Abstract

In recent years, Brazil channeled efforts around the global agenda for the health of people. In October 2011, with the technical and financial support of the Brazilian Government, the World Health Organization held the World Conference on the Social Determinants of Health, in Rio de Janeiro, Brazil. The Rio Declaration, which came out of this global conference, included multiple commitments drawn up by the government representatives who were present. This process of debate and exchange of global experiences widened and, in June 2012 the United Nations Conference on Sustainable Development was also held in Rio de Janeiro. Known as Rio+ 20, this global forum was attended by 190 nations and heads of state. They proposed changes especially in the ways in which the planet’s natural resources were being used. Besides environmental issues, other issues related to social policies such as health, education, work and housing were addressed. “The Future We Want for All”, the main document and product of this forum, received numerous contributions from global society. These discussions pushed for the implementation of global public policies that, through an extensive process of capacity building, translate these commitments of heads of states, from all over the world, into policies that act on social determinants of health, dealing with social inequities.

Global health; Sustainable development; International cooperation

Introduction

In recent years, Brazil has focused efforts around the global agenda for people’s health. In October 2011, the WHO held the World Conference on the Social Determinants of Health (WCSDH) in Rio de Janeiro, with the technical and financial support of the Brazilian Government. Aimed at the member states of the UN, over a thousand people attended this conference, among them representatives of the member states, Ministers of Health, members of the Diplomatic Corps, leaders of civil society organizations, public policy experts, and Brazilian and International researchers and members of academia.

The Rio Policy Statement¹1. Organização Mundial de Saúde (OMS). Declaração Politica do Rio de Janeiro sobre Determinantes Sociais da Saúde. 2011. [acessado 2015 dez 15]. Disponível em: http://www.who.int/sdhconference/declaration/Rio_political_declaration_portuguese.pdf.
http://www.who.int/sdhconference/declara... , one of the deliverables of this forum, lists a number of commitments along five priority dimensions, made by the Statespersons present. These were (i) improve healthcare and development governance, (ii) promote participation in policy formulation and implementation; (iii) increased guidance for the healthcare sector to reduce inequalities (iv) strengthen global collaboration and governance; (v) monitor progress and expand accountability/responsibility. The Rio policy Statement was signed by the other members states during the 2012 General Health Assembly.

The debate and exchange of global experiences expanded, and in June 2012 the UN National Conference on Sustainable Development(UNCSD) was held, also in Rio de Janeiro. Known as Rio+20, the event attracted the heads of 190 nations, and proposed a number of changes, especially on how the planet’s natural resources are being used. Beyond the environmental issue, the UNCSD also discussed social policies such as healthcare, education, labor and housing, among other topics. The Future we Want for All²2. Organização das Nações Unidas (2012). El futuro que queremos. Resolución aprobada por la Asamblea General el 27 de julio de 2012. [acessado 2015 dez 15]. Disponível em: http://daccess-dds-ny.un.org/doc/UNDOC/GEN/N11/476/13/PDF/N1147613.pdf?OpenElement
http://daccess-dds-ny.un.org/doc/UNDOC/G... , the main document and deliverable of this broad debate, was written with numerous contributions from government and non-government organizations from around the world. In the public hearing and drafting phase, because of initiatives by civil movements and local and international health organization, the so-called “draft zero”³3. Organização das Nações Unidas (2012). O Futuro que queremos. Rascunho Zero.[acessado 2015 dez 15]. Disponível em: http://www.onu.org.br/rio20/img/2012/01/OFuturoqueQueremos_rascunho_zero.pdf
http://www.onu.org.br/rio20/img/2012/01/... , the first version of the document, included nine paragraphs (138 - 146) on health, of which we highlight two, due to their significance.

138. We recognize that health is simultaneously a pre-condition, an output and indicator of all three dimensions of sustainable development. [...] We are convinced that it is important to focus actions on the social and environmental determinants of health, not only for the poor and vulnerable, but for the entire population, thus creating inclusive, fair, productive and healthy societies. [...]

