Ilona Kickbusch: Health is a political choice—but health for whom?

As health gets more political, the work of the WHO becomes more important

The WHO constitution states that health is the social responsibility of governments and that health is a right that people should have access to irrespective of other considerations. At the recent WHO Regional Committee for Europe meeting (RC67) held in Budapest, both the regional director Zsuzsanna Jakab and the recently elected Director General of the organisation, Tedros Adhanom Ghebreyesus, made one point repeatedly: health is a political choice.

As if to illustrate this three high level politicians came to address the delegates. The prime minister of Hungary, Viktor Orbán, opened the meeting, and the prime minister of Greece, Alexis Tsipras, and the deputy prime minister of Turkey, Recep Akdağ (who has previously served as health minister), contributed political speeches during the course of the meeting. They underlined the high relevance of health and described the political choices that their governments had made for health and health services. Their presentations showed clearly how far apart their political positions were—from a political choice that implied that health was available only to “our own nation” to one that ensured that healthcare is also accessible to migrants and refugees, giving access to all those that are vulnerable and need care.   

In a recent BMJ Opinion piece, Martin McKee gave a very optimistic and positive report of the RC67. He spoke of bridges and positive connections there for all to see—this reflects the best of the work of WHO, when it can achieve that, and the Regional Director must be congratulated. The new DG conveyed a new energy and determination that will help reposition WHO in the global landscape. But it is also important to take into account the undercurrents which can move in a different direction from the surface.

There was great nervousness from the organizers and delegates on how these three senior politicians would handle the big elephant in the room: migration. Just consider the differences:

  • Hungary, an EU country defying a European agreement and forcefully protecting its borders against refugees;
  • Turkey, a country that has taken in at least 3 million Syrians, but has also in the past acted as a spearhead for their journey to Greece. Now it has a widely challenged agreement with the EU to create a buffer zone;
  • Greece, a country that has been forced to take on the refugee burden (like Italy) by default of being an EU external border state and now has about 60 000 refugees stranded on its islands and throughout the country.

All of this relates to political choices for health. Alexis Tsipras spoke about the dilemma of having to make a political choice between “solidarity, dignity and international law” and “protecting only our own nation.” He pronounced that choosing the first was fulfilling the commitment to the founding principles of the European Union and the “only path to Europe’s future.” Viktor Orbán on the other hand spoke about the need “to defend our freedom against imperial efforts” by which he meant precisely the European Union whose values Tsipras said he was defending.

The approach to migration is one of the political choices for Europe as it fights for its future and identity. Solidarity for health will continue to be a central feature, within and between countries, for national populations, migrant, and refugees. With this fundamental challenge many other achievements move into the background. Orban rightly drew attention to the implementation of many national programmes to protect health such as raising taxes on unhealthy products and expanding screening programmes. Akdağ highlighted progress in tobacco control and universal health coverage, and Tsipras highlighted achievements made in getting the Greek health service back on track following recent austerity.

Throughout WHO’s history member states have been divided on the extent of government responsibility for health and on matters of the human right to health. This was an issue when negotiating the WHO constitution and it was constantly present during the cold war when attempts to make universal health coverage the norm were branded as “socialist”. The Alma Ata Declaration in 1978 was a rare achievement to overcome that divide. At first instance it might seem that all of this must be easier in the European Region of the WHO. On average the European member states will be more committed to the role of governments in ensuring universal health coverage than countries in some other WHO regions—the ongoing political fights over access to care in the USA are the most visible case in point.

But even in the EU recent developments related to austerity politics, financial demands on health systems, and pressure from private sector interests have made access to health more uneven and difficult for the vulnerable. And for many of the European Region member states outside of the European Union, the fiscal pressures are similar if not worse. On some issues it requires difficult negotiations to reach at least a minimal consensus between the 54 highly diverse member states. Besides the political division on the health rights of migrants and refugees, there is also disagreement on the sexual and reproductive health and rights” (SRHR) agenda, the right to health of people with different sexual orientation (LGTB) and the unwillingness to address the commercial determinants of health. As health gets more political, the work of the WHO becomes all the more important. The Regional Office’s work on migration and health is a case in point.   

Will it become easier or more difficult to manage the governance of the WHO in this new environment? To some extent this was difficult to judge at RC67 because there were no really contentious issues on the agenda and no discussions on the presentations from the various heads of government. There was strong agreement on moving forward with the implementation of the Sustainable Development Agenda 2030 and to work much more with other sectors and stakeholders. The Regional Director concluded: “Our message is reaching further and higher.”

Yet the undercurrents are swirling in the deep. Orban made clear that he would not allow any organisation to challenge Hungary’s sovereignty, a statement clearly directed towards the EU and possibly other parts of the multilateral system that stand for “globalism”. He explicitly excluded WHO, which he deemed helpful and supportive in the attempts to improve the health of the Hungarian population: “Whatever we think of sovereignty, WHO will always be needed,” he said. The important role of WHO in supporting both Greece and Turkey was also highlighted by the political leaders.

For the WHO leaders and for the UN system as a whole this is a critical message—these leaders agree that WHO delivers. But the changing geopolitical situation and the political shift in many countries of the European Region will require that WHO pays close attention to the political undercurrents and navigates them skilfully for the benefit of health for all.

Ilona Kickbusch is director of Global Health Centre, Graduate Institute for International and Development Studies, Geneva, Switzerland.

Competing interests: IK attended the Regional Committee as an advisor to the World Health Organisation.