Student Spotlight: Jillian Kowalchuk

With this guest contribution, we are initiating a new series on Healthy Policies which spotlights students who are exploring issues related to the political determinants of health. This first post comes from Jillian Kowalchuk who writes about Kingdon’s three streams model in relation to the Framework Convention in Tobacco Control, which  entered into force 11 years ago, today. 

Policy Entrepreneurs and Kingdon’s three streams model for agenda setting during the formation of the Framework Convention in Tobacco Control: a student applies theory to example

Jillian Kowalchuk

DL lunch-22

The creation of the Framework Convention in Tobacco Control (FCTC) in 2003 was the World Health Organization’s (WHO) first international treaty. Prior to the FCTC, there were no global regulations to combat tobacco use. Nor was there a structure in place to support countries that wished to enact policies.

Policies are made over time and are influenced by the interactions between people who have the power, ability and resources to get things done. Termed actors in academia, they drive the policy process and may include national, international, governmental, intergovernmental and local organizations and individuals (1). Hundreds of people were involved in the creation of the FCTC. This article will focus on a handful that paved the way for the FCTC to move from idea to reality. These ‘policy entrepreneurs” are key actors that create momentum and opportunities. They start the conversation, develop connections that support and guide the process so that a policy moves to the forefront of the agenda (2-4).

The idea of the FCTC began in the 1990’s with Ruth Roemer and Allyn Taylor. Ruth Roemer was a professor in law at UCLA and a formidable leader in public health law. Allyn Taylor is a global health law consultant whose PhD thesis in the 1990’s formed the partial basis for the FCTC. By the 1990s, the tobacco epidemic was becoming recognized as a monumental public health concern in most developed countries (2). Local, state and national tobacco control policies were intermittently emerging in various nations, however global statistics of the impact of tobacco use climbed. More than 3.5 million lives were lost to tobacco in 1998 alone (3).

The FCTC follows Kingdon’s theory of how policies get onto the agenda. Kingdon’s three streams model of agenda setting is the idea that it is the alignment of politics, the problem and the policy that creates a window of opportunity for a policy to move onto the agenda. The ‘policy stream’ involves the analyses of problem, debates and resolutions that reflect dominant social values that are feasible, and publically and politically acceptable. The ‘politics stream’ is the coming together of visible and hidden participants to advocate for a solution and create movement (5). Roemer and Taylor recognized the ‘problem stream’ of the tobacco epidemic; it would require international legislative agreements between countries in order to be successful. This was reiterated by Dr. Gro Harlem Brundtland, who was elected as Director General of the World Health Organization in 1998, and stated,

“Tobacco control cannot succeed solely through the efforts of individual governments, national non-governmental organizations and media advocates. We need an international response to an international problem” (3 p6).

The application of the ‘policy stream’ began with Roemer and Taylor networking through their spheres of influence in public health and law, to lobby that a tobacco control treaty was technically feasible and increasingly publically and politically necessary for the WHO to develop, negotiate and lead (3). Dr. Gro Brundland’s declaration was the ‘politics stream’ bridging together all three streams to place tobacco control on the global health agenda.

Visionaries with power of persuasion and resources used the political, problem and policy opportunities to create the FCTC. After 3 years of negotiating, the FCTC was adopted in 2003 and came into force in 2005. Today there are 180 signatory countries to the FCTC and the latest global progress report indicates that nearly 80% of these countries have adopted or strengthened tobacco control legislation after ratifying the Convention. Using the theoretical concept of ‘policy entrepreneurs’ and Kingdon’s ‘three streams model’ not only helps us to understand how the FCTC came to be, but also illustrates how policy solutions to major health problems can be achieved.


My deepest thanks to Dr. Sue Lawrence for her contributions to the structure, revision, overall support and encouragement in pursuing publishing this assignment as a blog submission.


1. Buse, K., Mays N., Walt G, editor. Making Health Policy. 2nd ed. Berkshire: Open Unversity Press; 2005.

2. Roemer R, Taylor A, Lariviere J. Origins of the WHO framework convention on tobacco control. American Journal of Public Health. 2005. p. 936–8.

3. World Health Organization. History of the WHO Framework Convention on Tobacco Control. Geneva; 2009 p. 1–58.

4. Jha P, Chaloupka FJ, editors. Tobacco control in developing countries. New York; 2000.

5. Kingdon J (2010) Agendas, Alternatives and Public Policies, updated 2nd edition. Harlow: Longman Classics.

Author Biography:

Jillian is a recent graduate from the MSc degree in Public Health from the London School of Hygiene and Tropical Medicine (LSHTM). She also holds a Bachelor of Arts degree in Psychology from the University of Alberta.

Jillian has consulted throughout her MSc at with the private public health consultancy Be the Change Group Inc. Jillian works nationally and internationally with high-risk and vulnerable populations, in creation of campaign designs, implementation research, monitoring and evaluation,  and technical writing. Jillian volunteers on various projects, including blogging for the University of London and currently sits on the Board of Directors for Does HIV Look Like Me? International.

