Advancing health by enhancing capabilities: An agenda for equitable global governance
A report by The Lancet - University of Oslo Youth Commission: Unni Gopinathan, Nicholas Watts, Cristóbal Cuadrado, Daniel Hougendobler, Saveetha Meganathan, Alexandre Lefebvre, Renzo Guinto, Tami Okamoto, Jacob Jorem, Waruguru Wanjau, Xiaoxiao Jiang, Nilofer Khan Habibullah, Peter Asilia and Usman Ahmad Mushtaq.
In a host of negotiation processes and governance forums, the redistribution of power and resources is crucial for the success of any proposal that seeks to advance global governance for health. At present, such power asymmetries and diverging interests must be recognized as part of the reality in which global decision-making occurs, and that the characteristics of the current system of global governance are difficult to change in the short-term. It would also be impudent for this (or any) report to conclude with a manifesto of principles, recommendations, and proposed ‘global changes’ designed to solve the major challenges facing humanity.
Hence, the recommendations provided below are suggestions, based on the preliminary work of the Youth Commission, for an agenda for equitable global governance.
Recommendation 1: Adopt the capability approach as a guiding framework for global governance for health
A multi-dimensional framework for well-being, where health is among several freedoms to protect and promote is proposed as guidance for global governance:
At the normative level, the inclusion of the capability approach in a global governance framework would ensure that attention is evenly devoted across diverse freedoms that people value. These freedoms include those identified to be essential by Sen - all of which have clear and important implications for health Equity:
- political and civil freedoms
- social opportunities
- economic opportunities,
- transparency in governance and economic life, and
- protective freedoms (social security and upholding the law)
At the policy level, the capability approach provides a means for decision-making and prioritization between various sectors and legitimate public objectives. It will provide a means for better evaluating the impact of global governance actions and policies according the impact they are expected to have on a variety of freedoms, with an ultimate concern for equity both within and between generations.
Recommendation 2: Enhance public scrutiny of global governance processes by launching a UN Civil Society Observatory
There is an urgent need and demand for civil society organizations (CSOs) to play an enhanced and more meaningful role in global decision-making processes. Therefore, we propose the creation of a UN Civil Society Observatory, which should consider three important aspects:
The decision-making bodies at the international level would be required to provide CSOs and the general public with proposed international decisions before they are decided, with adequate time given for CSOs examine the public impact of the decisions as well time to prepare and deliver oral or
written comments. This would provide the improved space and time for more inclusive and accurate public scrutiny of global decisions. It is vital that formalized CSO participation include all governance institutions and processes affecting health, including non-health IGOs, multilateral negotiations outside the auspices of an IGO, and bilateral treaty negotiations.
Allowing unchecked CSO participation would result in asymmetrical distribution of power, owing the divergence in resources and political connections between CSOs. Therefore, another aspect of the formalized CSO process must involve actively soliciting and facilitating the voices of those who are often left unrepresented, particularly those who are most likely to be affected by the proposed decision. A mechanism should be put in place in order to examine carefully who is likely to be affected by the decision, and to facilitate the full participation of currently excluded groups by allocating necessary funding and other resources.
Opening global decision to additional public scrutiny and debate would also improve the interaction between "global knowledge" (which more often refers to "expert knowledge" informed by conventional science), and local "social worlds" (earlier illustrated using indigenous peoples’ knowledge systems). Mechanisms should be put in place to facilitate and improve such "dialogue across difference", and such interactions should bring attention to how policies conceived at the global level affect diverse local communities worldwide.
Recommendation 3: Institutionalize intergenerational solidarity in national and global governance
In order for global governance to meet the intergenerational challenge identified earlier, mechanisms that foster intergenerational solidarity are required within existing international agencies and processes. As proposed by the existing Major Group on Children and Youth (MGCY) in the UN (147), a High Commissioner for Future Generations might be created at the international level, supported by a network of national level ombudspersons. It is anticipated that youth representatives will be accorded a greater political voice, backed by enhanced legitimacy from fellow young people in their respective countries. This new "power" provided for future generations will be crucial in strengthening global governance for health not only for this generation, but also for generations to come. Drawing from the UN Secretary-General’s report on intergenerational solidarity (62), below are a set of considerations that might serve as basis for this proposal.
As suggested by MGCY, the national level ombudsperson should be mandated to assess the long-term impacts, both locally and globally, of the public policies and legislative proposals, including potential impacts on future generations.
Similarly, the long-term impacts of global governance decisions should be assessed by the High Commissioner for Future Generations, by identifying the needs of the future generations and articulating these as precisely as possible, and by weighing these losses against the potential gains for current generations. This assessment should be released simultaneously together with proposed international decisions, thereby opening the opportunity for the public to voice their opinions and contribute further to this assessment.
Decisions resulting in potential small gains for current generations should not be made at the expense of potential large losses for future generations.
Meeting the intergenerational challenge by establishing a High Commissioner for Future Generations is closely related to the recent calls for adopting a paradigm of "Planetary Health" (148), which considers the health not just of the present generation, but also of the unborn generation, and the health of the larger ecosystem (which is in turn, critical for human survival).
While these recommendations may provide the blueprint for improved global governance for health that is concurrent with present and emerging challenges, further work is required to refine these ideas, provide examples of how they might be implemented, and most importantly, capture the imagination of leaders and the broader public alike. All stakeholders–governments, civil society, private sector, academia, students and young people–have an important role to play in advancing this conversation.
Global governance for health, supported by the capability approach, could raise the prominence and legitimacy of health on the global stage and provide a meaningful benchmark for weighing health against other important interests. There is hope that a strengthened system of global governance will lead us towards a world in which health inequities are no longer tolerated and the goal of ensuring the highest attainable standard of health, alongside the other important freedoms that reinforce it, is given the consideration it deserves.