139. We also recognize the importance of ensuring healthcare treatment coverage to improve health and promote social cohesion and sustainable human and economic development. We are committed to reinforcing healthcare system and providing equitable universal coverage. We appeal all players to be involved in a coordinated, cross-sectoral effort to urgently address the healthcare needs of the world’s population.

With these global forums behind us, we must now design and implement public policies that, via a broad process to develop skills and capabilities, translate the commitments made in these statements into measures to address healthcare inequality by acting on the social determinants of these grievances. The joint support of all nations is urgent, especially of those still in development to ensure the enforcement of measures based on the Rio Policy Statement and the document entitled The Future We Want for All. How can we combine our efforts around a post-WCSDH and post-Rio+20? What inclusive and broad factors should be in a global agenda post Millennium Development Goals (MDG)?

This paper examines the tensions, barriers and opportunities to implement new governance, capable of preparing agendas for global healthcare and the sustainable development of all people. It is a critical review⁴4. Booth et al. The literature review: its role within research.[acessado 2015 dez 15]. Disponível em: http://uk.sagepub.com/sites/default/files/upm-binaries/43465_Booth_et_al.pdf
http://uk.sagepub.com/sites/default/file... of the WHO documents approved in Rio de Janeiro, Brazil on October 21 2011. The “Rio Policy Statement on the Social Determinants of Health”, and the WHO document entitled “The Future We Want for All”, version approved on July 27 2012, in light of the concepts and guidelines of the WHO on “Universal Health Coverage”.

This analysis is basically limited to the commitments made by statespersons in these international conferences, in light of the WHO concept of Universal Health Coverage. Among other elements, this concept means lifetime equal access to integrated, quality healthcare services and actions based on individual needs. This in turn reinforces the need to define and implement inter-sector policies and interventions to act on the social determinants of health, and foster the commitment of society as a whole to promote health and well-being, with an emphasis on equality. [...] Strengthen the capabilities of the healthcare authorities to influence laws, regulations and extra-sector interventions that address the social determinants of health⁵5. Organização Mundial de Saúde/Organização Panamericana da Saúde (2014).Estratégia para cobertura universal de saúde. Washington (DC): OPAS; 2014.[acessado 2015 dez 15]. Disponível em: http://www.paho.org/bra/images/stories/Documentos2/ce154%20tema%204%203%20verso%207%20ago.pdf?ua=1
http://www.paho.org/bra/images/stories/D... .

Member states participating in both of these international forums, one linked to the World Health Organization – World Conference on the social determinants of health, held in Rio de Janeiro, Brazil in October 2011, and the other to the United Nations – the UN Conference on Sustainable Development (UNCSD)/Rio+20, held in Rio de Janeiro, Brazil in July 2012, committed to strengthen their healthcare systems to offer universal and equal healthcare coverage.

Migrating towards universal systems/universal health coverage

Universal Health Systems/Universal Coverage centralize the desires and efforts of many stakeholders and institutions, in particular in the context of initiatives listed by the United Nations following 2015. Healthcare and Universal Coverage are among the eleven priority themes defined by the United Nations General Secretary. The other themes are inequality, education, governance conflict and fragility, growth and employment, environmental sustainability, hunger, nutrition and food security, population dynamics, energy and water. It has been highlighted at a number of forums, among them a structured discussion space provided by the WHO, the United Nations Children’s Fund (UNICEF), UNAIDS/Joint United Nations Program on HIV/AIDS, and the governments of Sweden and Botswana for a global inquiry on health⁶6. World Health Organization WHO (2013). Health in the post-2015 development agenda.Report by the Secretariat. Geneva, 1 May 2013. [acessado 2015 dez 15]. Disponível em: http://apps.who.int/gb/ebwha/pdf_files/WHA66/A66_47-en.pdf
http://apps.who.int/gb/ebwha/pdf_files/W... . There has been very little progress made towards universal coverage based on strengthening universal health systems. This may be due to a focus on individual healthcare, restricting medical care to private insurance, to the detriment to the effective fostering of policies focused on public/collective health, or because they assign to the State the role of promoting individual health, rather than giving equal visibility to its role as a regulator. This is the source of tension and conflict between government regulators and the WHO.