Jillian currently is completing a research internship at The AIDS Service Organization (TASO) in Uganda before attending her graduation in March.

To explore future collaborations and to connect please find her at:

LinkedIn: Jillian Kowalchuk 

Twitter: @kowalchuk_jill




Global Health Working Group Promotes Ebola Open Letter

Last week a Workshop was held at the Centre for Global Health Policy at the University of Sussex which brought together a number of scholars, primarily UK-based International Relations scholars, to discuss the current Ebola crisis and the international response to it.

From this workshop arose an open letter on what the field of International Relations offers in terms of learning the lessons from the Ebola response:

The Ebola outbreak in West Africa has brought to light some important issues and tensions in global health, ranging from the institutions that have been created to service the international community – such as the World Health Organization (WHO) – to the role of governments, politics and ideas in determining how, where and what health issues are addressed. Failings in the management of and response to the Ebola outbreak have sparked a debate about the efficacy of the system of global health governance. This is a necessary debate for the global health community to engage in. When the time comes, we believe that analysts of global health politics and international relations have several valuable insights to help ‘learn the lessons’ from the 2014 Ebola outbreak.

First, on institutional reform: The Ebola outbreak has been an exceptional event. It should not be assumed that lessons drawn from this single event can provide a template for redesigning the everyday workings and agenda of an institution such as the WHO. The WHO has certainly made mistakes in the Ebola response, and these need to be recognized and addressed. However, the efficacy of its Ebola response is not the only metric by which this institution should be judged, nor should Ebola be used politically as an opportunity to further undermine the WHO.

Second, on institutional innovation: We have observed recent calls for the creation of a new international ‘rapid response’ agency for health emergencies. Clearly in some cases rapid response is of the utmost importance, and enhanced rapid response coordination and capacity is needed. However, emphasising rapid response to the detriment of other solutions is problematic, inasmuch as the former is by its very nature ill-suited to building long-term solutions to deep-seated problems. The international community must also be careful that creatingsuch a body may be counterproductive, by shifting attention away from the important task of strengthening in-country health systems which are best-placed to be first line responders to health emergencies.

Third, on the relationship between global health governance and national health systems: Any investigation into institutional failings in the response to Ebola in 2014 must be cognizant of the wider system of global health governance that has dominated questions of African health reform since 2000. A knee-jerk “blame game” of “who did not do what when they should” will only provide a veneer of accountability. Instead, we need a systematic unravelling of why health systems were so poorly developed in Guinea, Liberia and Sierra Leone. Here, reflecting on the impact of the goal-oriented mentality underpinning the Millennium Development Goals agenda cannot be avoided. We must also consider the roles of the actors (state and non-state) that have supposedly been responsible for supporting these health systems, and what they could have done better. The results of such analyses could go some way to providing the basis for thinking about how to build a more sustainable model of global health governance.

Fourth, on the centrality of politics to all institutions: Attempting to separate politics from the technical workings of institutions is a useless exercise – and a potentially dangerous one. All global health institutions are engaged in the management of resources, expectations and the interests of a myriad of state and non-state actors. They have to engage in political brokering, negotiation, leadership and policy design and implementation. The idea that international institutions can or should be “apolitical” has only contributed to limiting their agency, whilst obscuring the real politicking that occurs within and between these institutions. ‘Politics’ is not the problem, and it must be part of the solution.

Fifth, on power and inequalities: Contrary to a much-repeated refrain, disease does know borders. These borders may be those that separate nation-states from one another, but they can also be cultural, racial, economic, or gendered. Access to information and adequate healthcare, as well as exposure to health risk, are not equally shared but rather are dependent on a multitude of local, national and international divisions – not least inequalities in power and wealth. These need to be acknowledged, understood and deconstructed if we are to finally make good on the promise of delivering ‘health for all’.

The recent Ebola outbreak in West Africa – the latest in a depressing series of outbreaks in this region in recent decades – has highlighted the extent to which global health policy has become reactive rather than proactive. A failure to take bold political action in addressing the concerns we have highlighted in this letter will mean that the global health community will remain ill-equipped to respond to future outbreaks, still less to prevent them occurring.

Should you or any of your colleagues wish to sign this open letter please email Sophie Harman ( by Midday UK time on Monday 8th December with: ‘Please add my name to the open letter, *name and *institution’.

Canada and the post-2015 world: Part II

In this post, guest blogger Ronald Labonté concludes a two-part blog series about post-2015 development goals. Discussed are their relationship to health and specific steps Canada could take to encourage a healthy and progressive transition. Labonté holds a Canada Research Chair in Globalization and Health Equity at the Institute of Population Health, and is Professor in the Faculty of Medicine, University of Ottawa; and in the Faculty of Health Sciences, Flinders University of South Australia.

