Global Health & Human Security In 2012 and Beyond
The strengthening of response preparedness for global health threats has gained increasing attention on both public health and security agendas. Since the end of the Cold War, a majority of new wars have taken place within, rather than among, nation states and it has become increasingly clear that people cannot be protected solely through military defense of national borders. Similarly, an improved understanding of human development has highlighted numerous neglected insecurities that are faced daily by poor and marginalized individuals and communities. Increased globalization has also generated new risks and vulnerabilities, not only for those in developing nations, but for all, in a growing and ever more interconnected world.
The human security framework offers a novel approach for addressing various global issues, including global public health, that have stemmed from an imbalanced focus on economic development alone. It enables the development of people-centred initiatives, sound policy formulation and implementation, and a solid basis for international co-operation and multi-sectoral partnerships. Besides highlighting the problem of resources, this article also examines some of the issues and challenges that states and societies face as they respond to the multiplicity of problems related to global public health and human security.
Globally, over the past 30 years, three major trends have provided context for the re-emergence of the human security concept. These are: (i) new types of conflict; (ii) poverty; and (iii) rapidly increasing globalization. As a result, the scope of the security field has expanded from a narrow 20th century emphasis on national interests and inter-state conflict, to a broader ‘global’ focus of securing the well-being of individuals and communities.
Human security is seen to complement state security, enhance human rights and strengthen human development, seeking both to protect people against a wide range of threats and to empower them to act on their own behalf. Although the human security and human rights frameworks share a common value-base, the latter, whilst largely accepted, has lacked political power. Similarly, while human security and human development are linked, they are not synonymous; human development is a broader concept, defined as a process of ‘widening the range of people’s choices’; whilst human security means that people can ‘exercise these choices safely and freely’.
With evident roots in Enlightenment that can be traced as far back as the 18th and 19th centuries, if not earlier, the human security concept is not a historical anomaly. Conversely, an excessive narrowing of security thinking occurred during the course of the 20th century, linked perhaps to the extremely violent nature of the century and its ‘deep addiction to war’.
With an increasing worldwide recognition of the political, economic, technological, social and environmental interdependence among nations, and the inter-linkages among the world’s people, the human security approach provides scope for stronger integrated responses, by fostering both global and local identities. It promotes increased collaborations with international and multilateral organizations and, rather than simply relying on the nation state, human security calls for combined, holistic action by all sectors of society, although obligations among them vary.
is seen to
human rights and
seeking both to
against a wide
range of threats
and to empower
them to act on
their own behalf
Furthermore, while the state remains the primary producer of security, it is not a primary referent – power becomes re-distributed upwards and downwards from the sovereign state level. This is most clearly visualized by an exponential growth in civil society organizations and a monumental rise of trans-national companies and organizations, such as the World Bank, as well as regional development banks and organizations.
Although it has its shortcomings, human security, due to its comprehensive nature, is well equipped to capture the importance of addressing salient public health issues in today’s world. Health is a fundamental right of every human being and improving health globally is a key element of any strategy aimed at combating poverty and promoting development, as evidenced by its central focus in five out of the eight Millennium Development Goals (MDGs). Good health is also an intrinsic component of human security, and an instrumental tool for human security, by enabling a fuller range of human functioning, choice, freedom and equitable development.
While a common definition of global public health security may still be lacking, for those who understand it as it is presented in the United Nations Development Programme’s 1994 Human Development Report, the concept is compatible with a primary healthcare approach, emphasizing community involvement, self-sufficiency and protection of vulnerable groups such as pregnant women and the poor.
Strengthening Health Systems
Functioning health systems are the bedrock of global public health security. Their objective is to provide the highest level of health protection and healthcare across the population and to act as the first line of disease surveillance, for both infectious and chronic diseases. However, health systems can become rapidly overwhelmed. Additionally, more often than not, the power of modern health interventions, tools and technologies is simply not matched by the power of local systems to deliver services to those in greatest need, in a comprehensive way and on an adequate scale. Health systems are highly context-specific, and hence there is no single set of best practices that can be put forward as a model for best performance. However, they can be studied in terms of how they are regulated, governed and funded, and how services are provided, accessed and utilised.
Weak health systems disproportionately impact the poor, as they are given less respect, less access to information, less choice of providers and lower quality amenities. Indeed, a lack of access to healthcare, as well as disparities in quality of care provided, magnify social divides between males and females, rich and poor families, urban and rural areas, and indigenous and non-indigenous peoples and, by extension, ensure the continued impoverishment of those who are denied health services.
Factors contributing to weak health systems include a lack of resources and poor health infrastructure, resulting from under-investment or because the existing infrastructure has been damaged or destroyed by armed conflict or natural disasters. In addition to financial limitations, health system constraints such as shortage of health workers and support staff, and weak supply-chain management, significantly hamper the implementation and expansion of health interventions.
