To provide input into this, albeit limited, remit the the German Platform for Global Health   convened an international symposium entitled “Control or Prevention – the G20 Summit and Global Health” in Berlin on 15 May.  Thomas Gebauer of the German based NGO Medico International challenged symposium participants to question the tension between the global health security focus of the G20 Health Ministers and universalism – asking if global health security is simply about protecting “us” (people lucky enough to have access to quality UHC or wealthy enough to afford quality health care) from “them” (those lacking access to affordable, quality health care). The responses from the speakers were surprisingly similar for a geographically and professionally diverse group.  Amit Sengupta (People’s Health Movement) and Anne Roemer-Mahler (University of Sussex) highlighted the tension between the health security agenda and health for all noting that focusing on technological solutions often circumvents important political discussions about who sets global health priorities and the need to address the social and economic determinants of health. Others speakers, like Odile Frank of the NGO Forum for Health, highlighted the importance of reconfiguring the deeply inequitable status quo by looking beyond  health institutions, to other key  players like the International Labor Organization.

For me, the audience’s contributions were as interesting as the speakers’ messages. The audience of approximately 100, was largely comprised of students under the age of 30 – and the speakers, were, well, all past that age. On average I would say there was a generation between the two groups.  In their interventions audience members emphasized the importance of the environment to global health and wanted to know more about concepts like planetary health. They fully understood the One Health link between AMR and farming discussed by Christian Wagner-Ahifs of BUKP Pharma Kampagne and the importance of a multi-pronged strategy. Many audience members pointed out that the links between global health security, development, migration and planetary health require the political engagement of Health Ministers beyond the traditional health field.  The discussions also explored the tensions between national solidarity, advocated by trade unions, and global solidarity and the importance of acknowledging this challenge.

I took away three main messages  from the day.  First, progress in global health requires engaging with big picture influences on health, like the planetary boundaries we hurtle towards.  Second, a response to global health threats that focuses on  “medical countermeasures ” (that wonderful American term for e.g. drugs, devices, …), while necessary, is certainly not sufficient for advancing global health goals like the SDGs or health for all, which require social counter measures (perhaps even more), like globalized social protection and an international tax body. Finally, all present noted that this systemic change will take time and commitment and that garnering support for hard to measure objectives is difficult. This is why engaging young people in this struggle is vital. Their active political engagement and challenging of a global health agenda rooted in health security is the only way we will get real change.  This requires a long term commitment to education and activism for global health justice, like that shown by the Emerging Voices.  So, while the first ever G20 Health Ministers meeting is a welcome development its value can be judged by whether discussions and commitments move beyond the limited  health security agenda to include prevention.

Clearly, the OECD, with its mission of promoting policies that will improve the economic and social well-being of people around the world, remains a vital piece of the global health puzzle.  I was curious to hear about their priorities in the SDG era. We know that OECD-DAC (Development Co-operation Directorate) tracks trends in development assistance provided by wealthy countries (the elusive quest for the 0.7%) and although we rightly try to think and plan for a world “beyond aid”, clearly development assistance will remain part of the equation in many countries for the foreseeable future. But this conference was not about development. It focused on how global and national economies can work to foster inclusion – economic, social. I focused my limited time there on gauging the role of international taxation in this inclusion and, of course, the SDGs. Yes, I travelled to Paris to hear about international tax, specifically the OECD led Base Erosion and Profit Shifting (BEPS) Project. For the non-tax geeks, the progress of the BEPS Project is important because BEPS practices are conservatively estimated to result in an annual global tax revenue loss of USD100 to 240 billion – that buys a lot of social programmes.  For the extra-territorial obligations and tax geeks, proposals addressing the Westphalian grounding of the international taxation system is fascinating and may offer options for improving global equity through taxation.

Hard to believe, but the international taxation session with the sexy title “Income, Wealth and Tax” was one of the more interesting ones I have attended recently, but who would have thought that Panama would have been the Achilles Heel of offshore? The BEPS Project, discussed at length by Saint-Amans, has been working on one part of the “matching words with actions to deliver what is needed to advance on the SDGs” equation – in this case finding the money. Click the link for details of the 15 Actions in the BEPS Package.  South Africa’s Finance Minister, Pravin Jamnadas Gordhan, argued that those who keep money offshore limit the ability of governments to do what they should do – and that to make the changes necessary to stop these practices is a social justice issue.

