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Introduction

Today's global health crisis reflects widening inequalities within and between countries. As the rich get rich and the poor get poorer, advances in science and technology are securing better and longer lives for a small fraction of the world's population. Meanwhile children die of diarrhoea for want of clean water, people with AIDS die for want of affordable medicines, and people in all regions are increasingly cut off from the political, social and economic tools they can use to create their own health and well-being.

Global Health Watch 1 (2005-2006) is a collaboration of public health experts, non-governmental organizations, community groups, health workers and academics. It presents a hard-hitting assessment of inequalities in health and health care - and is aimed at challenging the major institutions, such as the World Health Organization, that influence health.

The Watch is divided into five thematic sections. This executive summary highlights some of the major points made in each of these sections, and supplements them with recommendations made in the accompanying advocacy document, Global Health Action .

Part A: Health and globalization

A1: Health for All in the 'borderless world'?

Globalization is a powerful force for change. Substantial increases in capital flows and trade between countries, as well as global and regional regulatory decisions made by bodies such as the World Trade Organization, have profound implications for health.

This chapter questions the success story painted by proponents of the current form of globalization, pointing to increases in poverty in Africa , eastern Europe, central Asia and Latin America and a rise in income inequalities in many countries (including wealthy ones) in recent years. Producers in developing countries have often been undermined by increased global competition from powerful nations after trade liberalization. In Mexico , for example, the liberalization of the corn sector under the North American Free Trade Agreement led to a flood of imports from the United States , where agribusiness is massively subsidised. Mexican corn production stagnated whilst prices declined. Small farmers became much poorer and some 700,000 agricultural jobs disappeared over the same period. Rural poverty rates rose to over 70%, the minimum wage lost over 75% of its purchasing power, and infant mortality rates amongst the poor increased.

Such damage highlights the need for sophisticated national management of global economic change - which is extremely difficult in many developing countries with run-down or underdeveloped public sectors. Furthermore, whilst many - especially richer - economies have social contracts, progressive taxation systems and laws and regulations to manage the human consequences of market failures at the national level, there is no 'global social contract' to manage the failures of globalization.

Those global mechanisms that do exist often reinforce problems. World Trade Organization agreements that liberalize trade in goods and services, and protect investor's rights create an uneven playing field for poorer nations and decrease the space for national decision-making. The battles over the ill-conceived WTO agreement on intellectual property rights is just one area where negative health implications of global regulation are highly visible.

Reforms to global economic governance are vital in the interests of health. All global, bilateral and regional trade agreements should subject to health and equity impact assessments. As a first step, the Watch calls for an international delegation of public health and trade experts to be nominated and mandated to attend WTO negotiations and provide public health warnings to national governments as well as submit a high-level report to the WHO. This could start with the Hong Kong talks in December 2005.

Governments and international agencies could edge towards a global social contract, by ramping up their commitments on aid and debt relief - which would mean going substantially beyond the gestures made at the recent G8 Summit - ending the imposition of trade liberalization on developing countries and reducing subsidies to their own producers. New sources of development financing to support health and development should be established. The Watch calls for the establishment of an international tax authority to prevent corporate tax avoidance (estimated to cost governments at least US$255 billion a year), as well as serious consideration of other taxes such as a currency transaction tax, a global environmental tax or an airline tax.

Part B: Health care services and systems

B1: Health care systems and approaches to health; B2: Medicines; B3: The global health worker crisis; B4: Sexual and reproductive health; B5: Gene technology.

Health systems are vital in the fight against poverty - apart from curing people, they can, if properly designed and managed, reduce the financial burden of illness, build social cohesion and mitigate the feelings of vulnerability and powerlessness that are at the heart of the experience of destitution. Yet hundreds of millions still lack access to even basic care. And in most of the world, where health care has to be purchased directly out of pocket, it regularly pushes people deeper into poverty.

The Watch presents new cross-national evidence which shows that higher levels of private finance and provision lead to worse health outcomes. The Watch explains how the commercialization of health care systems results in widening health care inequities, lower access to quality care for the poor, inefficiencies and a deterioration in trust and ethics. Supporting countries to build universal systems financed by taxation and insurance mechanisms is therefore critical.

