Health System Challenges and Responses in a Globalized World

1. 20 Years After Ottawa and the 8th Conference: Different Responses in a Globalized World Dr. Elinor Wilson Canadian Public Health Association

3. Epp plans to revamp “failing” health care system Ottawa Citizen, Nov 1986 Health System must aid quality of life, Epp says Toronto Star, Nov 1986 Health system not coping: Epp Toronto Star, Nov 1986 Health system not doing enough to help people; Epp says Montreal Gazette, Nov 1986 Health care inequities must be challenged, Epp tells conference Globe and Mail, Nov 1986 Health System ailing: Epp Winnipeg Free Press, Nov 1986 Health Reform is mainly talk, Leonard Shifrin Winnipeg Free Press, Nov 1986

4. “Political, economic, social, cultural, environmental, behavioural and biological factors can all favour health or be harmful to it.” Ottawa Charter for Health Promotion, 1986

5. “The primary determinants of disease are mainly economic and social: therefore its remedies must also be economic and social.” Geoffrey Rose

6. Inequalities as a Barrier • Unequal access to and use of basic resources; • Unequal access to primary health care; • Health policies and programs that perpetuate gender stereotypes; and • Inadequate and inappropriate health services.

7. If we could shrink the earth’s population to a village of precisely 100 people, with all the existing human ratios remaining the same, it would look something like this… 57 from Asia 21 from Europe 14 from the Western Hemisphere 8 from Africa 52 would be female 48 would be male 70 would be non-white 30 would be white 70 would be non-Christian 30 would be Christian 89 would be heterosexual 11 would be homosexual 6 would possess 59% of the entire world’s wealth and all 6 would be from the United States 80 would live in substandard housing 70 would be unable to read 50 would suffer from malnutrition 1 would be near death 1 would be near birth 1 (yes only 1) would have a college education 1 would own a computer

8. Income Inequities • The poorest 20% of the world’s people benefit from only 1% of world trade and 0.2% of world commercial lending • More than 75% of the world’s people enjoy only 16% of the world’s income - while the richest 20% have 85% of global income • The ratio of the income of the top 20% to that of the poorest 20% rose from 30 to 1 in 1960, to 61 to 1 in 1991 - and to 78 to 1 in 1994 • Public consumption per capita is $3985 in industrial countries, but $183 in developing countries

9. The World’s Priorities?Annual Expenditures Basic education for all Cosmetics in the United States Safe water and sanitation for all Ice cream in Europe Reproductive health for women Perfumes in Europe and the United States Basic health and nutrition Pet food in Europe and the United States Business entertainment in Japan Cigarettes in Europe Alcoholic drinks in Europe Narcotic drugs in the world Military spending in the world $ 6 billion* $ 8 billion $ 9 billion* $ 11 billion $ 12 billion* $ 12 billion $ 13 billion* $ 17 billion $ 36 billion $ 50 billion $105 billion $400 billion $780 billion *Estimated additional annual cost to achieve universal access to basic social services in all developing countries. Source: Human Development Report, 1998

10. Rethinking Spending Priorities • “If developing countries were capable of making adequate use of 24% of the $125 billion that they spend on armaments per year, • most of the primary healthcare (immunization of all children, elimination of severe malnutrition and reduction of moderate malnutrition, and provision of safe drinking water for all), • education (reduction of adult illiteracy, universal primary education, and education of women to the same level as men), • and population costs (provision of a basic family planning package to all willing couples, and stabilization of world population) could be covered.” R. Favaloro, A Revival of Paul Dudley White

11. Selected Laws for the Prevention of Chronic Diseases and Injuries Law Smoking bans or restrictions Tobacco excise taxes Required coverage of cessation services costs Zoning and land use requirements Child safety seat use laws Public Health Issue Addressed Exposure to environ-mental tobacco smoke Tobacco initiation and use Tobacco use Physical inactivity Unintentional injuries of children Effectiveness Strong evidence Strong evidence Sufficient evidence Review in progress Strong evidence How it works Requires behavioural change to change the environment Incurs a financial disincentive to involve behaviour change Requires organizational change that promotes behavioural change Requires environmental change that promotes behavioural change Directly requires behavioural change Mensah et al. Preventing Chronic Disease 2004;1(1):1-8.

