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Accountability for global health efforts that are NOT being made Gorik Ooms Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium   MacMillan Center for International and Area Studies at Yale, USA   May 2010
 
1. Are governments of poor countries accountable for potential domestic resources they are NOT spending on health? If so, to whom?  2. Are the International Monetary Fund (IMF) and the World Bank accountable for policies that are based on mutual NON-responsibility between states for global health? If so, to whom? 3. Are governments of rich countries accountable for the potential financial resources they are NOT allocating to international health aid? If so, to whom? 4. Challenges for mutual accountability, if we accept that responsibility for health is both national and international
Are governments of poor countries accountable for potential domestic resources they are NOT spending on health? If so, to whom?

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1. The document discusses the current state of the world and need for change, outlining two potential futures - a chaotic "Military World State" or an "Intelligent World" based on intelligence, innovation, integration and prosperity. 2. It describes the many crises facing the current unsustainable world and argues that a comprehensive transformation is needed to a smarter world prioritizing knowledge, innovation and technology. 3. A vision is outlined for creating an "Intelligent World" through building intelligent communities and digital infrastructures, guided by sustainability and innovation across society. Major technology companies are promoting concepts like smarter planets and smart connected communities to model and structure the future world.

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The document criticizes the U.S. medical system as being the most ineffective, unjust, inequitable and unethical among wealthy nations. It argues that the 2009 health reforms made the system worse. It provides examples showing racial and socioeconomic disparities in access to healthcare and health outcomes. It also discusses issues like the high costs of the system, medical bankruptcy, and how viewing patients as consumers is problematic.

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This document summarizes a report by the UN Special Rapporteur on extreme poverty and human rights. It finds that claims of impending eradication of extreme poverty are exaggerated and rely too heavily on flawed measures like the World Bank's international poverty line. In reality, billions still live in poverty without adequate standards of living. It argues the Sustainable Development Goals are failing on key issues like poverty, inequality, and climate change. To eliminate poverty, it says we must rethink the relationship between growth and poverty reduction, tackle inequality through redistribution, implement universal social protection, and center the role of government.

Possible answers: They are accountable to their inhabitants, because these all have a right to health, and it’s the government’s responsibility to realize that right; They are accountable to governments of donor countries, because it is just not fair to ask for aid, and then reduce domestic resources; They are accountable to inhabitants of other countries because poor health fuels epidemics (and they spill over), and poor health fuels unhappiness and ‘grunge’ (and that spills over too…)
Are the IMF and the World Bank accountable for policies that are based on mutual NON-responsibility between states for global health? What is mutual NON-responsibility between states for global health? What do the IMF and the World Bank have to do with this? To whom are the IMF and the World Bank accountable?
A few words about mutual NON-responsibility The February 2000 floods in southern Mozambique were so predictable that MSF created a base with rescue team and rubber boat in Chowke, three days before the city was flooded; During the days before the floods, MSF could not find funding for this rubber boat (US$ 2000 to buy it); During the days after the floods, donors were stumbling over each other to finance helicopters for MSF operations (US$ 2000 to rent it for an hour). The days before: no crisis  ->  ‘sustainable’ solutions (rich countries do not feel responsible) The days after: crisis  ->  ‘sustainability’ no longer matters (rich countries are willing to pay, because it is only for a while; a temporary solution for a temporary crisis)
 

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The document discusses strategies for poverty reduction in Indonesia, noting that prior to the 1997/98 Asian financial crisis, Indonesia had seen significant reductions in poverty through rapid economic growth coupled with investments in social infrastructure, agriculture, and rural development. However, the crisis severely impacted poverty levels. The document examines post-crisis poverty reduction programs and efforts to promote more equitable development across regions in Indonesia.

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Wider determinants of health include community empowerment and anti-poverty measures. There are different perspectives on health: as a right, consumption good, or investment. Health as a right involves government responsibility to ensure access and equity. As a consumption good, health is a personal objective not requiring special government responsibilities. As an investment, health affects workforce productivity. Development encompasses improving standards of living and expanding economic and social opportunities. It differs from economic growth, which is a quantitative increase, by transforming society for better well-being. Health plays a key role in development by increasing productivity.

