When the president of the World Bank says Thailand was right in rejecting the bank’s advice, while introducing its programme for universal health coverage (UHC), it is big news. When the director general of the World Health Organization (WHO) says, a fortnight later, that Big Soda and Big Food must be lined up alongside Big Tobacco and Big Alcohol as major public health threats, it is sensational. The global public health community has been stirred up by these two speeches delivered in the last six weeks.
On 22 May, Jim Kim addressed the World Health Assembly in Geneva as the first public health professional to become the president of World Bank. In a remarkable speech, twittered all over the world, he called for the present generation to “bring effective health services to every person in every community in every country in the world”. Espousing the cause of UHC, he praised the achievements of countries like Turkey and Thailand in implementing it. He pointed out that Turkey cut its infant mortality rate by 40% between 2003 and 2010.
What surprised his audience was, however, the forthright manner in which he said Thailand had been right in launching its UHC programme “against concerns over fiscal sustainability initially raised by my own institution, the World Bank Group”. He said “Thailand’s health leaders were determined to act boldly to provide access for their whole population. Today the world learns from Thailand’s example.”
As if that mea culpa was not sufficient enough to cause consternation, Kim proceeded to debunk the orthodoxy on user fees previously advocated by the World Bank as an essential part of health reforms in developing countries. Describing the levy of such fees for health care as “both unjust and unnecessary”, he said: “Anyone who has provided health care to poor people knows that even tiny out-of-pocket charges drastically reduce their use of needed services.” He went to say that “countries can replace point-of-service fee with a variety of forms of sustainable financing that don’t risk putting poor people in this potentially fatal blind. Elimination or sharp reduction of point-of-service payments is a common feature of all systems that have successfully achieved universal health coverage.”
On 8 June, Margaret Chan, head of the WHO, stunned delegates to the International Conference on Health Promotion at Helsinki with her bold critique of the food and beverage industry. Declaring that “efforts to prevent non-communicable diseases go against the business interests of powerful economic operators”, Chan said: “It is not just Big Tobacco anymore. Public health must also contend with Big Food, Big Soda and Big Alcohol. All of these industries fear regulations, and protect themselves by the same tactics.” Listing the various tactics used by these industries to subvert public policy, she was unusually candid in saying: “This is formidable opposition. Market power readily translates into political power. Few governments prioritize health over big business. As we learned from our experience with the tobacco industry, a powerful corporation can sell the public just about anything.”
Lamenting the “failure of political will to take on big business”, Chan minced no words in saying: “When industry is involved in policy-making, rest assured that the most effective control measure will be downplayed or left out entirely. This, too, is well documented and dangerous.” She said: “In the view of WHO, the formulation of health policies must be protected from distortion by commercial or vested interests”.
These two speeches reflect the growing recognition that the policy environment in public health is more profoundly influenced by the political economy than by scientific knowledge on health and disease.
This has been largely true over several centuries. Indeed the 19th century German scientist Rudolf Virchow had famously stated: “Politics is medicine on a grand scale.” However, contemporary trends in globalization of trade and the influence of global financial institutions like the World Bank bring this reality into stark relief as never before.
What is, however, reassuring is that both Kim and Chan have chosen to prioritize health over economic orthodoxy and corporate clout. This marks a phase of bold assertiveness in public health wherein protection of people’s health through creation of health promoting societies is placed centrally in the vision for global development in the 21st century.
India’s leaders too must pay attention to these two speeches, to comprehend what was said and why. Our hesitancy in moving towards UHC must be overcome and political commitment to that cause must be strengthened at both central and state levels.
The diffidence in developing and enforcing appropriate regulatory frameworks for tobacco, alcohol, processed food and beverages must be overcome, if public health is not to be eroded by these industries. When the global leaders of the world’s economic and health agencies both take a firm stand on aligning public policy to people’s health, surely that is advice worth listening to.
K. Srinath Reddy is president, Public Health Foundation of India