Abstract
Introduction
We describe the wide range of government sectors and national capabilities that would have roles in the development of collaborative strategies for the successful reduction of national health inequalities. We review the constraints that would need to be overcome in developing such a collaborative instrument. We advocate the establishment of such a group in any country committed to this objective and that it might be termed and function as a ‘National Council for the Reduction of Health Inequalities’.
We also indicate that much of the proposed action in reducing health inequalities internationally is likely to be against poverty which is so commonly associated with them and is therefore likely to be focused on Africa, the home of many of the world's poorest countries. Examples of Africa-related issues which commonly fall off national or international health agendas – uncontrolled population growth, agriculture and livestock development, arrangement for international health cooperation – have been discussed. Prospects are also presented for international cooperation in health to become a subject for discussion and promotion at the highest level of international diplomacy.
Health issues
Health planning constraints
A major problem in health planning is the fact that many of the influences which may have highly significant implications for health – such as housing, agriculture, finance, social services, education, engineering and infrastructural developments – lie outside normal areas of responsibility of national health ministries and within government sectors that have no primary responsibility for health. This is the reality, the planning dilemma that has to be faced by all countries, rich and poor alike, in seeking to formulate strategies for improving national or international health and reducing health inequalities.
It is a consideration that calls for new orderings of political priorities in relation to health, for alternative approaches to management, for new administrative procedures, and, in particular, for new mechanisms for coordinating ministerial government roles with each other and with those of other relevant government bodies and professional and civil-society groups – health and other professionals, policymakers, the media, community groups, social scientists, lobbyists, non-governmental organizations, national and international funding sources – and the introduction of administrative and executive initiatives for coordinating them. This is why the establishment of a National Council for the Prevention of Health Inequalities has become such an important need.
National policies and enactments
Income tax and benefits, education, employment and conditions of employment, housing and environment, mobility, transport and pollution, and nutrition are examples of health-related areas in which national policies and enactments might need to made or reviewed in the context of health.
It must be recognized that it is national governments, not international organizations that are the primary agents for safeguarding the rights of individuals. It is the role of governments – the political process, not international bureaucrats – to determine national policies and choices. Developing countries need to engage the world economy on their own terms, not on terms set by global markets and institutions. 1 They need to tailor economic policies to domestic needs. This is precisely what a globalization run by transnational corporations in their own interests has failed to achieve.
Because it is the home of the world's poorest countries, strategies for attacking poverty in Africa must have a special relevance in addressing global poverty and health inequalities. There is the need for a global contract between rich and poor countries – a contract in which both will be serious about their contractual obligations. Jonathan Sachs warns poor countries that they ‘would need to take ending poverty seriously and will have to devote a greater part of their national effort to cutting poverty rather than to war, corruption and political infighting’; 2 he warns the rich ones that ‘the more one looks at it, the more one sees that the question isn't whether the rich can afford to help the poor, but whether they can afford not to’. 2
There are, in addition, a number of examples of poverty-related areas of need in Africa that especially call for relevant national policies and actions. An important one is infrastructural capabilities – which are prerequisites for development. Another is effective birth-control strategies for the achievement of the population limitation without which development will be impossible. A third is the role of agriculture and livestock development.
Infrastructural developments
Infrastructural developments have been reflections of and conditions for national progress and developments throughout the ages. Their importance in health as in other areas of national growth and development often have not been sufficiently recognized – roads, power stations, schools and universities, dams. Their contributions to health become even more urgent particularly in rapidly expanding urban areas in Africa. Apart from the specialist purposes for which infrastructural developments are made their role and function often have direct or indirect relationships with national health protection or promotion. The potential importance of their contributions in the health field has been emphasized. 2,3
It must also be recognized that infrastructural developments can be powerful engines for meeting other global challenges – climate change, clean water availability, species survival, environmental protection and a host of other areas on which global health protection is critically dependent. These health and health-related roles and influences of infrastructural developments have not been sufficiently acknowledged in the development of national and global health strategies.
Uncontrolled population growth
Poverty, diminished food intake, too many births and poor antenatal care background factors to uncontrolled population growth – a prime cause of poverty and under-development worldwide. The high risks associated with uncontrolled births are well-known – high fetal losses, high prevalence of childhood malnutrition, poor growth and development of children, high maternal and infant mortality. There is thus a family health rationale for family planning. Family planning improves the health of the mother and child; and improved child health enhances motivation for family planning.
Uncontrolled population growth has long been an important consequence of inadequate or inappropriate family-planning policies and practices in African countries. It has been considered to be a prime cause of failure to achieve the Millennium Development Goals. And, in the in the absence of stabilization of population growth, the fight alike for improved education, development and elimination of poverty becomes more difficult.
Agriculture and livestock development
Neglect of agriculture and livestock development is another example of an issue that, like uncontrolled population growth, can retard education, development and the elimination of poverty. The Executive Summary of the Report of the Commission for Africa 4 concludes that African poverty and stagnation is the greatest tragedy of our time. Poverty on such a scale demands a forceful response. While this report focuses on Africa, many other parts of the world suffer from poverty and stagnation. The Commission's report rightly proposes action to constitute a coherent package since the problems are interlocking: they are vicious circles that reinforce one another. An outstanding example of this is the widespread epidemic of AIDS in Southern Africa (and elsewhere), which saps the energy and will power of rural livestock farmers such that attention to fodder crops and to livestock husbandry is neglected: animals are not dipped for disease control, or vaccinated or treated for disease, and husbandry may be left to the only able-bodied villagers, the old women.