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Foreign aid can contribute to economic growth by increasing investment, imports of capital goods, and human capital development. However, aid can also fuel conflict by being stolen or appropriated by governments and militias to support warring factions. Pakistan is cited as an example - despite receiving over $100 billion in aid over decades, it has not experienced reduced conflict or improved development outcomes. The effectiveness of aid depends on factors like governance and policies in the receiving country.

More contradictions… After the floods, many families were left without food reserves  -> food distributions ; Food distributions are never perfect, always some households are left out  -> malnourished kids -> therapeutic feeding center; Some kids did not get better, they were malnourished not because of the floods, but because of AIDS, and chronic diarrhea; AIDS treatment for these kids would have cost US$ 2000 for 10 years (same kids were rescued at US$ 2000 per hour)... Helicopters: Yes! Antiretroviral medicines? No!
So how did AIDS treatment get started then? As an emergency response!
Different concepts of sustainability: Ann Veneman, executive director of UNICEF, about interventions to address child mortality:  “These plans and budgets should emphasise the continuum of care from maternal to neonatal to child survival. But they should also ensure that interventions are prioritised and phased in according to the ability of both the health system to deliver them at scale, and  of governments to afford them and to sustain them in the longer term .” The World Health Report 2008 of the WHO:  “In a significant number of these low-expenditure, low-growth health economies, particularly in sub-Saharan Africa and fragile states, the steep increase in external funds directed towards health through bilateral channels or through the new generation of global financing instruments has boosted the vitality of the health sector. These external funds need to be progressively re-channelled in ways that help build institutional capacity  towards a longer-term goal of self-sustaining , universal coverage.”
Different concepts of sustainability: The World Bank’s ‘Health Financing Revisited: A Practitioner’s Guide’:  “Although the practical definition of fiscal sustainability may change for programs supported by the IMF and IDA, it is extremely unlikely that such definitions will be divorced from a country’s capacity to accommodate expenditures financed with aid  within the domestic budget constraint in a reasonable period of time , while maintaining sustainable levels of debt to GDP and debt service to exports.” Michel Kazatchkine, executive director of the Global Fund to fight AIDS, Tuberculosis and Malaria:  “The Global Fund has helped to change the development paradigm by introducing a new concept of sustainability. One that is not based solely on achieving domestic self-reliance but on sustained international support as well.”

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This testimony argues that funding international health and development programs is crucial for national security. It notes that diseases like HIV/AIDS and drug-resistant tuberculosis already cost the US health system greatly. It argues that reducing poverty and improving health globally through programs like those funded by USAID and UNICEF is far cheaper than dealing with disease outbreaks after they reach the US. Investing in these programs aligns with constitutional duties to provide for the common defense and general welfare.

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This document discusses how globalization has contributed to the immiserization (increasing misery and poverty) of African countries in two key ways: 1. Accelerated economic liberalization policies imposed by international financial institutions in response to debt crises have reduced the ability of African governments to intervene in their economies and allocate resources to development programs. 2. African countries have been marginalized in the global economy, recording stagnating or declining GDP per capita in contrast to growth in wealthier nations. Poverty levels have risen substantially in Africa while falling elsewhere in the developing world. The document argues that globalization has undermined the policy autonomy of African nations and exacerbated poverty, contradicting the promise of shared

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The Least Developed Countries Report 2011 puts forward a policy framework for enhancing the development impact of South–South cooperation, and proposes ways to leverage South–South financial cooperation for development in the LDCs.

So what do the IMF and the World Bank have to do with this? Peter Piot, former executive director of UNAIDS, during a speech at the World Bank: “ ...when I hear that countries are choosing to comply with medium-term expenditure ceilings at the expense of adequately funding AIDS programmes, it strikes me that someone isn’t looking hard enough for sound alternatives...  For countries emerging from conflict, the Bank has pioneered a careful programme of exceptions, running a calculated risk on the grounds that inaction would be riskier still. Let us now do something similar for AIDS, a risk far greater than conflict for many countries.”
 