12. Canadian Coalition for Public Health in the 21st Century • Formed as SARS underway • CIHR facilitation • CPHA urged to take lead • Now, 40 national organizations • Professional • Academic • Disease / condition • Advocacy • Multi-sectoral, multi-disciplinary

13. CCPH21 - Messages • National Public Health Leadership • Public Health Goals • Public Health Legislation • Overarching framework, and internal alignment • Adequate financing for public health at all levels • Strengthened public health human resources

14. ActNowBC:The Business Case 100% 100.0% Total 90% 80% 71.3% Health 70% 53.6% 60% 50% 41.6% Percent 40% Education 28.4% 27.0% 27.0% 30% 27.0% 16.6% 20% Other 10% 0% -0.6% -10% 04/05 05/06 06/07 07/08 08/09 09/10 10/11 11/12 12/13 13/14 14/15 15/16 16/17 17/18 Year Revenue Growth – 3% Education Growth – 3% Health Growth – 8% Balanced Budget Other spending reaches zero by 17/18

15. Conceptual Framework Strategic Communications Premier Committee on Social Development Committee on Natural Resources & the Economy StrongStart BCCabinet Committee Children & Family Develop. Aboriginal Relations & Reconciliation Advanced Education Education Transportation Community Services Forests & Range Agriculture & Lands Health Small Bus. & Revenue Economic Development Public Safety & Solicitor General Employment & Income Assistance Labour & Citizen’s Services Attorney General .Environment Energy, Mines & Petroleum Res Tourism, Sports & Arts Finance Coordination and Stewardship All sectors, municipalities, Non-Governmental Organizations, Agencies, Businesses and Industry ActNow BC provides a unifying brand for the strategic cross governmental and cross-sectoral initiative for creating a healthy BC population. Facilitates “improved alignment of cross-ministry policy”

16. From Black to Wanless and beyond: overview of UK health inequalities, investigations and recommendations since 1977 • The Black Report (1980) • Independent Inquiry into Inequalities in Health (1998) • Modernizing Government White Paper (1999) • Saving lives – Our Healthier National White Paper (1999) • The NHS3 Plan (2000) • Tackling Health Inequalities Cross-Cutting Review (2002) • Tackling Health Inequalities: A Programme for Action (2003) • The Wanless Reviews (2002, 2004) • Choosing healthy: making healthy choices easier (2004) • Tackling Health Inequalities: Status Report (2005)

17. WHO Global StrategyGoals The overall goal of the global strategy on diet, physical activity and health is to promote and protect health by guiding the development of an enabling environment for sustainable actions at individual, community, national and global levels that, when taken together, will lead to reduced disease and death rates related to unhealthy diet and physical inactivity.

18. Strategies used against the tobacco industry and possible similar responses against food industry Tobacco Strategy Accumulate and publicize evidence of health effects Exposure of industry advertising tactics Litigation Labelling of cigarette packets Possible analogous response to promote healthier diets Reports and advice to government from national expert groups (such as medical associations); multilateral organisations such as WHO take lead on identifying avoidable health risks of continuing overconsumption of unhealthy diets and lack of physical activity Release and dissemination of marketing strategies used to target young children; alternative sources of funds to support sports and similar events Parents could sue schools providing unhealthy diets; litigation against companies aggressively targeting young children Health warnings on high fat foods and high sugar soft drinks Ref: BMJ Volume 328 26 June 2004

19. Strategies used against the tobacco industry and possible similar responses against food industry (continued) Tobacco Strategy Taxing of cigarettes Publicize the social, economic and environmental impact of tobacco production Increase awareness of role of industry in supporting researchers Expose foreign governments that are enforcing the introduction and marketing of new brands of cigarettes into a country Possible analogous response to promote healthier diets Taxes on high sugar soft drinks and perhaps targeted high fat foods Campaigns by national, international, and non-governmental consumer groups; use of freedom of information disclosure; multilateral organisations such as WHO take lead on identifying, and naming, the effect of obesogenic environments Vigilance by peer reviewed journals, and other media, on noting industry links and possible conflicts of interest when publishing articles; increase publication of articles addressing the issue Exposure of the practice; pressure by consumer associations; use of World Trade Organisation rules that are in place to protect public health Ref: BMJ Volume 328 26 June 2004

20. Summary Points Large multinational companies control much of what we eat The convenience and availability of energy dense foods is contributing to the obesity epidemic The food industry is resisting public health attempts to change current practices Global strategies are needed similar to those used against the tobacco industry Ref: BMJ Volume 328 26 June 2004

21. Potential International Standards • Marketing restrictions for unhealthy food products • Restrictions in addressing & availability of unhealthy products in schools • Standard packaging & labeling of food products • Price a tax measures to reduce demand Ref: BMJ Volume 328 26 June 2004

22. WHO and Civil Society Linking for Better Change • Engaged with WHO to implement health programmes at country level; • Made outreach to remote areas and populations possible; • Advocated public health issues to a broad audience; and • Addressed sensitive issues and worked in alliance with WHO to raise funds more effectively.