For example, there is presently an estimated shortage of 4.3 million doctors, midwives, nurses and health support staff worldwide. Other major challenges include inadequate payment, motivation, training and supervision, as well as poor working environments. Furthermore, while appropriate local health information and data often do exist, they are often not utilized by policy makers or policy analysts, either because they do not have access to the information or because the appropriate data has not been used to answer important questions about health system performance.
Health system strengthening is a long-term continuous process of implementing effective changes in policies and management within the health sector. It requires both technical and political knowledge, and sustained action. While a majority of the now-developed countries built up universal services from a patchwork of public, private for-profit and charitable providers, this challenge now exists for many developing countries. The urgency of this matter is apparent, since the effectiveness of international collaborations, partnerships and networks, whose role it is to identify and respond to disease outbreaks in the coming decades, depends on the alertness and response capacities of the weakest health systems.
The 4 Es: Efficiency, Effectiveness, Equity and Evaluation
Recent studies have indicated that reducing bureaucracy by streamlining management, increasing cost-effectiveness, and improving efficiency through re-organizing services, decentralizing, and allocating resources to better address the needs of the population, result in sustainable strengthening of a health system.
Vast improvement can be achieved by introducing standards, norms, accountability and transparency, through international health law, ensuring rapid public-private responses, and sharing and translation of available knowledge. Apart from increased international and regional cooperation, it is essential that strengthening health systems also includes better targeting for budget allocation – available resources are not always optimally allocated, as funds tend to be directed to high-tech and high-cost curative services that benefit a select few in urban areas.
Similarly, for the human elements of capacity building, key constraints related to health worker staffing, quality control, infrastructure and logistics must be addressed, including ensuring high standards of safety, comprehensive bio-risk management and expanded health worker training. From the technical and operational angles the focus must also extend to laboratory infrastructure, technology/equipment use and maintenance, bio-specimen storage and transport and access to reference strains for specific diseases.
Global Health as a Global Public Good
Research is a critical part of any effort to improve global public health. Local research capacity strengthening is indeed a vital tool in developing local ownership and improving long-term sustainability of any health project. Biomedical and technological innovations cannot improve people’s health without research to find out how to apply the new products and technologies within diverse political, social, economic and environmental contexts. There is also a need to undertake research on social interventions aimed at improving public health – for example, those aimed at housing, welfare, employment, fiscal, transport and other policies and interventions – forming part of the cross-disciplinary fields of political epidemiology and social epidemiology. Moreover, functioning local health systems require good communication and transportation networks.
Research for health can make a major contribution to global public health security and, more generally, to global development agendas. Evidence-informed health policy that will maximize the synergies between research and policy is dependent upon generating improved ways of priority setting, as well as advances in problem-based planning and resource allocation. In moving forward, evaluation of existing health systems is an important step toward identifying capabilities, critical gaps, and areas where local, national and international priorities overlap. It is vital for countries to now move beyond pure rhetoric, and to participate more fully and more seriously in the principle of a global public health security regime – the One World & One Health – utilising a global public goods (GPGs) approach.
With the goal of human
security in mind, the
global community is
now faced with novel
opportunities, as well as
challenges, in moving
beyond the health
securitisation rhetoric to
improving health for all
A GPG is defined as having non-excludable, non-rival benefits that cut across borders, generations and populations. Each nation’s capacity to prevent and manage public health emergencies, and to take part in joint initiatives with other countries, is vital to decreasing health vulnerabilities, increasing health security, broadening partnerships and building diplomatic relations. A global approach takes into account that diseases do not recognize national boundaries and as a result policies and some interventions need also transcend political borders.
Treating public health as a GPG implies that society must ensure that the value of health is understood as a key dimension of global citizenship and keep it high on the global political agenda, as the provision of global public goods should have priority over national and sector-specific interests. Hence, there is a need to build and maintain a sense of global community, commitment and partnership. Indeed, approaching public health security within a context of collective global solidarity enhances the security of all. Global public health efforts are likely to flounder unless, and until, nation states cooperate in combining their national interests with a more inclusive GPGs approach, in order to provide more efficient and sustainable policies and strategies.
A Framework for the Future
Recently there have been new attempts to embark on a debate as to which values should drive global public health action. These values are reflected in discussions around the impact of globalization, human rights, global public goods, global solidarity and global social contracts. Whilst connecting health more directly to the self-interests of states in security, economic well-being and development has been a necessary starting point, it is not a sufficient step along the road to greater global public health security.
The global public health security concept may provide a new way of working collaboratively and sustainably towards a common goal, embracing human rights and well-being, rather than only enlightened national self-interest. With the goal of human security in mind, the global community is now faced with novel opportunities, as well as challenges, in moving beyond the health securitization rhetoric to improving health for all. There is now a unique opportunity to build upon and strengthen existing health systems using a human security framework, in order to improve the organization, resource management, technical guidance, monitoring, evaluation, capacity and overall mechanics of health care. This is ultimately where the key challenge exists – from establishing the global public health security framework to operationalizing it.
Julie Balen is a Junior Research Fellow at the Institute for Global Health Innovation, Imperial College London.