Noronha⁷7. Noronha JC. Cobertura universal de saúde: como misturar conceitos, confundir objetivos, abandonar princípios. Cad Saude Publica 2013; 29(5):847-849. argues that the 2010 WHO Report would be simply a declaratory report, listing a set of good intentions, as has been the case with many other reports, were it not for the fact that it piqued the interest of the more conservative healthcare circles - those that would defend a “service provider market” - in the proposal for “universal coverage” [...]. In fact, recent debates on the topic of pharmaceutical patents and the TRIPS Agreement (Trade-Related Aspects of Intellectual Property Rights), clearly compromise universal access to medicines and other critical healthcare inputs. Furthermore, the public hearing led by the WHO regarding “The Future We Want” reinforces this restrictive position and translates its limits.

On February 18, the WHO General Manager, in an inaugural speech at a meeting with World Bank managers and Ministers of State for Health on “Universal Healthcare Coverage”, clearly expressed that “financial reforms in healthcare are merely one component of the scenario. Citizens have growing expectations regarding health insurance. People expect free access to medicines and services, and demand quality. People want to be cared for by people who care.” Although the WHO recognizes that there is “no universal formula to deliver universal health coverage, and that each country must choose its own path”, when we look at those participating in this forum (WHO managers, members of the World Bank, Ministers and representatives of member states), itis clear that within each member state it is the Ministers of Health “who cares” about the health of the population. One of the core questions each country must address is who is responsible for universal coverage? Who pays the bill? The OMS General Director completed her presentation by mentioning an article by the Lancet about universal health coverage⁸8. World Health Organization DG Speech on UHC (2013).[acessado 2015 dez 15]. Disponível em: http://www.who.int/dg/speeches/2013/universal_health_coverage/en/index.html
http://www.who.int/dg/speeches/2013/univ... . In the foreword of the Latin American version of this journal, the editors point to the fact that the concept is core for the World Health Organization and for numerous governments around the world, and continue to state that universal coverage “is essential for all people, especially for the more vulnerable populations in the North and the South⁹9. International Journal of Cuban Health Medicine. Cobertura Universal de Salud en Latinoamerica. Experiencias compartidas:acelerando el paso hacia la cobertura universal de salud. Lancet 2015; 17(Supl. 1).[acessado 2015 dez 15]. Disponível em: http://www.medicc.org/mediccreview/index.php?issue=33
http://www.medicc.org/mediccreview/index... .

Combining efforts around the post-2015 agendas? How?

In early March 2013, The Lancet published an editorial entitled “Health and the post-2015 development agenda”¹⁰10. Health and the post-2015 development agenda. Lancet 2013; 381(9868):699. [acessado 2015 dez 15]. Disponível em: http://www.lancet.com/journals/lancet/article/PIIS0140-6736(13)60562-0/fulltext
http://www.lancet.com/journals/lancet/ar... , offering a quick analysis of the pros and cons of the MDG, highlighting the simple eight-goal approach, the clarity of the 18 targets and the possibility of measuring and comparing the 48 indicators in the document. The result of this careful strategy is that the MDG agenda has been embraced by all member states and civil society. However, the simplicity of its approach is also its weakness. In narrowing down the goals to a limited number, many elements were left out, notably the rising tide of non-communicable diseases, fostering fragmented initiatives and vertical programs to face them. Still according to this editorial, many MDG targets involve increasing or decreasing by a set proportion the population beyond a certain threshold. Therefore, investments have been channeled towards those individuals nearest the threshold, thus contributing to greater inequity in some areas.