Catch 22 Rich countries are reluctant to take long term responsibility for health in poor countries… IMF and World Bank assume that international aid for health is not reliable, therefore fiscal space is limited… Poor countries are discouraged from using all the available aid to increase expenditure, but they will not refuse the aid, they would rather decrease their domestic contribution… Rich countries find out that ‘aid does not work’, so they discontinue, or try yet another approach… IMF and World Bank are right to assume that international aid for health is not reliable…
To whom are the IMF and the World Bank accountable? Branko Milanovic, a World Bank economist:  “ Global bodies tend to be either irrelevant if representative, or if relevant, to be dominated by the rich.  A stark example of the latter situation is provided by the quota and the voting rights enjoyed by member countries of the IMF. There, as well as in the World Bank, votes do not follow either what may be deemed a truly global  one person = one vote  formula, or the international formula of  one country = one vote  (as, for example, in the United Nations General Assembly). The voting rights match rather closely the  one dollar = one vote  rule.”

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The Refugee Responsibility and Sustainability Index was created as part of my Personal Project at Lincoln Community School. This index asses the responsibility level of a country towards tackling refugee crises in three parts: One, whether or not a country has a responsibility to absorb and resettle refugees within their territories; Two whether or not a country has a responsibility to increase its contribution to humanitarian aid efforts; and Three the amount of overall contribution a country should make to help tackle any refugee crisis. To accurately and objectively measure this, parameters such as GDP Per-Capita, Natives per refugee, humanitarian aid given, and poverty rate amongst others have been taken into consideration. Made in collaboration with Mr. Stephan Anagnost (Mr. A)

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This document discusses the impact of crises on social programs and poverty. It notes that the current global economic crisis has led to a sharp decline in global GDP growth and industrial production in Turkey. Crises particularly hurt the poor, who have limited resources and coping abilities. An estimated 90 million more people will fall into extreme poverty by 2010 due to the crisis. The document also discusses lessons from previous crises, highlighting the need to anticipate social impacts and protect vulnerable groups from the early stages of crisis response. Effective crisis responses have been rapid, sizable, and focused on social safety nets and pro-poor policies.

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Are governments of rich countries accountable for financial resources they are NOT spending on international health aid?  Public health expenditure in G8 countries (2006) Total (% of GDP) Public (% of total) Canada 10.0% x 70.4% = 7.0% of GDP France 11.0% x 79.9% = 8.8% of GDP Germany 10.6% x 76.9% = 8.2% of GDP Italy  9.0% x 77.2% = 6.9% of GDP Japan  8.1% x 81.3% = 6.6% of GDP Russia  5.3% x 63.2% = 3.3% of GDP UK  8.2% x 87.3% = 7.1% of GDP USA 15.3% x 45.8% = 7.0% of GDP International aid for health? 0.03% of GDP
Remember one possible answer to the question about governments of poor countries being accountable to for the potential domestic resources they are not spending on health:  “They are accountable to inhabitants of other countries because poor health fuels epidemics (and they spill over), and poor health fuels unhappiness and ‘grunge’ (and that spills over too…)” If you agreed with that, would you agree that governments of rich countries are accountable  to their own inhabitants , for the epidemics they are not stopping elsewhere, and for the ‘grunge’ they are not ending elsewhere?
Reasons for international ‘grunge’ It requires very (very) little efforts from rich countries, to make a huge (huge) difference in poor countries There is something wrong with the politics of  globalization: Our world view for primary distribution of wealth is a global one, without state borders (the ‘global free market’) Our world view for secondary redistribution of wealth is globe composed of states, with clear state borders (national ‘social protection’)
Low-income countries: one billion people, with an average Gross Domestic Product (GDP) of US$565 per year. If they can spend US$3 out of every US$100 on health, that makes US$17 per person per year.  High-income countries: one billion people with an average GDP of US$43,000 per year. If they could spend US$0.13 out of every US$100 on international aid for health, that would make US$56 per person per year.

