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The Political Determinants of Health – 10 Years On

The Political Determinants of Health – 10 Years On

By Mara Linden
on January 25, 2024

As we can see every day on our tv screens and on social media, ours are times of escalating armed conflicts, climate chaos, democratic decline and health emergencies. Indeed, one message is emerging consistently across mainstream media and reports of international institutions: we live in an era of multiple crises. Earlier this week, at WHO’s Executive Board meeting, WHO DG Tedros used the term ‘emergencies’ many times during his opening remarks. Scientists now even have established a theoretical framework to better understand the underlying patterns of an interconnected ‘polycrisis’. Yet, the polycrisis does not come out of the blue. These crises – including in global health – are not merely a matter of ‘wicked problems’ and disease, they are very much a crisis of governance. At its core, health (and its determinants) is deeply political. The People’s Health Movement (PHM) has been arguing this throughout its various Global Health Watch volumes produced since 2005.

Ten years ago, The Lancet-University of Oslo Commission on Global Governance for Health released  a report on the political origins of health inequity. It aimed to examine new thinking and analyses on broader, transnational determinants of health. The Commission also provided several recommendations on how to improve global governance for health. The Collective on the Political Determinants of Health, a group of inter-disciplinary practitioners and scholars is taking this legacy forward. Last week, some Collective members and others took stock of 10 years of scholarship on the political determinants of health at a hybrid workshop organised in Oslo (of which recordings are now available).

The workshop opened with a panel that reflected on the impact and success of the Commission’s work, highlighting how the report has helped set the agenda. Building on the work of PHM and WHO’s Commission on the Social Determinants of Health (among others), the report helped to consolidate a conceptual shift in thinking of health, emphasizing social and political determinants (including governance challenges outside of the health sector) that shape health inequities; it also included youth perspectives – fairly new at the time. The panel in Oslo also reflected on shortcomings of the Commission, however, and on what was missing from the Commission’s analysis at the time: neoliberal capitalism, the lasting impact of the financial crisis, the increasing financialization of the global economy, the commercial determinants of health, the role of technology, and escalating climate change, for example. Granted, many of these have become more obvious since the publication of the Commission report. Panellists differed in their opinion on the need for pragmatism to move forward, versus more structural transformation of the capitalist system. Reflections on contemporary challenges of multipolarity (and particularly WHO’s role in this ‘new world’), public trust and transparency, and the relation between the private and public sector provided the backdrop for the sessions that followed in the afternoon and the day after.

Inputs from Collective members from around the world were diverse, both in terms of content and disciplines involved. Recurring themes were, among others: questions of power, the impact of economic discourses in global health, and the role of private actors (in the form of powerful companies, foundations, and in public-private partnerships). Many presentations highlighted the growing inequalities that characterise not just the field of global health, but have become very visible in health outcomes themselves. They questioned the lack of accountability and emphasized the need for more scrutiny of pervasive market-based rationalities, the normalisation of “Multistakeholderism”, digitalisation and artificial intelligence, and colonial legacies in contemporary structures of global health cooperation. Participants also touched upon some of the challenges of the current, increasingly fragmented geopolitical setting. Institutions set up by the Global North, such as the International Monetary Fund, are clearly ill-equipped to deal with this new reality, and it remains to be seen whether increasing regionalization (of institutions and/or research and development), strengthening of local and civil society structures, and respectful cooperation in general, will prove to be sufficient responses in times of multiple crises. In that regard, the workshop certainly provided ample food for thought to continue the discussion within and between academia, policymakers and political actors. Going forward, these discussions should include more insights from practice, socio-ecological movements, and from different positionalities, including voices often marginalized from these rather privileged debates.

As the workshop was taking place, a snowstorm in Oslo provided a mildly disruptive – but apt – backdrop. Indeed, the storm could be considered a metaphorical entry-point to the uncertain chaos that the nearby future may hold in relation to political developments and their impact on health inequities. Just across the park where we held our heated, but polite global health discussions, activists were staging their protests condemning the continuing armed wars and atrocities in Ukraine and Gaza. The activists presented us with a humble reminder to link our transnational policy and academic deliberations to the lived, harsh realities that a growing part of humanity experiences in our times. The political “World Order” is shifting, and the stability of Western imperial hegemony, also known as the Pax Americana, is increasingly affected – even if the annual World Economic Forum (Davos) meeting of powerful private and public actors, including global health elites, coincided with our workshop. Global health policy needs to reflect this shift – and we should thus study and propose alternative pathways and political models. This is not a time for mild reformism, tweaking around a failing system’s edges – it’s a time for paradigmatic change.

The authors are thankful to comments from Katerini Storeng.

Opening panel of the workshop

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