Given the lessons learned from the MDG, and in line with the conceptual simplicity of this global strategy, The Lancet editorial asks the question: how can we bear in mind and include, in the movement around the social determinants of health, a people-centered, not disease-centered, approach, and one that is centered on human rights, with equity at its heart? Based on these strategic themes, how can we create a global program of post-2015 targets?

In the context of a public hearing on universal health Coverage, expressed in the document entitled “Positioning Health in the Post – 2015, Development Agenda – WHO Discussion Paper”¹¹11. World Health Organization WHO (2012). Positioning Health in the Post 2015 Development Agenda. WHO Discussion Paper. (October 2012).[acessado 2015 dez 15]. Disponível em: http://www.who.int/topics/millennium_development_goals/post2015/WHOdiscussionpaper_October2012.pdf
http://www.who.int/topics/millennium_dev... , The Lancet editorial proposed a hierarchy of targets to maximize healthy life expectancy, replacing universal health coverage (UHC), which numerous currents see as a strong candidate for becoming the overarching global healthcare target post-2015.

Claiming that universal health coverage is an approach that does not consider the social determinants of health, which are difficult to measure and compare between countries, and that reflects the health status of a given area only indirectly, the editorial proposes arguments in favor of an approach defended by Cesar Victora et al.¹²12. International Epidemiological Association (IEA). 2014. Victora CG, Buffler P, Ebrahim S, Mandil A, Olsen J, Pearce N, Saracci R. A position paper by the International Epidemiological Association on “Health in the Post-2015 Development Agenda”. [acessado 2015 dez 15]. Disponível em: http://ieaweb.org/position-paper-health-in-the-post-2015-development-agenda/
http://ieaweb.org/position-paper-health-... , as how long people live for is an easily understood concept, which accounts for the multiple determinants of health and disease. Victora was the Chairman of the International Epidemiological Association (IEA) until 2014. The IEA initiative identifies three indicators: survival (including material and infant survival) disease burden (including non-communicable diseases and others not covered by the MDG), and risk factors (smoking and basic sanitation, among others). Universal Health Coverage (UHC) and access to basic healthcare services (such as immunizations and access to medicines) remain the targets through which healthy life expectancy will be achieved. Reduced out-of-pocket expenditure, and strengthened health systems are proposed indicators for this goal, according to the IEA.

Health as a precondition for development

In addition to support progress made and protect the investments to achieve the MDGs, the presence of health in the new post-2015 agenda will address three macro issues: an inconclusive agenda, new challenges and health as part of the development agenda. In the ‘incomplete agenda” we must include equality across countries, populations and programs, or the millennium development goals that have yet to be reached, thus defending the effort for continuity and progress of the current health goals in the MDG, as well as continued political commitment and financial support, and continued national and international investment.

The agenda of challenges includes chronic non-communicable diseases (CNCD), access to all of the services needed and actions that extend to the social, economic and environmental determinants of health, and not just the biomedical causes of disease. One must focus on the “end” as well as the “means”, with themes such as: health as a right, equality, equal opportunities, global agreements on sanitary security, stronger and more resilient healthcare systems, innovation and efficiency regarding financial imitations, economic, social and environmental problems, and multi-sector responses that include health as an outcome of all policies.

Looking at ‘health in the context of sustainable development’, the recommendation is that healthy people contribute more to society, and that healthcare policies contribute to reducing poverty by providing the financial protection inherent to universal coverage. We call attention to how difficult it is to have all of these dimensions reflected in goals or targets. Competition between them would have a negative impact on health. The core question lies in the content linked to this theme in the documents analyzed, and the consistency of universal coverage as the concept of the ‘unified healthcare system’ Brazil has been using for almost 30 years, ever since the Federal Constitution of 1988.

