The global health system is under pressure from many sides. The traditionally influential actors, such as WHO, see their positions as threatened. New actors based in civil society and intergovernmental organisations demand to be heard. In this complex landscape, governance becomes a momentous issue. Here, we will discuss Lawrence Gostin’s idea of an international governance mechanism for global health – a global convention for health – on the basis of an evaluation of this idea undertaken by the Norwegian Knowledge Centre for the Health Services.
Illustration Supernøtt Popsløyd
In the contemporary arena for global health there is evidence of constantly increasing pressures with regard to funding, management and organisation. The problem resides in an increasing number of actors and a consequent fragmentation of the global health effort. Greater demands are imposed on cooperation between private bodies, civil society, intergovernmental organisations and nation-states, which in combination give rise to numerous and complex forms of interaction. For this reason, the existing global-level framework for health has several weaknesses.
The obligations of the nation-states with regard to human rights are unclear (1) , and they are respected only when convenient. The principles of the Alma Ata Declaration (2) with regard to cross-sectoral primary health-service interventions have proven difficult to adhere to as long as billions are poured into sector-specific services (3) . Nor are the principles of the Paris Declaration on efficiency, adaptation and coordination having the effect envisaged (5) . In the past year, the UN has elaborated a global strategy for the health of women and children (6) . Even though this initiative has a narrow focus, it is intended to serve in the long term as a basis for improved accountability across health-care systems. Civil society is also mobilising to reform global health. For example, the AIDS movement has helped draw attention to the health situation of the poor, and by extension promoted the development of sustainable funding mechanisms and effective forms of treatment (7) .
A number of questions pertaining to global health remain unanswered, however. This has induced some to investigate what could be achieved with the aid of a new set of supranational regulations based on a new international consensus concerning the key challenges to global health. In 2007, Professor Lawrence Gostin of Georgetown University in Washington D.C. proposed that a global framework convention for health could promote reforms in this area (8) . In his pioneering article, Gostin outlined how a global convention could help coordinate the efforts of individual actors, build capacity through cooperation and improve the efficiency of development assistance efforts by establishing criteria for accountability, transparency, better funding and agreed standards for what should be considered as the basic needs for survival. There is reason to assume that Gostin’s idea of a global convention for health, as opposed to previous frameworks in this area, holds the potential to produce a unified and coordinated effort on the part of the international community.
In the summer of 2009, the Norwegian Knowledge Centre for the Health Services was commissioned by the Directorate of Health to prepare a report that discussed the strengths and weaknesses of Gostin’s idea (1) . The main points in the report were published in an American journal (9) and the content was debated by an international group of experts at a meeting held at the Directorate of Health on 17 March 2010. The meeting concluded with a consensual declaration that served as the basis for a global coordination project, in which work is focused on studying national and international obligations with regard to health, as well as appropriate governance mechanisms that can ensure efficiency and fitness for purpose (10) . An explicit goal for this work is to facilitate future endorsement of a global convention for health.
In this article, we will start by presenting Gostin’s idea for such a convention, and proceed to discuss those main purposes of a convention that are emphasised in the Knowledge Centre report.. Finally, we will point out certain new development trends.
A framework convention for global health?
A framework convention for global health?
Gostin claims that a global convention for health will be able to: «…powerfully improve global health governance [...] by committing states to a set of targets, both economic and logistic, and dismantle barriers to constructive engagement by the private and charitable sectors» (8) .
According to Gostin, a future health convention can be based on a process by which the states agree on certain basic principles for health assistance globally (box 1). He has also proposed specific protocols in order to achieve goals that require negotiations. The protocol approach could help formulate a number of minimum standards that a majority of the parties can endorse (1, 9). In this manner, international actors can gradually assume obligations. Minimum specifications, such as a joint definition of the basic needs for survival, provide room for innovations, encourage joint efforts and are crucial to good future relations (11) .
Box 1
According to Lawrence Gostin, a framework convention may encompass:
Purpose and objectives for constructive international cooperation
Rules for coordination of processes, priorities and activities
Specific financial commitments and funding mechanisms
Institutional structures, such as a secretariat and technical consultants
Monitoring schemes
Enforcement mechanisms and mediation in conflicts
Main purposes of a global convention for health
Main purposes of a global convention for health
Accountability to the population
Accountability to the population
A global convention should aim to establish comprehensive structures of accountability at all levels of society (8) . In developing countries, increased taxes or establishment of taxation systems could help contribute to increased transparency in national financial matters. The question remains, however, whether the populations of poor countries will accept such interference. Often there is no social contract between government and citizens, and this makes it impossible to collect taxes or design taxation systems. A global convention for health could serve as a suitable instrument for the imposition of national taxation regimes or to give legitimacy to tax collection, which will counteract corruption and promote transparency and accountability (1, 9) .
Basic survival needs
Basic survival needs
General comment no. 14 from the UN Committee on Economic, Social and Cultural Rights (CESCR) outlines a number of key rights, the totality of which represents a minimum package (or a subsistence minimum) – access to health services, nutrition, essential medicines, shelter, sanitary facilities and clean drinking water.
