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A Social Contract for Global Health Investments in Times of Resilience

By Remco van de Pas
on March 27, 2015

The last year saw the re-emergence of a century-old economic idea, namely that investing in health is (good) value for money. The Lancet Commission on Investing in Health (CIH), prompted by the 20th anniversary of the 1993 World Development Report, has argued that a Grand Convergence in health is possible by the year 2035. Global health 2035: a world converging within a generation, the CIH report, calculated that “for every dollar invested in convergence related interventions, the economic benefits are 9-20 times higher”.  

The notion that investing in health leads to (potentially enormous) economic returns is nothing new, though. By way of example, let’s have a look at excerpts from a medical article from the Dutch Colonial Indies, 1879, modern Indonesia:

”The Deli planters association purpose was to implement unity in the handling of the workforce, and to co-operate with regard to importing workers and organizing work. According to this arrangement, the workers brought in from overseas were obliged to work on the plantation for a fixed wage and under stipulated conditions, while the employer was bound to provide housing, food, and, amongst other things, free medical treatment and medicine. This sort of agreement was of the greatest importance for the viability of the enterprises because of the huge losses which sickness caused to the productivity of the plantations. And a high mortality rate was equally damaging to the company’s good name and could cause problems for recruiting new workers. Humane and economic considerations clearly went hand in hand” (Source: Dutch Medicine in the Malay Archipelago, 1816-1942, p.75).

The Dutch did not call the project “Global health 1890, a convergence within a generation” (generations were considerably shorter then); the colonial administration found the title a tad too revolutionary and just considered it “robust tropical medicine”.

On a more serious note, key questions regarding the ‘Global Health 2035’ agenda are then: who (really) benefits (most) from the foreseen economic benefits, in the long run, and who (really) benefits (most) from the reduced mortality in LMICs?

National and global political economy discourses and the debate on social justice and health equity come into play here. Global Health 2035 uses the concept of growth in a country’s ‘full income’, which is mainly GDP change adjusted for the value of mortality change (“the income growth measured in national income accounts plus the value of additional life years (VLYs) gained in that period”). But the report doesn’t refer to ‘full income‘ distribution over socio-economic quintiles nor does it take into account negative externalities impacting on health (e.g. natural resource depletion and climate change). The report also fails to fully recognize the massively unequal and unjust social and living conditions that shape the health status of communities, the so-called upstream determinants of health.

The CIH recommendation for progressive universalism as a pro-poor pathway towards Universal Health Coverage is presented as an efficient way towards health and financial protection.  We will not deny it has obvious merits. However, if we really want health inequalities to reduce substantially, UHC must be embedded in broader social protection schemes, both at national and global levels.  So far the thinking on a grand convergence for global health has not included reflections on global social protection mechanisms.  To kickstart this – in our opinion vital – debate in a further globalizing world, the health community could perhaps discuss and frame UHC in the context of ILO’s Social Protection Floor initiative. The example from the Deli Planters Association from more than a century ago demonstrates that a social contract is needed to guarantee both human security and economic objectives.  As the economic case for health investments is nowadays made for many global health topics, such as maternal, neonatal and child health or the health workforce,  we feel there should also be some reflection on how universal and equitable access will be guaranteed to such services as part of the Post -2015 development framework. In short, how can a social contract theory be applied to current investments and governance arrangements in global health?  Is it still national governments that have the main responsibility for guaranteeing their citizens’ rights, or should there be supranational arrangements, involving also non-governmental actors, at the regional (e.g. EU) or at the global level?

The latest episode in the ‘investment for health’ saga is the notion of ‘resilient health systems’. This has become a major lesson of the Ebola outbreak in West-Africa. In the words of Jim Yong Kim, medical doctor by training but more importantly the president of the World Bank group:

“The other main goal of a pandemic facility (by the World Bank) is to promote greater country investments in preparedness, which starts with having a strong, resilient health system. The Ebola crisis lays bare the consequences of inadequate public health capacity, from disease surveillance and laboratory analysis to frontline health services and community health workers: People die; economic growth rates decline; and countries, their neighbors, and the entire world, are put at risk.”

Although still very much in love with UHC, WHO has also rather eagerly embraced the concept of a ‘resilient health system’ lately, so resilience is likely to become a leading theme in the health SDG and broader post-2015 development framework. I am still struggling to fully understand the concept of a resilient health system, its scope and implications from a human rights and health equity perspective. If you already see clearer, please do not hesitate to get in touch.

In the meantime, let us learn from history and think of social contracts fit for this era. It might make the planet and the human species just a tiny bit more resilient.

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