Governance for sustainable development post-2015

In joint effort with the Colombian Government, between 2 and 8 March 2015, CEPAL held the Conference on Sustainable Development in Latin America and the Caribbean in Bogota, to follow up on the agenda for post-2015 development. Hundreds of government and civil society representatives from across the region participated in this forum. Among the many themes discussed were hot to monitor progress of MDG in the region, priority themes post-2015, how to reduce vulnerability (in particular for the small island states in the Caribbean), and more robust governance and financial infrastructure to support sustainable development. In fact, in considering the huge differences between countries in the region in terms of sustainable development, and the multiple and growing incentives by government, private and non-government organization in Latin America and the Caribbean, one must recognize that the theme of shared coordination and management of actions and policies, and the strategies used to fund them, are at the core of creating an agenda that can continue to address the challenges post-2015.

Daring and creative attitudes must be taken by governments in Latin America and the Caribbean along a number of initiatives, such as developing capabilities at all levels to adopt a horizontal governance model, to strengthen the consistency of inter-sector and inter-institutional policies for s, to seek approaches to funding and actions that focus on reducing the huge social inequalities within and between the countries in the region.

For three days, the conference discussed Sustainable Development in Latin America and the Caribbean, and the need to invest in the MDGs became evident, as did the need to be less dependent on the traditional cooperation models and for the countries in the region to continue to pressure multilateral agencies. These international agencies must recognize and consider the differences and unique characteristics of the countries in the region¹³13. Comissão Econômica para a América Latina e o Caribe (CEPAL).Conferencia sobre el Desarrollo Sostenible en América Latina y el Caribe: Seguimiento de la agenda para el desarrollo después de 2015 y Río+20 y el Foro del Caribe: Definición de una Agenda para el Desarrollo Sostenible ante la Realidad de los Países del Caribe en el Siglo XXI, Bogotá – Colombia, 5 a 9 de março de 2013.[acessado 2015 dez 15]. Disponível em: http://www.cepal.org/cgi-bin/getprod.asp?xml=/rio20/noticias/paginas/5/48925/P48925.xml&xsl=/rio20/tpl/p18f-st.xsl&base=/rio20/tpl/top-bottom.xsl
http://www.cepal.org/cgi-bin/getprod.asp... .

In the current scenario of a global movement in defense of universal health coverage, it is not by chance that other sectors cover the area, and the political commitments and strategy to strengthen health institutions around universal access to services and inputs. It is also not by chance that at the recent Caribbean Forum: The “Definition of an agenda for sustainable development” that preceded the Bogota Conference on Sustainable Development for Latin America and the Caribbean, experts and employees from 30 nations in the region completed their work with a commitment in healthcare to “address the multidimensional challenges of communicable and non-communicable diseases in a holistic manner, including through ensuring universal access to primary health care services for promotion, prevention, treatment and rehabilitation”¹⁴14. Comissão Econômica para a América Latina e o Caribe (CEPAL). Foro del Caribe: Definición de una Agenda para el Desarrollo Sostenible ante la Realidad de los Países del Caribe en el Siglo XXI. Conclusiones. Março de 2013. [acessado 2015 dez 15]. Disponível em: http://www.cepal.org/rio20/noticias/paginas/5/48925/2013-158-Rio+20-Definicion_de_una_agenda.pdf
http://www.cepal.org/rio20/noticias/pagi... .

It is well known however, that while health includes guaranteed universal access to medical-sanitary care, it is not limited to this. Health policies require concrete actions on the social determinants of health, and firm measures regarding factors that affect the quality of life of populations. To this end, the March 2013 forum made recommendations that have had a direct impact and require short and long term changes.

Public health policies are essentially inter-sectoral policies. The international financial crisis of 2008, made worse by a shortage of foods, the energy crisis and global warning, stressed old problems and revealed new challenges of growing intensity and complexity. Today there is not a single nation that can ensure healthcare for all its citizens and face all of its determinants without daring integration across government sectors.