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SAHARO works without regard to creed, race, gender, or ethnicity, and is one of the reputed humanitarian networks. SAHARO provides a beacon of hope for thousands of women, men and children in times of hardship and contributes to the development of social justice in times of peace. Saharo’ mandate includes integral development, emergency relief, advocacy, peace building, respect for human rights and support for proper stewardship of the planet’s environment and resources. The SAHARO approach is based on the social teaching, which focuses on the dignity of the human person. Saharo’ work on behalf of the poor manifests God’s love for all of creation. SAHARO believes that the weak and oppressed are not objects of pity, but agents of change leading the struggle to eradicate dehumanizing poverty, unacceptable living and working conditions, and unjust social, political, economic and cultural structures. What makes SAHARO unique is its ongoing presence in communities, before, during and after crisis situations. Important, too, is that being part of civil society and incorporating the perspective of the poor, Saharo can continuously adapt its strategies to an ever changing environment. SAHARO fights poverty, exclusion, intolerance and discrimination. More importantly, it empowers people to participate fully in all matters affecting their lives, and it advocates on their behalf at national and international forums. SAHARO promotes partnership: local autonomy is paramount in ensuring effective teamwork for the good of all. By pooling expertise and resources, SAHARO is able to identify issues at the grassroots, analyze them at national and international levels, and then take action locally, regionally and globally

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The problem with two very different superimposed world views, one global (free market), one national (social protection); based on the economic theory of Gunnar Myrdal: A free market does not evolve towards equilibrium, but away from equilibrium Economic growth centers (families, clans, cities, regions) invest their gains in more comparative advantages Economic growth centers continue to ‘win’ the competition, and attract human skills and capital from elsewhere, a self-amplifying dynamic The government needs to intervene constantly, impose taxes and invest them in social protection, to create equal opportunity But what if the self-amplifying dynamic happens at the global level, and the correction at the national level?
 
Mahboob Mahmood, quoted by Kishore Mahbubani, in ‘Beyond the age of innocence: rebuilding trust between America and the World’: “ The central promise of militant Islam is creation of a just society. The importance of the notion of justice in Islamic societies cannot be overemphasized—in these societies, freedom, democracy and rule of law are weak memes—but justice is a strong meme. The delivery of justice is and has always be the kernel of Islamic socio-political thought. Up to today, militant Islam has succeeded by emphasizing the injustice of the prevailing order—… A good policy will only succeed if it is capable of addressing and defeating militant Islam on the grounds of its central promise and its ultimate incapability—the creation of a just society.”
Thomas Pogge: “ Responsibility for a person’s human rights falls on  all and only those  who participate with this person in the  same social system .  It is their responsibility, collectively, to structure this system so that all its participants have secure access to the objects of their human rights.”  What is the social system we want to promote? The family, the city, the nation, the state, the globe? Or a combination?

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Challenges for mutual accountability, if we accept that responsibility for health is both national and international There is no global government… Can we agree, by convention (respecting state sovereignty) on minimum domestic efforts? Can we agree, by convention, on burden sharing between all rich countries? Can we agree, by convention, on some kind of institution that oversees and coordinates both?

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Global Responsibilities for Health Care

