obligation

49
The Human Right To Health

• Key sources
• The Universal Declaration (UDHR)
• The International Covenant on Economic, Social
  and Cultural Rights (Article 12)
• Convention on Torture
• Convention on Elimination of All Forms of
  Discrimination Against Women
• Convention on the Rights of the Child

50
UN Commission on Human Rights Interim Report,
2003

• Right to health includes underlying health
  determinants (specifically water/sanitation,
  maternal/child programs, education)
• Right is judiciable
• Right is superordinate to trade agreements but
  presently lacks clarity on legal content (how to
  enforce)
• TRIPS/GATS (prevents health care access) cited as
  actual, or potential, human rights violations
• Progressive liberalization may contradict
  progressive realization of right to health

51
Right to Health Impact Assessment Methodology,
Trade Agreements

• Called for by Paul Hunt, UN Special Rapporteur on
  the Right to Health, 2004
• Research proposal to Canadian government,
  comprising 3 stages
• Outcome indicators based on right to health
  evaluation criteria (Article 12)
• Pathways analyses linking liberalization to
  outcomes based on narrative reviews
• Field-testing of workshop methodology with CSOs
  in India, Mexico, South Africa and Canada
• Link with WHO trade and health group

52
The prescriptions a short list of reforms for
global health

• Increased development assistance (0.7) untied,
  in cash
• Debt cancellation/meaningful reduction
• Global tax (carbon tax, Tobin tax) for wealth
  redistribution
• Fair trade (special differential treatment for
  developing nations)
• Development box in AoA for food security and
  livelihood protection

53
Right to health or right to trade?

• WTO preamble declares liberalization only a means
  to the end of development and sustainability
  prove it by
• Subordinating WTO to right to health
• equitable access to health care, education,
  water/sanitation, housing, food (ICESCR)
• And, at very least, the Millennium Development
  Goals
• not, as the so-called Doha Development round
  argues, take development dimensions into
  account in trade agreements, but ensure that
  agreements serve development goals

54
Available now University of Cape Town Press/IDRC
Books
55
Health for Some Death, Disease and Disparity in
a Globalizing EraRonald Labonte, Ted Schrecker,
Amit Sen Gupta

• March 20, 2005
• www.socialjustice.org
• E-mail justice_at_socialjustice.org
• C15 C5 shipping