In Brazil, despite the emergence of numerous tragic episodes of corruption and an almost all-encompassing crisis, the perspective of social mobility associated with wealth distribution, job creation and income policies suggest a scenario that is a challenge to the former paradox of economic growth and social development. How to design a healthcare policy that fulfills the values of the Brazilian Constitution and the Organic Health Law in a situation, where a significant portion of the population still lives below the poverty line? How to ensure good Health and Education policies, internationally considered low politics, as opposed to the security of high politics military spending, when in situations of budget shrinkage it is the former that are cut first?¹⁵15. Matida A. Arroz, feijão, saúde, educação: política Pública de Saúde no Brasil. Cien Saude Colet 2011; 16(3):1668-1668.

The challenges to build a new horizontal, inclusive and participative governance model require strong and sovereign States. It is urgent to organize a parliament that is transparent and committed to the sovereignty and quality of life of those it represents. The basic guidelines and overall strategies should originate in the government decision makers. The great debates between the public and private must always focus on reducing inequality, protecting citizen quality of life and promoting sustainable development. Inter-sector and inter-institutional policies involving the environment, migratory flows, trade in general, investments, the generation of jobs and income, education, health, sanitation, agriculture, and urban planning require a State that plays its role as incentivize, service provider and regulator. Furthermore, a cooperative and supportive private sector and intense and continued involvement of civil society are also required.

Conclusion

Based on our discussion of governance for health and sustainable development, one must recognize important progress made in the documents submitted to the WHO Executive Board (EB) and the website, in particular paragraphs 13 to 16 of document EB 132/12¹⁶16. World Health Organization. El consejo ejecutivo (2013). Monitoreo del Logro de los Objetivos de Desarrollo del Milenio relacionados con la Salud. [acessado 2015 dez 15]. Disponível em: http://apps.who.int/gb/ebwha/pdf_files/EB132/B132_12-sp.pdf
http://apps.who.int/gb/ebwha/pdf_files/E... , which state that: Programs to foster world health are undergoing a transformation that will influence how development priorities will be defined going forward, and work on this topic must include the social, economic and environmental determinants of health, and not be limited solely to the biomedical causes of disease.

Universal coverage is just one of the dimensions of universal systems, that also include at least ‘full service’ (all of the services required to meet all of the needs of the population at the right time), ‘equality’ (equal access for all), and ‘quality’. In fact, limiting the concept to universal coverage does not ensure the right to comprehensive, equal and quality care.

“The proposal of ‘ensuring’ as a strategy to fund healthcare included in the WHO document, especially when it mentions that The goal of universal health coverage [...] it has two interrelated components: coverage with needed health services (prevention, promotion, treatment and rehabilitation) and coverage with financial risk protection, for everyone. Thus, the WHO focuses universality on medical care and the risk of catastrophic spending. In Brazil, although the existence of supplemental care is acknowledged, health is a constitutional ‘right’ and a ‘duty of the state’. The document goes on, stating that: It is not about a fixed minimum package but making progress on several fronts: the range of services that are available to people; the proportion of the costs of those services that are covered; and the proportion of the population that is covered¹⁶16. World Health Organization. El consejo ejecutivo (2013). Monitoreo del Logro de los Objetivos de Desarrollo del Milenio relacionados con la Salud. [acessado 2015 dez 15]. Disponível em: http://apps.who.int/gb/ebwha/pdf_files/EB132/B132_12-sp.pdf
http://apps.who.int/gb/ebwha/pdf_files/E... .

In a version centered on individual and curative attention, rather than on collective attention and public health, the World Health Organization over-stresses individual care. Therefore, while recognizing the importance of this component to comprehensive care, we must insist on the matter of public health, in particular in its regulatory function, which the document in question appears to explicitly avoid, given that it is in this function of public care where there are conflicts with other United Nations agencies such as the WTO, in particular regarding pharmaceutical patents, and the TRIPS agreement (Trade-Related Aspects of Intellectual Property Rights), known to inhibit universal access to drugs and other critical health inputs. It is in the face of this reality and with these challenges and tensions that a global agenda, common for all, would be extremely appropriate and translate into an invitation to defend life.

Acknowledgments

To Dr. Maria Cecilia Minayo, Chief Editor of the journal Science and Public Health, by the stimulation and attention given to this article.

References

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