  • 1. Accountability for global health efforts that are NOT being made Gorik Ooms Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium MacMillan Center for International and Area Studies at Yale, USA May 2010
  • 2.  
  • 3. 1. Are governments of poor countries accountable for potential domestic resources they are NOT spending on health? If so, to whom? 2. Are the International Monetary Fund (IMF) and the World Bank accountable for policies that are based on mutual NON-responsibility between states for global health? If so, to whom? 3. Are governments of rich countries accountable for the potential financial resources they are NOT allocating to international health aid? If so, to whom? 4. Challenges for mutual accountability, if we accept that responsibility for health is both national and international
  • 4. Are governments of poor countries accountable for potential domestic resources they are NOT spending on health? If so, to whom?
  • 5. Possible answers: They are accountable to their inhabitants, because these all have a right to health, and it’s the government’s responsibility to realize that right; They are accountable to governments of donor countries, because it is just not fair to ask for aid, and then reduce domestic resources; They are accountable to inhabitants of other countries because poor health fuels epidemics (and they spill over), and poor health fuels unhappiness and ‘grunge’ (and that spills over too…)
  • 6. Are the IMF and the World Bank accountable for policies that are based on mutual NON-responsibility between states for global health? What is mutual NON-responsibility between states for global health? What do the IMF and the World Bank have to do with this? To whom are the IMF and the World Bank accountable?
  • 7. A few words about mutual NON-responsibility The February 2000 floods in southern Mozambique were so predictable that MSF created a base with rescue team and rubber boat in Chowke, three days before the city was flooded; During the days before the floods, MSF could not find funding for this rubber boat (US$ 2000 to buy it); During the days after the floods, donors were stumbling over each other to finance helicopters for MSF operations (US$ 2000 to rent it for an hour). The days before: no crisis -> ‘sustainable’ solutions (rich countries do not feel responsible) The days after: crisis -> ‘sustainability’ no longer matters (rich countries are willing to pay, because it is only for a while; a temporary solution for a temporary crisis)
  • 8.  
  • 9. More contradictions… After the floods, many families were left without food reserves -> food distributions ; Food distributions are never perfect, always some households are left out -> malnourished kids -> therapeutic feeding center; Some kids did not get better, they were malnourished not because of the floods, but because of AIDS, and chronic diarrhea; AIDS treatment for these kids would have cost US$ 2000 for 10 years (same kids were rescued at US$ 2000 per hour)... Helicopters: Yes! Antiretroviral medicines? No!
  • 10. So how did AIDS treatment get started then? As an emergency response!
  • 11. Different concepts of sustainability: Ann Veneman, executive director of UNICEF, about interventions to address child mortality: “These plans and budgets should emphasise the continuum of care from maternal to neonatal to child survival. But they should also ensure that interventions are prioritised and phased in according to the ability of both the health system to deliver them at scale, and of governments to afford them and to sustain them in the longer term .” The World Health Report 2008 of the WHO: “In a significant number of these low-expenditure, low-growth health economies, particularly in sub-Saharan Africa and fragile states, the steep increase in external funds directed towards health through bilateral channels or through the new generation of global financing instruments has boosted the vitality of the health sector. These external funds need to be progressively re-channelled in ways that help build institutional capacity towards a longer-term goal of self-sustaining , universal coverage.”
  • 12. Different concepts of sustainability: The World Bank’s ‘Health Financing Revisited: A Practitioner’s Guide’: “Although the practical definition of fiscal sustainability may change for programs supported by the IMF and IDA, it is extremely unlikely that such definitions will be divorced from a country’s capacity to accommodate expenditures financed with aid within the domestic budget constraint in a reasonable period of time , while maintaining sustainable levels of debt to GDP and debt service to exports.” Michel Kazatchkine, executive director of the Global Fund to fight AIDS, Tuberculosis and Malaria: “The Global Fund has helped to change the development paradigm by introducing a new concept of sustainability. One that is not based solely on achieving domestic self-reliance but on sustained international support as well.”
  • 13. So what do the IMF and the World Bank have to do with this? Peter Piot, former executive director of UNAIDS, during a speech at the World Bank: “ ...when I hear that countries are choosing to comply with medium-term expenditure ceilings at the expense of adequately funding AIDS programmes, it strikes me that someone isn’t looking hard enough for sound alternatives... For countries emerging from conflict, the Bank has pioneered a careful programme of exceptions, running a calculated risk on the grounds that inaction would be riskier still. Let us now do something similar for AIDS, a risk far greater than conflict for many countries.”