Recall that the discourse and decisions taken at the Financing for Development Conference in Addis Ababa in July 2015, focused on shifting responsibility for financing to national governments. In a ‘world beyond aid’ this makes sense but in a world where national tax administrations are based on Westphalian logic, and often coupled with weak tax administrations, this shifts responsibility to an entity that is incapable of collecting sufficient revenue to fund a government’s obligations.  I have never considered the US IRS – Internal Revenue Service – to be weak but Saint-Amans noted $2.1 trillion of US corporate profit sits in Bermuda. With figures like that it becomes easier to see why the US Treasury does not have enough money to spend on infrastructure. That is why, as Minister Gordhan argues, this is a social justice issue.  Speaking with him later he stressed that a depleted treasury cannot fight HIV and AIDS in South Africa, cannot develop a strong education and health system and that multilateral cooperation on taxation is needed to address this global problem.

Global level tax avoidance and evasion affects everyone because in a globalized international economy it undermines the ability of governments to deliver on their promises, contributing to an unjust global system, increasing inequality on the global and national scale, eroding trust in government (and of course the expression of this frustration through wild and other strikes and support for anti-government types like Donald Trump or nationalist political movements in Europe). The loss in the legitimacy of a belief in a common good or in society – (yes, Maggie, there is such a thing) – sets us on a path to nationalism (or worse) and away from social solidarity. So, BEPS has great potential. But, will BEPS really deliver some of the change that is needed?  This comes down to implementation and political will. Broadening BEPS beyond OECD members was endorsed by the G20 Finance Ministers at their meeting on 26-27 February in Shanghai, China which means that all interested countries and jurisdictions, including developing economies, can now express their interest in joining the BEPS framework. So, I think that BEPS is an initiative that is worth monitoring and engaging with, even if it might only deliver some of what it attempts to do. However, whether BEPS and other initiatives (including corporate codes of conduct, the Optional Protocol to the International Covenant on Economic, Social and Cultural Rights) aimed at infusing more fairness into globalization (often voluntary with weak accountability mechanisms) will deliver sufficiently and quickly enough to reverse the seemingly unstoppable rise of populism, remains an open question.

The SDGs session, entitled “2030 Sustainable Development Agenda”, brought together, among others, the CEOs of big NGOs (Save the Children, ONE), a Slovenian Government Minister  and the President of the Pontifical Council for Justice and Peace – yes, the Pope endorses the SDGs. It focused on the importance of statistics in advancing the SDGs. The OECD’s Chief Statistician, Martine Durand, highlighted that the World will need granular data to monitor progress and hold governments accountable. She argued that the OECD is in a good position to provide this data and that for future monitoring the OECD will apply an SDG lens to OECD strategies and policy. ONE’s Michael Elliott linked back to the importance of accountability and argued that the BEPS Project is an example of one way to track progress.  Aart de Geus, of Bertelsmann Stiftung, announced that in cooperation with Bertelsmann and the OECD, the Sustainable Development Solutions Network – will produce an annual SDG dashboard and urged those interested to get involved from the start.

So, (a flooded) Paris provided a little more clarity on where the money to finance the SDGs may come from, but clearly implementation will be challenging. However, given the destabilizing impact of growing national and global inequity it is clearly in all of our interests, including the G20, to look for opportunities to shift the current trajectory because advancing the SDGs will require vast investments and a different approach to global engagement.

This year’s theme, “priority setting for UHC”, provided a focus for our end of project reflections and session entitled “projecting implementing priorities”.

However, our session was complemented, or perhaps even overshadowed, by the ‘opening night’ dinner debate which saw Gopher Prof. Larry Gostin debate Prof. Dean Jamison on the resolution “This House believes that cost-effectiveness is more important than human rights considerations for setting priorities in health in real life situations.” Before examining what we learned from that debate I will reflect on the session and conclude on where Gophers will focus post-Go4Health.

