Health and politics

Beyond the localities of people’s daily lives, what broader conditions and decisions determine health care? The nation-state is in modern history the most visible of boundaries that delimits the scope and jurisdiction of health care and public health. Nation-states, however, are not static or isolated entities. On the contrary, they are subject to both internal dynamics and external forces. Few regions of the world illustrate this better than the Baltic Sea Region, which in the period between 1985 and 2005 went from being part of the Soviet Union, to become independent states, and finally part of the European Union. Toward the end of that period, these countries were also part of new international collaborations to curb the spread of infectious disease. Focus on the Baltic states thus enables us to observe how changing national and international political circumstances affects the health care sector.

This paper is a reflection on the interconnectedness of health and politics. While the connection is hardly new, it receives current attention by academics and by policy makers alike, it is integral to the relation between global and national health governance. Public health is inextricably linked to the moral and instrumental objective of a government to maintain a healthy population, essentially promoting health and protecting against disease. Obviously, there are large variations in states’ attentiveness to equity and fair distribution of the means to health. However, the state remains at the core, in need of legitimacy from the people it seeks to govern, enforcing a social contract to justify its rule. From the public health perspective, there is also an age-long conviction that effective governance is a necessary companion to science in order to reach health goals (1) . Increasingly, local and national politics are influenced by decisions taken beyond their own national boundaries, in regional and international forums, or even in other states. Thus, the link between politics and health requires attention on a domestic and international level.

The paper draws from ongoing research on global health at the University of Oslo which applies a political science and international relations perspective on ways in which current global and national health governance blend and mutually constitute each other. As academic discipline, political science is engaged in revealing the relationships underlying political events and conditions. Otto von Bismarck coined politics as the art of the possible, and the practice of public health should indeed be familiar with the recognition that gold standards are good ideals, but seldom attainable in practice given the realities of conflicting interests and positions, uncertain science and disputed knowledge.

Questions about the dynamic relationship between global health initiatives and countries own health systems in the protection of individual and population health are at the heart of contemporary discussions about global health governance.

The global-national interface as a conceptual frame for studying politics and public health

The interaction of global and national efforts in the protection of individual health can be understood as two overlapping realms of governance.

In general terms, the global governance realm is the collective action or cooperation that takes place outside the realm of the state: It normally includes the work of the World Health Organization and other international organizations, and what we also term international institutions – generally understood as the rules and norms governing interaction. Cooperation between countries, within regions or across, also forms part of this realm.

The concept of global health security gained foothold since the turn of the millennium as a distinct international political project to control the cross-border spread infectious disease. This kind of cooperation has historical roots in intergovernmental agreements to contain the spread of infectious disease in the mid-17^th century. Still, a renewed focus on health as part of national security rose back up on political agendas in the late 1990s as part of an increased focus on emerging infectious diseases, of which HIV/ AIDS was an ‘early’ example, as well as tuberculosis (as re-emerging), and later followed by the severe acute respiratory syndrome (SARS) outbreak and the potential of highly virulent influenzas. Observers have noted that there was an international build-up of scientific and political attention to the ‘return of the microbe’, with responses modeled on the smallpox disease eradication model; surveillance, outbreak investigation and containment, striving «…to transcend certain limitations posed by the national governance of public health» (2, p. 61). In the 1990s, the emerging disease problem was part of US national security discussions, linking also to the bio security issue (2, p. 69).

The effort to build a global response-network has been firmly established as a global collaborative effort anchored in the WHO, emphasizing that global public health security would not just stop infectious disease at national borders, but seek to prepare for outbreaks in advance and ensure rapid action through an early warning system, sought implemented in member states (3). A study reviewing country policy documents on global health, found that the fear of pandemics as part of a health security argument recurred most frequently (4). Health security is in other words a very powerful driver of international health collaboration.

The national health governance realm spans from central decision-making to district-and community-level health care services, or simply put, a system for public health to both protect against health risks but also to provide services. The state’s role as provider varies along a continuum from political control to market liberalization. As global health governance efforts seek a deeper integration and wider reach, national governments become the gatekeepers to their health care systems and populations, for better or worse. Sometimes, populations represent a potential impact-factor for international projects, a potentially valuable asset to both governments and international initiatives. At other times, governments may be wary of imposed limitations on their sovereignty and control, but also mindful of their need for legitimacy both domestically and internationally. This is obviously a balancing act for governments. In any case, the current reality is that the national health governance realm works in relation to a widening group of state and non-state actors where the separating lines between domestic and international health is increasingly blurred.

The new form of country-global interaction can be captured analytically in the concept of interfaces, as «…socio-political spaces of recurrent interactions (…) in the handling of transnational and international affairs» (5). The term is an adaptation from sociology (6,7), and recently used to analyze the participation of South Africa and Brazil in international trade negotiations over access to hiv/aids medicines as two emerging developing countries increasingly able to set and influence global agendas (5,8). Wogart et al propose a typology of interfaces that captures ways in which domestic actors interact with global arenas: One relates to the framing and influence over discourses, where for instance media and expert commissions shape perceptions of influential persons on important political issues. The second type of interface relates to resource transfers, where funding of multilateral organizations and country interventions play an important part. The third point of interaction is organizational and decision-making interfaces, capturing the range of initiatives, partnerships and alliances as meeting places between country and global constituencies. Depending on the issue area, the organizational interface may also include legal interfaces between international and domestic law (5, p.10). While a conceptual focus on interfaces sees governance as a relational phenomena, it still emphasizes the need to understand the participating actors «… in their original structural context, their sets of reference points and constraining/enabling properties» (7, p.62). The importance of understanding what goes on at the interfaces, is to identify the conditions under which international collaboration succeeds in improving the protection of individual health.