A host of reports has appeared in recent years, many calling on the West to increase investment in poverty-stricken areas, but so frequently these reports fail to recognize that ‘coherent packages’ are achievable only from the bottom up. Funding agencies may be unwilling to provide support until there is evidence of movement at the basic level where animals provide the energy and draught power for agriculture. The buffalo, ox, donkey, camel (and in some areas the yak and elephant) are essential for basic needs for plowing, transport and the like. Successful agriculture demands healthy draught animals: the loss of the animal energy provider may have serious consequences for the peasant family.
Dangerous diseases do not just cause sickness and death in animals: they trap countries in poverty and undermine efforts to improve human welfare by striking at the incomes, property and economic security of rural and urban families through profound impacts on public health, food security and the environment. Sickness and death in her flock of goats mean the widow has no milk to sell and no way to benefit from communal grazing land. After loss of a cow, there is nothing to pull a cart to market or plough a field. And loss of a herd throws an extended family or whole village into poverty because these animals represent the community's accumulated wealth and property – the life savings of generations.
Livestock health is fundamental to productive agriculture and the lives of millions in Africa and elsewhere in developing countries. Controlling these dangerous animal diseases is not only vital to overcoming poverty but also essential for G8 countries to ensure that these infections are not accidentally or deliberately brought to their shores.
Six years ago (2005) a UK-based group, of which one of us (EJLS) was a member, proposed in a letter to Prime Minister Blair that the G8 commits to leading the effort to control the most important animal diseases in Africa to build on the successful eradication of Rinderpest, for example, once the world's most feared cattle disease. It was proposed that a task force, either independent or under the umbrella of FAO or the Commonwealth, would investigate and recommend animal disease control programmes to be implemented through national veterinary services in Africa (Soulsby, personal communication). Benefits of aid to reduce animal diseases in Africa would include:
The alleviation of poverty on a continental scale with commensurate gains in human welfare through stimulation of the market economy from the lowest levels; Progress towards sustainable food security by support for the very smallest, as well as larger scale, producers; A safe and environmentally sustainable supply of protein that will reduce reliance on the trade and consumption of meat from wild species, which is associated with the origin and spread of highly infectious and fatal human diseases; Global human and agricultural health benefits from reducing dangerous diseases at their most important source. Ebola, Marburg and Lasso Hemorrhagic Fever, Monkey Pox, African Swine Fever, Classical Swine Fever, West Nile Virus, Sheep Pox, Peste des Petits Ruminants and other infections can spread within 24 hours from a remote area in Africa to people in London and New York or to the intensive agricultural industries of Europe and the United States. Countries held in poverty by these dangerous animal diseases all over the world do not have the science and technology base to develop the solutions.
The response of the G8 Conference was not encouraging, the UK pleading, for example, that much fundamental aid was already provided to least developed countries. The plea was not for more aid but for a coherent package to address issues starting at the grass root levels, in this case basic agriculture. Until the rural farmers start to develop profitable enterprises, minor as they might be, major corporations of the G8 nations will be unwilling to fund unprofitable undertakings.
Strengthening international cooperation in health
Our conviction that health is a matter for international discussion and collaboration is well supported. In their 2007 Oslo Ministerial Declaration Foreign Ministers of Brazil, Finance, Indonesia, Norway, Senegal, South Africa and Thailand, while acknowledging that investment in health is fundamental to economic growth and development, strongly affirmed their perception of health as one of the most important, yet still broadly neglected, long-term foreign policy issues of our time. ‘We have, therefore agreed to make impact on health a point of departure and a defining lens that each one of our countries will use to examine key elements of foreign policy and development strategies, and to engage in a dialogue on how to deal with policy options from this perspective… The initiative will build the case for why global health should hold a strategic place on the international agenda’. 5
Summary and conclusions
The goal defined in the title of this series of papers is challenging. Successive UK governments have affirmed that the reduction of health inequalities would be a ‘matter of social justice’. Our advocacy is for it to become a universal international objective.
This paper has discussed what in our view would be the national and international health planning and collaborative capabilities that would be essential preconditions for success in reducing global health inequalities. The unavailability in most countries of established opportunities and arrangements for the wide intersectoral, whole-of-government, collaborative health planning and action that would be essential for success is a major constraint. This is why the establishment of a National Council for the Reduction of Health Inequalities or a comparable body would be of such importance.
At the global level many health hazards that make large contributions to health inequalities also fall off, or fail to get on, the relevant national or international health discussion agendas. We have discussed examples like uncontrolled population growth, and agriculture and livestock development.
The proposals set out in this paper would need to be widely disseminated and discussed if they are to have a global reach. The urgency of the need for the international health community to make a start in this direction has been emphasized. Advocacy for the strengthening of international cooperation in health has been enhanced by a recent proposal from representatives from a significant number of countries that international health should be a subject for consultation and promotion at the highest level of international diplomacy. The benefits of this development could be substantial.
There is a serious economic, not just health, issue presented here. A case for universal social justice is being made. The challenges unfolding around the world call for the slowing of the pace not only of health, but of their accompanying economic inequalities as well.
DECLARATIONS
Competing interests
None declared
Funding
None
Ethical approval
Not applicable
Guarantor
KS
Contributorship
Both authors contributed equally
Acknowledgements
The authors are grateful to the following colleagues for their discussions of aspects of this paper and for advice in its preparation: Charles Engel, Cedric Hassall, Michael Marmot, Calum Macpherson, Sonny Ramphal, former Commonwealth Secretary General Bishnodat Persaud, former Commonwealth Economic Advisor Lord Rea