In actively engaging with the post SDG process Go4Health advanced two goals, UHC anchored in the right to health and a healthy environment. Of the many themes tied to these goals that emerged in the final session I will focus on two: the role of local participation in developing the SDGs (and in particular, the challenge of linking local priorities to global decision making)  and the rise of the global health security agenda – does it displace or complement the right to health agenda championed by Go4Health?

Go4Health researchers engaged with communities that are marginalized in different regions of the globe, including Latin America, sub-Saharan Africa and South East Asia. The importance of addressing government accountability for action, or non-action on realizing health rights was a common theme that emerged from all regions. Claudio Schuftan of the People’s Health Movement challenged our findings as being more of the same and asking why we did more research when we know the problem? The ensuing heated debate showed he had struck a chord, with discussion ranging from how activist should academics be, when is there enough evidence and when do activists become arrogant? Most agreed that if beggars are to become rights claimants, more human rights education is needed and that engaging with marginalized communities that are marginalized is a tool for education and empowerment.  As several Gophers from BRAC’s James P Grant School of Public Health in Bangladesh argued, communities know their rights but holding those responsible accountable for violations and changing policy remains a huge challenge.

In the presentations surveying the evolution from the MDGs  to the SDGs several Gophers noted how challenging it was to research a moving target – i.e. the post-2015 MDG negotiations merging with the Sustainable Development Agenda. Who are the relevant policy makers to interview?  When you add the Ebola and Zika pandemics into the mix, tracking the pivot towards the global health security agenda and its impact on global health governance (including questions about WHO’s effectiveness) creates a real headache for researchers. Larry Gostin, one of the most plugged in people on the global health planet, clearly finds it exciting and challenging and stressed the need for UHC to go beyond health care – or as Lisa Forman, of the University of Toronto, elegantly termed it, “think outside the UHC box” and address issues like trade, taxation, macro-economic policies and  the environment.  Larry reiterated his call for civil society inclusion in global health governance – tying nicely to the earlier sessions – and the importance of different global health constituencies working together and not siloeing.

Lawyer versus economist

Which brings me to the opening dinner debate where Larry convinced the PMAC crowd that a rights based approach to advancing UHC brings more than a purely cost effectiveness approach.  In Thailand, the result was not surprising as Thais know that “for the triangle to move the mountain” (i.e. to launch UHC) you need to appeal to the public and politicians to solve seemingly intractable problems. So, Larry’s ‘victory’ in this debate was not surprising. Having said that, cost effective technocrats and human rights lawyers are increasingly learning how to work together, in the SDG health era. Or so we hope.

Beyond Go4Health

So where does Go4Health go now? The G.O. behind Go4Health – Gorik Ooms – has shifted his attention and energy to defending human rights defenders. As he noted in the Go4Health session, every wave, every gust of wind is part of your path to your final goal. Go4Health demonstrated that medical doctors , lawyers and political scientists can work together and learn from each other. The product of such collaboration can be very rich. So, even though 29 February 2016  is the formal end date of the project, Gophers have found numerous ways to continue working together and will continue to attack disciplinary silos. Finally, many Gophers will now look at the impact of global health security concerns on global health policy and governance. Accountability , inclusion, legitimacy and social justice will remain key concerns and critically engaging with the UHC 2030 Alliance and its work on a UHC accountability framework one entry point. Go4Health thus continues, but in a different form because we are not there yet. UHC is not yet anchored in the right to health.

So, what do the 19 October Canadian federal elections have to do with global health and planetary health? Probably many readers are more familiar with the progressive ideas of Naomi Klein than the retrograde ideas and actions of Prime Minister Stephen Harper’s government. Based on his track record over the past nine years, I  argue that Harper’s re-election would be dangerous for planetary and global health for two key reasons: his obvious contempt for multilateralism and the potential impact of a rogue Canada on global support for transnational solutions to shared problems.

To be fair, Harper is feted in some circles as a global health “good guy” as he launched the Muskoka Initiative on maternal, newborn and child health and has recently reaffirmed Canada’s commitment.  I too applaud this leadership.