23. People’s Charter for Health • Health as a Human Right • Determinants of health • Social and political challenges • Environmental challenges • War, violence, conflict and natural disasters • People centered health sector • People’s participation for a healthy world

24. Global Peoples Health Charter: Significance • It endorses health as a social, economic and political issue and as a fundamental human right; • It identifies inequality, poverty, exploitation, violence and injustice as the roots of preventable ill-health; • It underlines the imperative that “health for all” means challenging powerful economic interests, opposing globalization as the current iniquitous development model; it thus drastically changes our political and economic priorities; • It brings in a new perspective and the voices from the poor and the marginalized (the rarely heard) encouraging people to develop their own local solutions; and • It encourages people to hold accountable their own local authorities, national governments, international organizations and national and transnational corporations.

25. United Nations High-Level Panel • Poverty, infectious disease and environmental degradation; • Armed conflict – both within and among states; • Organized crime; • Terrorism; and • Weapons of mass destruction

26. “The very values of an enlightened and civilized society demand that privilege be replaced by generalized entitlements – if not ultimately by world citizenship then by citizens rights for all human beings of the world.” Ralf Dahrendorf

27. Global approach to governance: We must move: • From nation state to Multi actor accountability • From national to international and global accountability • From focus on civil and political rights to economic, social and cultural rights • From punitive to positive ethos (name and shame) • From multi party to inclusive models of democracy • From poverty eradication as a development goal to poverty eradication as social justice (UNDP 2000) Ilona Kickbusch

28. Five Action Areas • Health as a global public good • Health as a key component of global security • Strengthening global health governance for interdependence • Accepting health as a key factor of sound business practice and social responsibility • Accepting ethical principle of health as global citizenship Ilona Kickbusch, Leavell Lecture, 2004

29. Global Health Treaty • Should ensure a common high level of health protection and health rights for all citizens, wherever they live, love, work and play (and travel, buy or google) • From those risks and threats to their health, safety and well-being which are beyond the control of individuals and communities • Cannot be effectively tackled by nation states alone but need to be multiactor (e.g. health threats, unsafe products, unfair commercial practices). Ilona Kickbusch

30. Global Health Treaty (continued) • Reform and strengthen global institutions and international law for health and bind a wide range of actors • Introduce and ensure new sustainable financing mechanisms • Control unsafe goods and products, ensure corporate accountability • Address health dimensions of trans-boundary/collective human security issues • Fight major diseases and defined global health emergencies including rapid response • Create surveillance and information systems • Harmonize aid to give priority support to PHC and PH health infrastructures • Strengthen professional capacity and ensure human resources at a global level and address the brain drain. Ilona Kickbusch

31. Future Perfect: Health for All • Health will be a human right, but one which implies responsibilities • Individuals will be respected and given the right to make choices, but they will have the skills, knowledge and power to make informed choices • Where individuals and groups lack the means to exercise responsibility - because of poverty, illiteracy, social isolation or joblessness - it will be society’s task to strengthen the socio-environmental system in ways that enable them to make healthful choices • Health and wellbeing will be the ultimate aim of social and economic development • There will be health and wellbeing for whole populations, e.g., women and Aboriginal people Ilona Kickbusch

32. “Implicit in the idea of “globalization” rather then “internationalization” is the idea that we are moving beyond the era of growing ties between nations and are beginning to contemplate something beyond the existing conception of the nation state.” Peter Singer, One World, 2002

33. Imagine what would happen if the nations of the world spent as much on development as on building the machines of war. Imagine a world where every human being would live in freedom and dignity. Imagine a world in which we would shed the same tears when a child dies in Darfur or Vancouver. Imagine a world where we would settle our differences through diplomacy and dialogue and not through bombs or bullets. Imagine if the only nuclear weapons remaining were the relics in our museums. Imagine the legacy we Could leave to our children. Imagine that such a world is within our grasp. Mohamed Elbaradei, Nobel Lecture, 2005

34. “There are no excuses left, no rationalizations to hide behind, no murky slanders to justify indifference – there will only be the mass graves of the betrayed.” Stephen Lewis, UN Envoy HIV/AIDS