Last week WHO launched a special issue of Health Systems & Reform about "Common Goods for Health"—services which have an enormous impact on health and a clear economic rationale for being financed if not provided collectively. Nevertheless, unless a crisis occurs, we tend to underinvest in these Common Goods for Health—things like environmental regulation, epidemiological surveillance, disaster preparedness, slowing the emergence of anti-microbial resistant diseases, safe roads, and sanitation.
The issue analyzes this underinvestment in Common Goods for Health, exposing factors like collective agency problems, externalities, and free-riding, as well as short-term thinking and underestimating risks. You can't open a newspaper without reading about some failure of Common Goods for Health. Periodic epidemics like SARs and more recently Ebola raise the alarm about weaknesses in the global epidemiological surveillance and response systems. Interest and investment is high—for a while—and then other short-term priorities occupy the political space. The opportunity costs of taking action became more salient than the threat.
With so many obstacles to providing these critical services, it is worth asking why countries produce Common Goods for Health at all? How do countries ever reach the point where they are willing to tax themselves to invest in services that are in the public interest? Services that are invisible when they work; and only become visible when the crises they are meant to prevent occur?
Common Goods for Health: a brief history
History shows us that until the mid-20th century, most decisions to produce Common Goods for Health weren't motivated by the public interest. Rather, they were motivated by the interests of elites. For centuries, elites viewed mass education as a threat. Only in the 19th century did elites promote mass education after they came to see it as a tool for building national identity and strong armies. The origins of Universal Health Coverage (UHC)—discussed at the UN meetings this week—are also tied up with elite interests. Bismarck's plan for social health insurance is widely considered to be the first step of any country toward UHC, but it was primarily created to quiet civil unrest and coopt labor unions.
Since the 1950s, however, a very different idea has emerged: the idea that governments should solve collective problems for the benefit of the public. If fully embraced, this idea is much more aligned with adequate investment in Common Goods for Health. But we know all too well that getting action on these services and policies requires more than petitioning benevolent states to do what's right. It is fundamentally a political process.
And as a political process it seems to have three fundamental characteristics related to identity, salience, and interests.
How to get the Goods
Identity is important because it defines "the public" for which the Common Goods for Health are produced … and we know identity is socially constructed. The people we consider part of "us" and for whom we are willing to sacrifice has changed over human history from families and clans, to villages and principalities, to kingdoms and nations. The Sri Lankan case study in the special issue mentions "Days of Tranquility" during which the combatants in a horrific civil war stopped fighting so allow immunization campaigns could take place. Both sides considered the children to be important enough—a common responsibility—that they abided by temporary ceasefires. By contrast, we can see what happens when this collective identity is lacking in the way Congolese factions are using the Ebola crisis to gain leverage against their adversaries. These stark extremes show that constructing a sense of collective identity is required at both the national and global level if we're going to produce the Common Goods for Health we need.
Salience is important because people typically don't solve problems until they face a crisis, such as cholera outbreaks, natural disasters, political unrest, and wars. When those in power are confronted by a problem they can't ignore, they invest in solving them. It is sobering to learn that creating the US Center for Disease Control was not motivated by the public interest in surveillance of domestic infectious disease. Rather it was the salience to government officials of the potential threat posed by biowarfare against American soldiers during the Korean War that carried the day. Most action on environmental regulation since the 1970s has been driven by the visibility of unswimmable rivers, choking smog, or debris on beaches. Investment in vaccines and surveillance for Ebola obviously jumped as a result of the epidemic in West Africa.
Interests are important because even though many countries today are democratic, we know that political and economic elites still have the power to drive or block change. India demonstrates both sides of this dynamic. Inter-ministerial coordination for disaster relief has made dramatic progress in India, it seems, in part, because it is relatively inexpensive and doesn't directly confront economic interests. By contrast, solving the massive problem of air pollution in India's major cities requires significant economic change. The big question is when India's elites will consider air pollution to be a greater threat to their interests than the immediate economic costs.
We've known for a long time that we need to work collectively to solve our problems. That was essentially the wisdom of establishing the UN system in the first place. It was behind the Montreal Protocol to address the thinning of the ozone layer. Yet, these days, the will to cooperate seems to have run aground.
Yet, there is a way forward. We actually have solutions for epidemics, anti-microbial resistance, air pollution, and even climate change. However, to apply those solutions, exhortation is not enough. We need to build wider collective identities, raise the salience of these problems to a fevered pitch, and find innovative ways to recast elite interests so that they favor change. When we do that, we'll be able to marshal the resources and produce these very necessary Common Goods for Health.