A global health equity agenda for the G8 summit
http://www.100md.com
《英国医生杂志》
1 Globalisation and Health Equity Research Program, Institute of Population Health, University of Ottawa, Ottawa, Ontario, K1N 6N5, Canada, 2 People's Health Movement—India, New Delhi 110 017, India
Correspondence to: R Labonte rlabonte@uottawa.ca
The G8 summit in July could be used to enable developing countries to meet the millennium development goals. What should world leaders commit to?
Development policies and aid need to reflect the importance of the key social determinants of health: education; nutrition and food safety; and water, sanitation, and housing. G8 support for all of these areas has been inadequate and often compromised by an insistence on cost recovery and other market oriented policies that undermine health equity.5 Larger donations and multiyear commitments from donors are required in all of these sectors if low income countries are to achieve the millennium development goals.3 4
A comprehensive strategy for increased aid should be developed in the context of a clear timetable for G7 countries to attain the longstanding United Nations target of allocating 0.7% of their gross national income to developmental aid. France has made a firm commitment to reach this target by 2012; the United Kingdom has made a soft promise to do so by 2013. The performance of several other European countries shows that achieving this goal consistently is possible (fig 1). A generic commitment by the G7 to match this performance should be accompanied by a separate commitment to doubling present development aid to Africa within three years. The UK's proposed international finance facility (which would float bonds based on pledged increases) can achieve this, but only if all donor countries commit to a timetable to reach the 0.7% target. Questions remain about the pattern of aid after 2015 under the proposal, and about the logic of paying hundreds of millions of dollars in interest to bond investors rather than channelling these resources directly to meeting basic needs.12 New forms of global taxation are also an attractive option, although agreement on these would be politically difficult to achieve in the short term. Taxation could be used alone or alongside the international finance facility.12
Fig 1 Trends in development aid donated by G7 and selected European countriesw5-7
Crucially, development aid must not be encumbered by conditions that undermine equity—for example, placing ceilings on health and education expenditures or requiring cost recovery in the form of user fees. Donors should require no more than fiscal transparency, accountability, and targeting of resources at basic needs. The fiscal constraints that governments invoke to justify their slowness in responding to global health needs must be assessed in the context of (for instance) world military expenditures, recent tax cuts in the United States and other G8 countries, and the trivial cost for the G7 of meeting the 0.7% target (fig 2).
Fig 2 Annual cost of increasing development aid to 0.7% of gross national income. Costs are given in terms of the price of a Big Mac in the listed countries (the Big Mac indexw8), development figures are from 2004,w7 and population figures from 2003w9
Debt cancellation
The G8 have consistently adhered to a statement made at the end of the 2001 Genoa summit: "Drawing the poorest countries into the global economy is the surest way to address their fundamental aspirations."18 Lack of rapid progress toward the millennium development goals shows that such integration may not improve health equity because of the asymmetric nature of global markets.19 In particular, current trade rules prevent low and middle income countries from using policies to protect domestic markets and enterprises, such as favouring domestic firms in procurement and limiting intellectual property protection, that rich countries used at earlier stages of their own development.20 Continued barriers to exports of agricultural products from low income countries are a special problem. Tariffs and huge producer subsidies, equivalent to several times the annual value of development aid,21 depress world market prices beyond the competitive ability of otherwise efficient producers, such as African cotton growers.w12
Although export driven growth is far from a panacea, the G8 must make firm and transparent commitments to improve market access, unilaterally and through the European Union and World Trade Organization. The G8 must also ensure that its commitment to strengthen provisions for special and differential treatment, historically a key mechanism for levelling the economic playing field, does not become a way of further subordinating the interests of developing countries within the multilateral trading system.12 Another important step is to ensure that developing countries can actually use the health related exemptions to harmonised intellectual property protection, which will improve access to essential medicines.22
Rights based approach to health and development
Hunt P. Economic, social and cultural rights: the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, report of the special rapporteur. New York: UN Economic and Social Council, 2003. (Document E/CN.4/2003/58). http://ap.ohchr.org/documents/mainec.aspx http://daccessdds.un.org/doc/UNDOC/GEN/G03/109/79/PDF/G0310979.pdf?OpenElement (accessed 10 Feb 2005).