However, if we look beyond the window dressing of Muskoka, I believe we see a very worrying Canada – a country that rejects multilateralism to advance its own limited short-term agenda, a country that rejects the concept of common but differentiated responsibilities relating to climate change.

There are finite resources on this planet and much conflict is driven by competition for  these resources. The negotiation and ratification of international treaties that address issues of global concern can help to avert conflict and advance global goods. However, such agreements require that states relinquish a degree of sovereignty to further global aims. In the area of climate change, the Kyoto protocol put in place an agreement for addressing common but differentiated responsibility with respect to greenhouse gases. Canada ratified the Kyoto Protocol.  But complying with it required tough political decisions that would reshape the Canadian economy, moving it away from a reliance on the extraction and exploitation of natural resources.

Canada has not taken such decisions. Instead, under Harper, Canada has become a selfish, short-sighted global actor as evidenced by the December 2011 decision to pull out of the Kyoto Protocol. Some may argue that Harper has adopted a realist vision rooted in playing to Canada’s current economic strengths. However, the opposition to tar sands-related projects like the Keystone XL Pipeline by Canada’s traditional ally the United States underlines the short-termism and lack of sophistication in the Harper team’s analysis.

The Kyoto withdrawal decision meant that the Canadian extractive economy could continue to develop the tar sands of Alberta, long opposed for their huge environmental footprint, without worrying about capping greenhouse gas emissions as required by the Kyoto Protocol promise. Alberta’s tar sands represent the third largest reserves in the world, after Saudi Arabia and Venezuela and their ongoing development is supported by the Harper government, and others, who call them oil sands. Thankfully for the planet, the drop in oil prices has had a negative impact on tar sands development – and, unfortunately, on the entire Canadian economy.

Okay, I hear you say, Canada may be a G7 member, but it is a small global player with no nuclear weapons and very little global influence. Agreed, but by withdrawing from an international agreement that attempts to address one of the biggest threats to our planet, they send a worrying signal to other countries about global solidarity.  I believe this signal can have spillover effects; encouraging selfish behavior by others and undermining progress towards the global mindset required to address issues of global concern that impact on social justice – from taxation, to the environment, to health. Such behavior undermines the urgent transformation in our values and our practices based on recognition of our interdependence and the interconnectedness of the risks we face, called for in the Lancet Manifesto.

If Harper is re-elected, it is unlikely that Canada will look beyond its national borders and interests and work with other nations to support ambitious climate goals in Paris that address global risks. On the positive side, Canada has submitted an intended nationally determined contribution (INDC) for COP 21. Unsurprisingly, this INDC is rated as “inadequate” by the independent scientific team at Climate Action Tracker. This is bad news for the SDGs and the planet itself.

On 19 October, the world needs Canadians to reject the Harper government’s vision as “inadequate”, and elect someone who engages with the international community in a progressive manner. As a global health scholar, I hope for a new leader who will use Canada’s voice and influence to advance global health in Paris and beyond. Unfortunately Naomi Klein is not on the ballot.

No, this blog aims to whet your appetite to participate in a European Development Days (EDD)  session on the SDGs and UHC – and Don Juan is playing a key role in it. In this case, Don Juan is a Guatemalan community leader, whose work is truly admirable.

By now, you probably feel like we have tricked you into this blog under false pretences but, hey, our story is about a Don Juan, and we can guarantee you that some people are afraid of Don Juan. Very afraid, actually. Why? Because as a community leader he is focused on improving his media skills, including videoing, to hold authorities to account for failing to address barriers to access to health care services in his community. As the ongoing global discussions around the SDGs and UHC largely focus on governments and financial risk pooling there is less discussion about the key role of communities and civil society leaders in shaping and validating this process and outcomes. As you probably know, many American police forces are now afraid of cameras – and the truth they can reveal. Global health can learn a thing or two from this. So increasing Don Juan’s effectiveness, and that of other community leaders can scare leaders who are not working for their people, not working to realise their rights. They might try to clamp down on these community leaders, but that will be in vain, as Don Juan can never be caught!

