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Is better health the fundamental goal, and will politicians collaborate effectively?
A decade ago the US Institute of Medicine argued compellingly that it was no more than enlightened self interest for countries to invest in global health.1 Such investment would help to protect their own citizens from external threats, strengthen the global economy, and contribute to international security. In the intervening period, support for placing health at the centre of foreign policy has gathered momentum. Earlier this year the Global Health and Foreign Policy Initiative was established by a group of foreign ministers convened by the Norwegian and French governments,2 and in the United Kingdom Sir Liam Donaldson, the UK's chief medical adviser, has proposed a government-wide strategy for global health.3
The British proposals identify five reasons for promoting global health. These are to improve global security and health protection, enhance sustainable development, improve trade by promoting health as a commodity, maximise global public goods, and encourage a human rights approach to health. An interdepartmental steering group has been established to take this agenda forward across government and has embarked on a wide-ranging consultation to help it fill in the details.
The United Kingdom is in a strong position to provide leadership on this issue. The government has already led in areas such as international debt relief; UK overseas aid is recognised to be extremely effective; and many UK universities and government agencies are already fully engaged in the global health agenda. Yet there are also weaknesses in the UK position. Most obviously, there is the special relationship with the United States, during a period when the Bush administration has made no secret of its contempt for concerted international action to tackle many of the world's problems.4 Another weakness, although not unique to the United Kingdom, is the inherent contradiction between promotion of health and the pursuit of other policies, such as support for British arms exporters and potential tensions between international trade and pro-poor development. Even in the health arena there are contradictions, with the Crisp report encouraging junior doctors to gain experience abroad5 and the new system of medical training discouraging them.6
Sir Liam's important proposal captures the spirit of the times but, to promote real change, all those with a potential contribution to make must engage genuinely with it, wherever they are in government. For this to happen, some fundamental issues must be resolved.
Firstly, agreement is needed across government on whether the improvement of health is a fundamental goal in its own right, or whether it is simply an instrument to achieve other goals, such as promoting economic growth. This distinction becomes important when objectives conflict. Health is implicit in many of the government's stated international priorities,7 but nowhere is there an explicit statement of the importance of improving health to match that of, for example, poverty reduction. Similarly, the millennium development goals, to which the UK government has signed up, include some important aspects of health but exclude others, such as virtually all of the burden of disease among adults.8 As a consequence, the rapidly increasing problem of non-communicable disease in low and middle income countries barely features on the international agenda.9 Linked to this is the immediate need to establish clear criteria on what to include in a global health policy. Otherwise, the UK strategy will seem like a disconnected shopping list, all too easy for government ministries to ignore.
How will this national strategy be taken forward in Europe? The European Union has a common foreign and security policy, so that, with a few exceptions, member states vote as block in international forums. Achieving a European consensus on global health will not be easy, especially given some governments' preoccupation with current revisions to the European Treaties. It will be important to build alliances with like minded governments, especially those thatwho will hold the rotating EU presidency in the near future.
The UK global health strategy must be sustained over the long term: short term fixes will not do. The creation of an interdepartmental steering group is a good first step, and the recent appointment as a minister in the Foreign Office of the committed internationalist Mark Malloch Brown bodes well. Commitment by the other political parties and, critically, by the administrations in Scotland, Wales, and Northern Ireland is also essential. The consultation process has already visited Edinburgh and Cardiff. Some mechanism is also needed to include the views of the UK's remaining overseas territories, many of which are especially vulnerable to global forces.
Competing interests: None declared..
Provenance and peer review: commissioned; not externally peer reviewed