Commission on Macroeconomics and Health. Macroeconomics and health: investing in health for economic development. Geneva, World Health Organization, 2001.
United Nations Millennium Project. Investing in development: a practical plan to achieve the millennium development goals. London: Earthscan, 2005. http://unmp.forumone.com/eng_full_report/TF1mainreportComplete-highres.pdf (accessed 10 Feb 2005).
Sachs JD, McArthur JW, Schmidt-Traub G, Kruk M, Bahadur C, Faye M, et al. Ending Africa's poverty trap. Brookings Papers on Economic Activity 2004;(1): 117-240.
Labonte R, Schrecker T, Sanders D, Meeus W. Fatal indifference: the G8, Africa and global health. Cape Town: University of Cape Town Press, 2004.
Michaud C. Development assistance for health (DAH): recent trends and resource allocation. Paper prepared for second consultation, Commission on Macroeconomics and Health, October 29-30, 2003. www.who.int/entity/macrohealth/events/health_for_poor/en/dah_trends_nov10.pdf (accessed 10 Feb 2005).
Radelet S. Aid effectiveness and the millennium development goals. Washington, DC: Center for Global Development, 2004. (Working paper No 39.)
Lister G, Ingram A, Prowle M. Country case study: UK financing of international cooperation for health. New York: Office of Development Studies, UN Development Programme, 2004. www.nuffieldtrust.org.uk/policy_themes/docs/undp7.pdf (accessed 10 Feb 2005).
Chen L, Evans T, Anand S, Boufford J, Brown H, Chowdhury M, et al. Human resources for health: overcoming the crisis. Lancet 2004;364: 1984-90.
New Partnership for Africa's Development. Health strategy. NEPAD Secretariat, 2002. www.afro.who.int/dsd/nepad_health_strategy.pdf (accessed 10 Feb 2005).
Global Forum for Health Research. The 10/90 report on health research, 2003-2004. Geneva: GFHR, 2004.
Labonte R, Schrecker T. The G8, Africa and global health: a platform for global health equity for the 2005 summit. London, Nuffield Trust, 2005.
Cheru F. Report of the independent expert on the effects of structural adjustment policies on the full enjoyment of human rights. New York: United Nations Economic and Social Council, 1999. (Document E/CN.4/1999/50.) http://daccessdds.un.org/doc/UNDOC/GEN/G99/110/09/PDF/G9911009.pdf?OpenElement (accessed 10 Feb 2005).
Pettifor A, Greenhill R. Debt relief and the millennium development goals. New York: United Nations Development Programme, Human Development Report Office, 2002.
Cheru F. The highly indebted poor countries initiative: a human rights assessment of the poverty reduction strategy papers. New York: United Nations Economic and Social Council, 2001. (Document E/CN.4/2001/56.) http://daccessdds.un.org/doc/UNDOC/GEN/G01/101/84/PDF/G0110184.pdf?OpenElement (accessed 10 Feb 2005).
Hanlon J. How much debt must be cancelled? J Int Develop 2000;12: 877-901.
G8 Information Centre. G7 finance ministers' conclusions on development, London, 5 February, 2005. www.g8.utoronto.ca/finance/fm050205_dev.htm (accessed 10 Feb 2005).
G8 Information Centre. Final communiqué. Genoa, July 22, 2001. http://www.g8.utoronto.ca/summit/2001genoa/finalcommunique.html (accessed 10 Feb 2005).
Birdsall N. A stormy day on an open field: asymmetry and convergence in the global economy. In Gruen D, O'Brien T, Lawson J, eds. Globalisation, living standards and inequality: recent progress and continuing challenges. Proceedings of a conference held in Sydney, 27-28 May 2002. Canberra, Reserve Bank of Australia, 2002: 37-65.
Chang H-J. Kicking away the ladder: development strategy in historical perspective. London, Anthem Press, 2002.
Organisation for Economic Cooperation and Development. Agricultural policies in OECD countries at a glance. Paris: OECD, 2004.