Developed nations give US $10 billion annually in aid to the health sector in developing countries. This is roughly the same as the amount spent on ice cream in Europe every year and equivalent to about 10% of England 's National Health Service budget. Yet even this small amount of aid can cause immense problems in poorer countries, as donor programmes are often unco-ordinated and focus on specific diseases to the detriment of the health system as a whole. In addition, structural adjustment programmes and neoliberal health sector policies which have been recommended by donors in return for aid threaten to entrench the commercialization of health care.

The Watch calls for the repair and development of health care systems based on the following 10-point agenda for action addressed to national governments and international donors and agencies (more detail on the recommendations is available from both the Watch itself and the accompanying advocacy document, Global Health Action ):

• Provide adequate funding for health care systems
• Take better care of public sector workers
• Ensure that public financing and provision underpin health care systems
• Abolish user fees that push people into poverty
• Adopt new health systems indicators and targets that incentivize countries to improve the health system rather than simply tackle specific diseases
• Reverse the commercialization of health care systems by using regulatory and legislative instruments; and search for ways in which the private sector's resources can be harnessed for the public good
• Strengthen health management and adopt the District Health System as the model for organising health care systems
• Improve donor assistance within the health sector
• Promote community empowerment to improve the accountability of the health system
• Promote trust and ethical behaviour to combat the corrosive effects of commercialization.

Further chapters in this section tackle other high-profile issues. The chapter on the global health worker crisis highlights and costs Africa 's subsidy to the UK NHS in the form of its skilled migrants and calls for compensation for low-income countries facing severe staff-shortages. The chapter on medicines focuses on the effects of global agreements on intellectual property rights on access to medicines. The chapter also reveals significant deficiencies in the current system for financing the research and development of medicines, and the existence of unhealthy relationships between Big Pharma and regulatory authorities mandated to protect public health, the medical profession and the research community.

This theme is carried over into a chapter that looks at developments in gene technology. The unravelling the human genome is raising questions about who owns life itself and threatens to accentuate an individual-focused, biomedical conception of health at the expense of a more efficient public health approach.

Finally, a chapter on sexual and reproductive health highlights the ongoing need to link health care to broader cultural, economic and political relations within society - in this case, in terms of gender. Advocacy which challenges injustices in access to health care needs to link with a broad range of different actors beyond the bounds of the health professions.

Part C: Health of vulnerable groups

C1: Indigenous peoples; C2: Disabled people

Listening to and bringing forward the voices of the excluded and marginalized are key roles for civil society worldwide. This first Global Health Watch focuses on two groups of people - Indigenous Peoples and people with disabilities - whose concerns are often marginalized and whose unfulfilled rights present fundamental challenges to policymakers.

Discrimination against both sets of people runs deep. Indigenous Peoples are often seen as backward and even as a block on modernization and development. People with disabilities are often regarded as abnormal and denied full human rights as a result. The relationships of both these groups with many health professionals have historically mirrored and reinforced the prejudices in the wider society. These chapters describe ways in which both groups have resisted and set their own agendas in the context of both health care and in society as a whole - but there is still a long way to go.

Key recommendations include:

Strengthening the voice of Indigenous and disabled people in health and development decision-making processes; implementing or setting up international conventions to guarantee a focus for the development of rights and claims at national and local levels; challenging discriminatory attitudes and practices amongst health professionals and the wider public; tailoring health services and research to support the needs of vulnerable groups whilst respecting principles of self-determination; and lobbying WHO to devote greater funding and profile to its work on these marginalized communities.

Section D: The wider health context

D1: Climate change; D2: Water; D3: Food; D4: Education; D5: War

The 1978 Alma Ata Declaration recognized that the goal of 'Health for All' would be achieved only by addressing the underlying social, economic and environmental determinants of health. Simply improving health care services would not be enough. Health care professionals and health care systems can facilitate and promote action for health in a range of different sectors.

Part D of the Global Health Watch demonstrates why this approach is needed by discussing the profound health impacts of lack of access to water and education, conflict, food insecurity and climate change. To take just one example: the failure to meet international targets on gender parity in primary and secondary education will, in 2005 alone, lead to the unnecessary deaths of 1 million children under 5.