  • 14.  
  • 15. Catch 22 Rich countries are reluctant to take long term responsibility for health in poor countries… IMF and World Bank assume that international aid for health is not reliable, therefore fiscal space is limited… Poor countries are discouraged from using all the available aid to increase expenditure, but they will not refuse the aid, they would rather decrease their domestic contribution… Rich countries find out that ‘aid does not work’, so they discontinue, or try yet another approach… IMF and World Bank are right to assume that international aid for health is not reliable…
  • 16. To whom are the IMF and the World Bank accountable? Branko Milanovic, a World Bank economist: “ Global bodies tend to be either irrelevant if representative, or if relevant, to be dominated by the rich. A stark example of the latter situation is provided by the quota and the voting rights enjoyed by member countries of the IMF. There, as well as in the World Bank, votes do not follow either what may be deemed a truly global one person = one vote formula, or the international formula of one country = one vote (as, for example, in the United Nations General Assembly). The voting rights match rather closely the one dollar = one vote rule.”
  • 17. Are governments of rich countries accountable for financial resources they are NOT spending on international health aid? Public health expenditure in G8 countries (2006) Total (% of GDP) Public (% of total) Canada 10.0% x 70.4% = 7.0% of GDP France 11.0% x 79.9% = 8.8% of GDP Germany 10.6% x 76.9% = 8.2% of GDP Italy 9.0% x 77.2% = 6.9% of GDP Japan 8.1% x 81.3% = 6.6% of GDP Russia 5.3% x 63.2% = 3.3% of GDP UK 8.2% x 87.3% = 7.1% of GDP USA 15.3% x 45.8% = 7.0% of GDP International aid for health? 0.03% of GDP
  • 18. Remember one possible answer to the question about governments of poor countries being accountable to for the potential domestic resources they are not spending on health: “They are accountable to inhabitants of other countries because poor health fuels epidemics (and they spill over), and poor health fuels unhappiness and ‘grunge’ (and that spills over too…)” If you agreed with that, would you agree that governments of rich countries are accountable to their own inhabitants , for the epidemics they are not stopping elsewhere, and for the ‘grunge’ they are not ending elsewhere?
  • 19. Reasons for international ‘grunge’ It requires very (very) little efforts from rich countries, to make a huge (huge) difference in poor countries There is something wrong with the politics of globalization: Our world view for primary distribution of wealth is a global one, without state borders (the ‘global free market’) Our world view for secondary redistribution of wealth is globe composed of states, with clear state borders (national ‘social protection’)
  • 20. Low-income countries: one billion people, with an average Gross Domestic Product (GDP) of US$565 per year. If they can spend US$3 out of every US$100 on health, that makes US$17 per person per year. High-income countries: one billion people with an average GDP of US$43,000 per year. If they could spend US$0.13 out of every US$100 on international aid for health, that would make US$56 per person per year.
  • 21. The problem with two very different superimposed world views, one global (free market), one national (social protection); based on the economic theory of Gunnar Myrdal: A free market does not evolve towards equilibrium, but away from equilibrium Economic growth centers (families, clans, cities, regions) invest their gains in more comparative advantages Economic growth centers continue to ‘win’ the competition, and attract human skills and capital from elsewhere, a self-amplifying dynamic The government needs to intervene constantly, impose taxes and invest them in social protection, to create equal opportunity But what if the self-amplifying dynamic happens at the global level, and the correction at the national level?
  • 22.  
  • 23. Mahboob Mahmood, quoted by Kishore Mahbubani, in ‘Beyond the age of innocence: rebuilding trust between America and the World’: “ The central promise of militant Islam is creation of a just society. The importance of the notion of justice in Islamic societies cannot be overemphasized—in these societies, freedom, democracy and rule of law are weak memes—but justice is a strong meme. The delivery of justice is and has always be the kernel of Islamic socio-political thought. Up to today, militant Islam has succeeded by emphasizing the injustice of the prevailing order—… A good policy will only succeed if it is capable of addressing and defeating militant Islam on the grounds of its central promise and its ultimate incapability—the creation of a just society.”
  • 24. Thomas Pogge: “ Responsibility for a person’s human rights falls on all and only those who participate with this person in the same social system . It is their responsibility, collectively, to structure this system so that all its participants have secure access to the objects of their human rights.” What is the social system we want to promote? The family, the city, the nation, the state, the globe? Or a combination?
  • 25. Challenges for mutual accountability, if we accept that responsibility for health is both national and international There is no global government… Can we agree, by convention (respecting state sovereignty) on minimum domestic efforts? Can we agree, by convention, on burden sharing between all rich countries? Can we agree, by convention, on some kind of institution that oversees and coordinates both?