Jawara F, Kwa E, Sharma S. Behind the scenes at the WTO: the real world of international trade negotiations/lessons of Cancun. 2nd ed. London: Zed Books, 2004.(Ronald Labonte, Canada research chair1, )
Correspondence to: R Labonte rlabonte@uottawa.ca
The G8 summit in July could be used to enable developing countries to meet the millennium development goals. What should world leaders commit to?
Development policies and aid need to reflect the importance of the key social determinants of health: education; nutrition and food safety; and water, sanitation, and housing. G8 support for all of these areas has been inadequate and often compromised by an insistence on cost recovery and other market oriented policies that undermine health equity.5 Larger donations and multiyear commitments from donors are required in all of these sectors if low income countries are to achieve the millennium development goals.3 4
A comprehensive strategy for increased aid should be developed in the context of a clear timetable for G7 countries to attain the longstanding United Nations target of allocating 0.7% of their gross national income to developmental aid. France has made a firm commitment to reach this target by 2012; the United Kingdom has made a soft promise to do so by 2013. The performance of several other European countries shows that achieving this goal consistently is possible (fig 1). A generic commitment by the G7 to match this performance should be accompanied by a separate commitment to doubling present development aid to Africa within three years. The UK's proposed international finance facility (which would float bonds based on pledged increases) can achieve this, but only if all donor countries commit to a timetable to reach the 0.7% target. Questions remain about the pattern of aid after 2015 under the proposal, and about the logic of paying hundreds of millions of dollars in interest to bond investors rather than channelling these resources directly to meeting basic needs.12 New forms of global taxation are also an attractive option, although agreement on these would be politically difficult to achieve in the short term. Taxation could be used alone or alongside the international finance facility.12
Fig 1 Trends in development aid donated by G7 and selected European countriesw5-7
Crucially, development aid must not be encumbered by conditions that undermine equity—for example, placing ceilings on health and education expenditures or requiring cost recovery in the form of user fees. Donors should require no more than fiscal transparency, accountability, and targeting of resources at basic needs. The fiscal constraints that governments invoke to justify their slowness in responding to global health needs must be assessed in the context of (for instance) world military expenditures, recent tax cuts in the United States and other G8 countries, and the trivial cost for the G7 of meeting the 0.7% target (fig 2).
Fig 2 Annual cost of increasing development aid to 0.7% of gross national income. Costs are given in terms of the price of a Big Mac in the listed countries (the Big Mac indexw8), development figures are from 2004,w7 and population figures from 2003w9
Debt cancellation
The G8 have consistently adhered to a statement made at the end of the 2001 Genoa summit: "Drawing the poorest countries into the global economy is the surest way to address their fundamental aspirations."18 Lack of rapid progress toward the millennium development goals shows that such integration may not improve health equity because of the asymmetric nature of global markets.19 In particular, current trade rules prevent low and middle income countries from using policies to protect domestic markets and enterprises, such as favouring domestic firms in procurement and limiting intellectual property protection, that rich countries used at earlier stages of their own development.20 Continued barriers to exports of agricultural products from low income countries are a special problem. Tariffs and huge producer subsidies, equivalent to several times the annual value of development aid,21 depress world market prices beyond the competitive ability of otherwise efficient producers, such as African cotton growers.w12
Although export driven growth is far from a panacea, the G8 must make firm and transparent commitments to improve market access, unilaterally and through the European Union and World Trade Organization. The G8 must also ensure that its commitment to strengthen provisions for special and differential treatment, historically a key mechanism for levelling the economic playing field, does not become a way of further subordinating the interests of developing countries within the multilateral trading system.12 Another important step is to ensure that developing countries can actually use the health related exemptions to harmonised intellectual property protection, which will improve access to essential medicines.22
Rights based approach to health and development
Hunt P. Economic, social and cultural rights: the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, report of the special rapporteur. New York: UN Economic and Social Council, 2003. (Document E/CN.4/2003/58). http://ap.ohchr.org/documents/mainec.aspx http://daccessdds.un.org/doc/UNDOC/GEN/G03/109/79/PDF/G0310979.pdf?OpenElement (accessed 10 Feb 2005).
Commission on Macroeconomics and Health. Macroeconomics and health: investing in health for economic development. Geneva, World Health Organization, 2001.