An important element of a global convention for health would consist in redefining basic needs for survival for the world’s poor. Unlike previous regulatory initiatives, a convention-based regime would seek to give voice to civil society, to allow a definition to emerge from below (1) .
Coordination
Coordination
Since 2000, incentives have consistently favoured the establishment of disease-specific provision of health services. Some claim that this takes place at the cost of general and coordinated efforts to promote holistic health-care systems (12) . We therefore believe that attention should be devoted to the integration of existing disease-specific efforts into a holistic health-care system. The problem, however, as laconically expressed by Senegal’s UN volunteer programme, is that «everybody wants to coordinate, but nobody wants to be coordinated» (13) . A global convention for health could serve as a suitable instrument for addressing the challenges related to coordination, including the conflict between vertical and horizontal initiatives (1, 9) ,
Cooperation
Cooperation
One of the most important objectives of the convention is to establish fair international, national and local cooperation, with mutually binding obligations that can provide long-term capacity for the health-care systems (8) . A legal instrument with potential to shape the character of future international relations should seek an optimal balance of the different interests. A global convention for health will be able to establish rules for balancing interests as well as for channelling commitments (8) .
Allocation of health care
Allocation of health care
It is difficult to determine an «appropriate» level of administrative costs and other costs of delivery. Increased control of the costs of delivery can ensure that the development assistance provided is efficient and that a larger proportion of the funding is spent as foreseen (14) . The major problem in the allocation of health aid, however, appears to be associated with the large number of aid organisations (15) . A global convention for health can lower the costs of delivery and ensure that aid is provided to those who need it. This can be ensured by facilitating forms of development assistance administration that are binding for recipients as well as donors. Whether a health convention can reduce the number of aid organisations is a more complicated question (1, 9) .
Funding
Funding
Global health investments have increased during recent years (16, 17) . In spite of better funding, some are claiming that there is insufficient knowledge of the precise costs, the nature of the sources of funding and the management of the funds (17) . There is a need for better control of the mechanisms of funding, to ensure accountability and efficiency. According to Gostin, a global convention for health could contribute to a reform of the funding of global health initiatives. This could be done by establishing realistic goals for global expenditure on health as a proportion of the gross domestic product of each country (8) . In addition, a set of agreed rules could legitimise as well as simplify the establishment of innovative financial instruments and determine the principles for defensible financial management (1, 9) .
A health convention – a realistic idea?
A health convention – a realistic idea?
The World Health Organization (WHO) would be the most likely candidate for the role of coordinator for further discussions pertaining to a global framework convention for health. WHO is also the most likely agency to undertake the initiation and implementation of a process leading towards signature.
Often, self-interest is the prevailing policy in the field of global health. A main challenge for the promotion of a future global convention for health is likely to consist in establishing a better balance between positions, interests and needs among nations, populations and international organisations. The interests of developing countries will be diametrically opposed to those of industrialised countries, and the same is likely to be the case in the relationship between vertical and horizontal health initiatives. There is also reason to believe that those who might want to engage in correcting the inequalities in health in medium- and high-income countries will encounter stiff resistance.
Existing processes to establish international agreement are characterised by uncertainty. To ensure that the priorities expressed by global actors reflect demands by civil society and concur with principles of good governance, the way must be laid for transparency, like-mindedness and willingness to surrender some sovereignty (10) . Rich countries with notable inequalities in their own health care must also be willing to face demands for improvement from the international community.
There is a risk that a convention will exacerbate the imbalance between donor countries and the global governance level, coordinated and managed by donor countries and other donors (18) . A major emphasis on health in the context of aid may erode the recipient countries’ responsibility for establishing the required healthcare systems. In some quarters a certain fatigue can be discerned with regard to new governance models intended to revolutionise health-related development assistance. There is a risk that a health convention will be regarded as having little chance of success.
A final challenge consists in the enforcement of the rules that a global convention for health will define. The rich countries are unlikely to ratify a set of rules that can be enforced coercively, and without opportunities for enforcement any obligations soon become illusory. Against this background, there is a need for certain clarifications and specifications, especially in terms of implementation. How can the idea be realised without making the obligations too unwieldy for the potential parties? In another article in this series we will present a further development of Gostin’s idea of a convention. The presentation is based on complexity theory, and we argue that a purely facilitating framework will represent a realistic compromise for global management (19) .
Conclusion
Conclusion
A global framework convention for health could be a suitable instrument for handling some of the greatest challenges related to global health. It could structure and legitimise interventions, involve stakeholders, streamline processes and define minimum standards for health services. A convention should be designed especially to exploit the energy created in the encounter between civil society, international organisations and national authorities. This kind of cooperation has the potential to improve health at the system and individual levels. However, management at the global level is a complex matter, and the effects of such interventions are difficult to predict. The WHO is a natural harbour for a convention, but it remains uncertain whether the institution will assume a coordinating role in subsequent discussions.