At our EDD session, Guatemalan researcher Lorena Ruano will be sharing what she has learned from Don Juan (sounds a bit ambiguous, so, more accurately, she’ll tell us how communities can hold governments accountable for advancing the right to health. (We’re still considering to ask Bryan Adams to come over to Brussels as well and play ‘Have you ever really loved a woman?’ only for us in the session)

Even if you are not afraid of  Don Juan, perhaps you are afraid, like Bill Gates (not a babe magnet, last time we checked) of the SDGs because they look too much like an unwieldy development bible? Well, then we have something for you too. Heidelberg’s Albrecht Jahn will discuss financing and UHC. Finally, Peter Hill, from the University of Queensland – we have a hunch he also was sort of a Don Juan in his young days – will dwell on whether or not the SDGs will usher in a new era of global cooperation.

So, lots of interesting important issues to discuss in our session for the daredevils among you. Please join us at the EDD on 3 June at 16:30 for the session ‘Shared responsibility for the right to health in the post-2015 agenda’.

The 7 July Overseas Development Institute (ODI) conference addressing this issue was a lively, thought provoking event. The excellent chairing by the witty Simon Fanshawe (Kaleidoscope Trust) ensured that the packed panels (7 minutes per speaker!) progressed more smoothly than my fraught Channel crossing Eurostar ordeal involving over eight hours of delays.

LGBT Discrimination – a Trojan Horse?

Jessica Horn (African based women’s rights consultant) argued persuasively that the choice to discriminate is a political one and that LGBT-phobia is a Trojan Horse through which African leaders can distract voters and restrict debate on other power related issues.  Several panellists suggested that Western grandstanding helps further polarize the issue and is counterproductive.  There was much agreement that it is time for Westerners to get off the moral high horse and quietly fund the priorities of grass roots activists and engage with global and regional mechanisms like the African Commission on Human and People’s Rights.

Is LGBT Discrimination the Most Important Issue?

Elizabeth Ohene, former Ghanaian Minister for Information, asked the audience a key question, “are LGBT rights the most important”?  The discussion around this topic ranged from calls for more research into the impact of exclusion on LGBT by Fabrice Houdart, (Washington based World Bank official) to the view advanced by Ms. Marta Foresti, (London based ODI Director of Politics and Governance), that this issue is no different from many other complex development issues.

I would agree with both and draw a parallel to reproductive health. Prior to the 1980s very little data was collected on maternal mortality in low-income countries. Once the 5000 000 deaths per year figure was announced it became a rallying point for calls for more attention and funding to reproductive health and rights through countering multiple discriminations and strengthening health systems.  Like other marginalized groups, (e.g. disabled people and women) the impact of exclusion ranges from the personal to the macroeconomic.  So, yes, the evidence base matters for policy advocacy and should be strengthened.  We know about the murder of high profile LGBT activists like Uganda’s David Kato but little about the impact of exclusion on individuals and their families and still less about the economic consequences of excluding LGBT people (read Adebisi Alimi’s piece arguing for more research).

To answer Ms. Ohene I would argue that discrimination and exclusion are the key issue that we need to address through an economic and political prism and there are parallels with other complex development issues. As Ms. Horn argued the entry points for LGBT rights are similar to those for women’s rights; including human rights and building an evidence base to document the multiple costs of exclusion. One approach, building an evidence base to show that exclusion has an economic impact on a country is not new. However focusing on the economic impact of excluding the LGBT communities will help to quantify the problem. Documenting the impact of discrimination and exclusion on mental health deserves much of our attention but is unlikely to be of as much interest to those that fund research, like the World Bank. To effect the long-term societal change that makes such exclusion unacceptable is a long hard struggle in all societies that requires solidarity with the LGBT communities.

So, yes, ‘aid donors’ can help support LGBT rights but not through conditionalities or loud denunciations.  How? By better understanding the politics behind the LGBT backlash, working with local organisations (not rushing in with a neo-colonial agenda), quiet multi-level diplomacy (like that of Norway which actively supports sexual rights on the international stage with money and programming but does not issue loud condemnations – i.e. lots of carrots little stick) and by supporting research to build an evidence base.

Despite over eight hours of travel delays, and no time to visit Marks & Spencer to buy biscuits, I am happy I attended in part to show solidarity with LGBT communities– we are all engaged in the same struggle.