United Nations Millennium Project. Investing in development: a practical plan to achieve the millennium development goals. London: Earthscan, 2005. http://unmp.forumone.com/eng_full_report/TF1mainreportComplete-highres.pdf (accessed 10 Feb 2005).
Sachs JD, McArthur JW, Schmidt-Traub G, Kruk M, Bahadur C, Faye M, et al. Ending Africa's poverty trap. Brookings Papers on Economic Activity 2004;(1): 117-240.
Labonte R, Schrecker T, Sanders D, Meeus W. Fatal indifference: the G8, Africa and global health. Cape Town: University of Cape Town Press, 2004.
Michaud C. Development assistance for health (DAH): recent trends and resource allocation. Paper prepared for second consultation, Commission on Macroeconomics and Health, October 29-30, 2003. www.who.int/entity/macrohealth/events/health_for_poor/en/dah_trends_nov10.pdf (accessed 10 Feb 2005).
Radelet S. Aid effectiveness and the millennium development goals. Washington, DC: Center for Global Development, 2004. (Working paper No 39.)
Lister G, Ingram A, Prowle M. Country case study: UK financing of international cooperation for health. New York: Office of Development Studies, UN Development Programme, 2004. www.nuffieldtrust.org.uk/policy_themes/docs/undp7.pdf (accessed 10 Feb 2005).
Chen L, Evans T, Anand S, Boufford J, Brown H, Chowdhury M, et al. Human resources for health: overcoming the crisis. Lancet 2004;364: 1984-90.
New Partnership for Africa's Development. Health strategy. NEPAD Secretariat, 2002. www.afro.who.int/dsd/nepad_health_strategy.pdf (accessed 10 Feb 2005).
Global Forum for Health Research. The 10/90 report on health research, 2003-2004. Geneva: GFHR, 2004.
Labonte R, Schrecker T. The G8, Africa and global health: a platform for global health equity for the 2005 summit. London, Nuffield Trust, 2005.
Cheru F. Report of the independent expert on the effects of structural adjustment policies on the full enjoyment of human rights. New York: United Nations Economic and Social Council, 1999. (Document E/CN.4/1999/50.) http://daccessdds.un.org/doc/UNDOC/GEN/G99/110/09/PDF/G9911009.pdf?OpenElement (accessed 10 Feb 2005).
Pettifor A, Greenhill R. Debt relief and the millennium development goals. New York: United Nations Development Programme, Human Development Report Office, 2002.
Cheru F. The highly indebted poor countries initiative: a human rights assessment of the poverty reduction strategy papers. New York: United Nations Economic and Social Council, 2001. (Document E/CN.4/2001/56.) http://daccessdds.un.org/doc/UNDOC/GEN/G01/101/84/PDF/G0110184.pdf?OpenElement (accessed 10 Feb 2005).
Hanlon J. How much debt must be cancelled? J Int Develop 2000;12: 877-901.
G8 Information Centre. G7 finance ministers' conclusions on development, London, 5 February, 2005. www.g8.utoronto.ca/finance/fm050205_dev.htm (accessed 10 Feb 2005).
G8 Information Centre. Final communiqué. Genoa, July 22, 2001. http://www.g8.utoronto.ca/summit/2001genoa/finalcommunique.html (accessed 10 Feb 2005).
Birdsall N. A stormy day on an open field: asymmetry and convergence in the global economy. In Gruen D, O'Brien T, Lawson J, eds. Globalisation, living standards and inequality: recent progress and continuing challenges. Proceedings of a conference held in Sydney, 27-28 May 2002. Canberra, Reserve Bank of Australia, 2002: 37-65.
Chang H-J. Kicking away the ladder: development strategy in historical perspective. London, Anthem Press, 2002.
Organisation for Economic Cooperation and Development. Agricultural policies in OECD countries at a glance. Paris: OECD, 2004.
Jawara F, Kwa E, Sharma S. Behind the scenes at the WTO: the real world of international trade negotiations/lessons of Cancun. 2nd ed. London: Zed Books, 2004.(Ronald Labonte, Canada research chair1, )