You may have missed this news from mid-October: Due to the plethora of humanitarian disasters demanding global resources, along with the diminishing international combat presence in Afghanistan, the World Food Programme (WFP) has been forced to cut food rations in Afghanistan, affecting up to 1 million people. With its funding appeal experiencing about a $150 million shortfall, the WFP determined that it had to cut rations from 2,100 to 1,500 calories per person to avoid having to cut off some people from food aid entirely. Incredibly, the United Nation’s Afghanistan humanitarian appeal is among the better funded appeals, at 61% funded as of November 10, compared to 46% for UN humanitarian appeals overall, with some appeals many months old still below 40% — and even below 30% — funded, including for the Republic of Congo, Somalia, Chad, Burkina Faso, Nigeria, and Iraq.
The major public health story of the past weeks continues to be the Ebola epidemic in Sierra Leone, Liberia, and Guinea, even as U.S. media coverage has been dominated by fears of Ebola in the United States, with states implementing quarantines and other highly restrictive policies — responses likely unconstitutional in their failure to be based in public health need. The crisis in West Africa persists, with very encouraging but also quite fragile indications of progress in Liberia, yet concerns of the epidemic worsening in Sierra Leone, and stable or worsening in Guinea.
Together, Ebola in West Africa and hunger in Afghanistan – in particular, as emblematic of a world that seems incapable of providing – or unwilling to provide – the required resources and policy focus on the current multitude of global humanitarian and health-related crises, hold a number of lessons for what needs to be incorporated into a more effective global governance for health. And as we will get to, a Framework Convention on Global Health could be a significant step towards embedding these into global governance structures.
Among the lessons are these eight:
This could take multiple forms. A reformed WHO or other entity might be charged with leadership training, mentoring, and other capacity-building activities (even simple measures like funding for highly skilled interns). Further, a Right to Health Capacity Fund could support civil society capacity, public education on the right to health, and government institutions that can further the right to health, from judiciaries and parliamentary human rights committees to national human rights institutions and, critically, health workers themselves. Global accountability mechanisms will need to manage the difficult balance of holding nominal health leaders and political decision-makers to account without pulling funding or other support that is needed to advance people’s health. Whatever form these take, national and local civil society participation will be critical in determining the balance.
Could global governance foster such personal effects? Perhaps so. For example, it could channel funding for policymakers to travel to places of ill health, whether in the throes or aftermath of a humanitarian disaster or disease outbreak or simply communities on the short end of immense global and national health inequities. With a growing interest in technology for accountability, governance functions could also support technology to link people across countries and communities. Could traveling electrons and satellite signals create human bonds? And besides direct support, governance might set standards or policies that could catalyze national and local efforts towards these ends.
What is the role of global governance for health in this? In some targeted areas it is easier to see its role, such as building on WHO action (see this World Health Assembly resolution, para. 2(8)) to strengthen the norm against and further stigmatize targeting health workers and facilities in conflict, and the norm of protecting and not discriminating against health workers who meet their professional duty of caring for all in a conflict – whatever side their patients are on. Global financing structures could increase funding to local women’s and human rights organizations working to change norms – and laws – on violence against women, including to more effectively enforce laws that are on the books to prosecute perpetrators of violence, and to provide shelter to women who are being abused. A World Health Assembly resolution from May 2014 has further areas of action, such as providing the necessary health services to survivors of violence, enhancing data collection and intersectoral collaboration, and contributing to norm change. The resolution also requires WHO to develop a plan of action to strengthen the health sector’s response to violence against women and children. The global health community could step up support to health workers aiding women who are targeted in conflicts, responding to both their physical and mental health needs, and documenting the crimes to facilitate prosecution.
Looking to war more broadly, a start might be simply to create greater institutional linkages between WHO and other health structures with entities, from intergovernmental to non-governmental, whose main mission is peace. Might it be possible for the global community to do more to support community health leaders in peacebuilding and peacemaking functions? Or target sustained health system reconstruction efforts in post-conflict countries as part of a return to functioning societies, reducing the possibilities of renewed conflict?
At least these areas would be a start. You may have other ideas to contribute.
This will require new comprehensive, well-developed resource needs estimates, including for building capacities to detect and respond to disease outbreaks, estimates that to my knowledge are yet to be developed. Resource needs estimates then need to be translated into the necessary financing, requiring that financing frameworks or structures encompass the full scope of these health necessities – and the political will and legal commitments to ensure these funds through domestic resources, topped off by international assistance and innovative financing.
For the final two lessons, we move from the expanse of health to the traditional realm of global health, health systems and, narrower still, medical technologies. For Ebola reminds us of the centrality of effective medical technologies, vaccines and medicines that can stave off disaster, or save lives if disaster does strike.
Determining how to integrate these priorities into reformed global governance for health – while beginning to implement them now – is a pressing task. Disease outbreaks happen on their timetable, not ours. Humanitarian aid shortfalls are a sadly common reality. People are dying because of weak health systems and inadequate health financing today.
One platform for these changes could be the Framework Convention on Global Health (FCGH), a proposed global health treaty that would be based in the right to health and aimed at closing national and global health inequities. It would reform global governance for health, from creating greater accountability from local through global levels to elevating health in other legal regimes, such as trade and investment. With developing comprehensive, quality, rights-based health systems as one of its core elements, it could have gone far towards limiting the scope of the present outbreak.
Along with the health systems focus, already central to the FCGH, the governance reforms proposed above would fit well within other proposed treaty elements. Among them, the broader funding could fit within the national and global health domestic financing framework, the links to animal health could be among the greater sectoral integration of efforts to address the social determinants of health, and the outbreak-conscious R&D could be part of the R&D aspect of the FCGH, which could ultimately be a full protocol. The FCGH, still in its formative stages, could be formulated to incorporate other aspects of the above reforms as well.
Our difficulty in sustained focus on situations that demand it may be one reason that we seem to have trouble learning from past incidents, that the same warnings (an underfunded humanitarian disaster, a disease outbreak) seem to be followed by the same promises (we pledge our support, we will do better next time), but too little changes.
An FCGH could instead embed these lessons and promises into a reformed governance, building them into the sustained structures of global health. It is one more reason to support the FCGH. And it would be one way to ensure that the suffering in West Africa, in Afghanistan, and in so many other places around the world produces not cries that echo in our ears only until they don’t, but instead propels us to act, and to honor – in their pain, and in their deaths – the lives of those whom we, as a global community, failed to sufficiently value in their times of greatest need. And from support for civil society to investments in national health systems, it is one way to enable presently poorer or conflict-ridden countries to themselves have the capacity to address health threats of all sorts, a sure way to turn cries of sorrow into smiles of hope.
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The views reflected in this blog are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.