Globalization and social determinants of health: Promoting health equity in global governance (part 3 of 3)

Globalization and Health BioMed Central Review Open Access Globalization and social determinants of health: Promoting health equity in global governance (part 3 of 3) Ronald Labonté1 and Ted Schrecker*2 Address: 1Department of Epidemiology and Community Medicine, Faculty of Medicine and Institute of Population Health, University of Ottawa, Canada and 2Department of Epidemiology and Community Medicine, Faculty of Medicine and Institute of Population Health, University of Ottawa, Canada Email: Ronald Labonté - ; Ted Schrecker* - * Corresponding author Published: 19 June 2007 Globalization and Health 2007, 3:7 doi:10.1186/1744-8603-3-7 Received: 31 October 2006 Accepted: 19 June 2007 This article is available from: http://www.globalizationandhealth.com/content/3/1/7 © 2007 Labonté and Schrecker; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract This article is the third in a three-part review of research on globalization and the social determinants of health (SDH). In the first article of the series, we identified and defended an economically oriented definition of globalization and addressed a number of important conceptual and metholodogical issues. In the second article, we identified and described seven key clusters of pathways relevant to globalization's influence on SDH. This discussion provided the basis for the premise from which we begin this article: interventions to reduce health inequities by way of SDH are inextricably linked with social protection, economic management and development strategy. Reflecting this insight, and against the background of the Millennium Development Goals (MDGs), we focus on the asymmetrical distribution of gains, losses and power that is characteristic of globalization in its current form and identify a number of areas for innovation on the part of the international community: making more resources available for health systems, as part of the more general task of expanding and improving development assistance; expanding debt relief and taking poverty reduction more seriously; reforming the international trade regime; considering the implications of health as a human right; and protecting the policy space available to national governments to address social determinants of health, notably with respect to the hypermobility of financial capital. We conclude by suggesting that responses to globalization's effects on social determinants of health can be classified with reference to two contrasting visions of the future, reflecting quite distinct values. Background This article is the third in a three-part review of research on globalization and the social determinants of health (SDH). In the first article of the series, we identified and defended an economically oriented definition of globalization and addressed a number of important conceptual and methodological issues. In the second article, we identified and described seven key clusters of pathways rele- vant to globalization's influence on SDH. This discussion provided the basis for the premise from which we begin this article: interventions to reduce health inequities by way of SDH are inextricably linked with social protection policy, economic management and development strategy. It follows that when the objective is to reduce health inequities by way of SDH, the scale at which an intervention Page 1 of 15 (page number not for citation purposes) Globalization and Health 2007, 3:7 must be implemented is not necessarily the scale at which the problem arises. For example, addressing the poverty of individuals and households may demand policy responses on the part of state/provincial and national governments, yet they may be limited in their ability to act effectively because of constraints that are created by, and can best be changed by, actors outside their national borders, such as multilateral institutions or institutional investors. This interconnectedness is a distinguishing characteristic of contemporary globalization, and provides the basis for Pogge's argument that the industrialized world has an ethical obligation to reduce poverty outside its own borders [1]. We do not mean here to write domestic political action out of the picture; far from it. Szreter's work on industrializing England shows that the formation of effective domestic political coalitions was necessary to the translation of economic growth into improved population health status [2-4]. However globalization shapes the environment within which such coalitions operate, and affects their chances of success in a variety of ways. In 2000, a resolution of the UN General Assembly committed the international community to achieving the Millennium Development Goals (MDGs), by the year 2015 in most cases. Three of the Goals, which involve reducing child and maternal mortality and reversing the spread of HIV/AIDS, malaria, and other communicable diseases, are explicitly health-related. Four others directly address crucial social determinants of (ill) health: extreme poverty, undernourishment, environmental hazards, and lack of access to education. Targets that have been developed with respect to each of the goals state more specific milestones, such as reducing by half the proportion of the world's people without safe drinking water [5] The MDGs arguably represent a 'first' in terms of commitments by the international community to a specific development agenda. They are unambitious when viewed against the sheer volume of unmet basic human needs. Particularly notable is the modesty of the poverty reduction target (reducing by half, in the year 2015, the proportion of the world's people living on less than $1/day) when viewed against the background of expanding global affluence [6]. Similarly, compare the MDG 7 target of improving the lives of 100 million slum dwellers per year by 2020 with the estimate that if present trends continue, 1.4 billion people worldwide will live in slums in 2020 [7]. A further problem is that, apart from MDG 3 on gender equity in education, the MDGs are stated in terms of societal averages – meaning that a country may be able to achieve MDG targets related to health, such as under-5 mortality, while failing to improve the health status of the worst-off groups [8,9]. http://www.globalizationandhealth.com/content/3/1/7 On the other hand, the MDGs are ambitious when viewed against the uneven pace of recent progress toward meeting the needs they address. Substantial progress has been made toward achieving the MDG targets in some regions. In others, especially sub-Saharan Africa, the situation is grim [10,11]. Recent syntheses of available evidence, notably those by the UK Commission on Africa and the UN Millennium Project, des (...truncated)