Despite the diversity of topics, there are several points of convergence. For instance, it is invariably the health of poorer and more vulnerable groups that is worst affected by changes in people's external environments or in services that sustain health. Rapid climate change will hit the poorest hardest; conflict damages the fragile coping strategies of vulnerable households; and the privatization of water and education services increases poverty.

The need to reduce inequities through a strong public sector response in health-sustaining services mirrors that required in the health care sector itself. Key services around the world have been affected by constraints put on public expenditure. Joined-up responses in education, water and health might focus on campaigns for ending IMF and World Bank expenditure restrictions on public budgets, monitoring of public spending, and blocking multinational takeovers of essential services.

The growing power of the corporate sector is evident in the chapters on climate change, water and food security. A lack of democratic oversight of corporate actions is resulting in an unhealthy imbalance between corporate freedom and the achievement of social and public health objectives. The health community needs to assert its authority to promote and protect health by insisting on stronger international and national regulation of markets.

Section E: Holding to account

E1: World Health Organization; E2: UNICEF; E3: World Bank and International Monetary Fund; E4: Big business; E5: Aid; E6: Debt relief; E7: Essential health research

IIn this section, the Watch goes beyond other 'world reports' on health and development to reflect on the performance of global institutions, governments and corporations.

The monitoring component of the Watch is diverse, combining short and long pieces on these different actors. But again, common themes emerge. First amongst these is meanness. The chapter on aid shows how the growth in wealth of developed nations over the last forty years, is accompanied by levels of development assistance to the developing world that is the same as it was in the 1960s. Despite repayments worth billions of dollars, the citizens of developing countries are still paying for an unjust debt burden created in part by unethical and negligent lending practices.

The second common theme is lack of democracy. The chapters on the international institutions - WHO, Unicef, the World Bank and the International Monetary Fund, as well as analysis of the World Trade Organization in part A of the Watch - reveal a crisis of governance provoked by the attempts of rich nations to shape the international order in their favour. The recent US-driven appointments of Paul Wolfowitz and Ann Veneman to head the World Bank and Unicef respectively are symptoms of the crisis. The chapters suggest reforms to re-balance the scales of influence.

A third theme is organisational failure. Mismanagement and distorted priorities are a common factor in the despair felt by many working in and around the health-promoting international institutions. A deliberately long chapter on WHO concentrates not only the harsh external environment the organization faces, but the internal management problems which lead to organizational paralysis. But, as the chapter shows, change from within is possible if consensus, greater and more rationally-allocated funding, and management change occurs.

Finally, public action can make a difference. Two case studies on tobacco control and the marketing of breastmilk substitutes show how harmful business activities can be mitigated through the enforcement of codes of conduct and regulatory intervention.

A key focus for recommendations is the World Health Organization (further detail available in the Watch ).

Steering the global health ship

• Substantially increase funding for WHO with more proportionately devoted to its core budget with fewer strings attached. WHO has been fulfilling its global mandate on a two-yearly budget of little more than US$ 2 billion - totally inadequate for its task. Increased resources must be allocated more rationally, with greater funding for the core budget, and avoidance of energy-wasting competition between programmes and other international health agencies.
• Open a debate on WHO's key roles to avoid mission-creep and to develop consensus within and beyond the organization.
• Strengthen WHO's role at country level and give it a mandate to help governments co-ordinate global, bilateral and international NGO initiatives to improve health.

An organization of the people not just of governments

• Expand current efforts to reach out to civil society, especially in the developing world. Ensure that public-interest civil society organizations are differentiated from those acting as a front for commercial interests
• Temper the politicised nature of the WHO leadership elections - possible solutions include a wider franchise, perhaps of international public health experts and civil society organizations. Candidates should be required to publish a manifesto and debate their vision for the organization publicly.

Improve the management of the organization

• Meeting the challenges of global health today requires improving the mix of the professional staff - away from a reliance on doctors, to ensuring that there are a wider variety of health professionals, more social scientists, economists, public policy specialists, lawyers and pharmacists employed. More representation from developing countries should be coupled with stronger regional offices run by experienced professionals.
• Proof of effective leadership and management should be a criterion for staff recruitment, especially at senior levels.
• Stronger capacity and independence of WHO personnel departments with better staff support, and more effective mechanisms to combat corruption, nepotism and abuse of staff.