Part I of this post commented on a number of global and intergovernmental initiatives to define new post-2015 development goals, specifically the sustainable development goals, the UN high level panel report and the health goals mooted by the World Health Organization. It also included brief analyses of the role Canada could play in each. Part II focuses more closely on Canada’s role, with some specific recommendations for a healthy and progressive stance we could be taking.

Aid, trade and health

Canada still lacks foreign policy coherence, in that we pursue trade and investment agreements that could compromise health equity globally, while committing to a charity model of international health aid. (We are far from alone in this regard.) More troubling is the trend to tie development assistance to the trade and economic interests of donor countries. The ‘trade not aid’ rhetoric has led to ever-larger sums of ODA being allocated to ‘aid for trade’. If Canada is to join in this chorus (which seems imminent with the transfer of its aid department to that of foreign affairs and trade) then the rules of trade treaties that we negotiate should clearly provide disproportionate benefits to poorer, aid-recipient countries. This is not presently the case. This lack of foreign policy coherence has salience both for UHC (where high-income countries with health financing and service industries are mobilizing to sweep the global low- and middle-income country field); and for control of noncommunicable diseases, where trade and investment treaties are posing risks to public health regulation (10).

Here, Canada could support growing public health advocacy to establish full health carve outs and strengthened health exceptions in trade treaties, starting with the detailed texts of the ‘agreed in principle’ Comprehensive Economic and Trade Agreement (CETA) with the EU, and the still to be completed 12-nation Trans Pacific Partnership Agreement (TPPA), the other major countries being the USA, Japan and Australia. There is growing support amongst some of the TPPA’s negotiating countries for a tobacco carve out in that treaty, such that no tobacco control policy could be challenged in a trade dispute. Such tobacco exceptionalism, while good for health as far as it goes, could nonetheless be problematic if we are also concerned with the global health risks posed by Big Food, Big Alcohol or Big Pharma. A more radical approach would be to ensure that such treaties include a provision requiring deference to WHO soft law (e.g. the Framework Convention on Tobacco Control) or World Health Assembly approved global actions plans (e.g. on noncommunicable diseases) whenever a public health policy or regulation is subject to a trade or investment dispute. Given Canada’s current obsession with striking trade and investment treaties with as many countries as possible – indeed, the only new foreign policy by our Conservative government commits to a ‘sea change in the way Canada’s diplomatic assets are deployed around the world’ such that all are ‘harnessed to support the commercial success by Canadian companies’ (11) – we are unlikely to lead this charge. At the same time, according to the leaked TPPA chapter on intellectual property rights, Canada has been opposing almost every effort by the USA to extend patent protection in that treaty beyond provisions in the WTO’s TRIPS Agreement (12). So there may be some room for a stronger global public health presence in Canadian trade policy.

 Aid for tax reforms instead?

Aid disbursements will be necessary for many low-income countries, especially in sub-Saharan Africa, since taxation reforms are still years away in being effectively developed. But aid is no substitute for domestic economic empowerment; and taxation is fundamental to that empowerment, and to responsible state building and the social contract between well-functioning states and their citizens. Thirty or more years of advice to or obligations on developing country governments by the IMF and World Bank to keep taxes low to attract foreign direct investment have done well for the investors, but poorly for most of the countries’ citizens.

Somewhat late in the game, both the IMF and World Bank are now talking about the need for developing countries to substantially increase their taxation rates and improve their taxation systems (though still favouring regressive consumption over progressive income or corporate taxes). This is not to say that African countries have not been trying to comply, with their tax to GDP ratio in recent years rising to between 17 and 20 percent (13). But this rate is still too low to be adequate (the EU 15 countries average over 40 percent), and still inefficient and full of exemptions for imports, investors and transnational profits. As well, the continuing importance of tariffs as a form of taxation for some of these countries means that in any Canadian trade treaty involving developing countries, including those in South Asia where the tax to GDP is the lowest in the world, high tariff reductions should not be on the agenda until there is evidence of effective and transparent progressive tax systems in place. Why not aid for progressive taxation reforms, rather than (or at least in addition to) aid for trade?

Given that Canada has also become the Western world’s global mining giant thanks to the domestic tax breaks we give to mining companies, we also have a potential role to play in supporting developing countries (especially those in Africa and Latin America) in their efforts to increase their persistently low royalty rates, which were largely imposed during structural adjustment programs in the 1980s and 1990s.

We could also join with other countries in supporting innovations in global taxation. Why is Canada not supporting financial transaction taxes? Why haven’t we joined the very basic UNITAID airline tax? Why are we not doing more to close offshore financial centers, tax havens?

Canada could take an assertive role in the most recent G20 promise to develop a more transparent international tax identification system so that taxes are paid where production profits are earned, avoiding the toxic practice of transfer pricing through tax haven countries (14). In doing so it might also begin to stem the illicit capital flows, especially from Africa, which in the past 40 years has topped $1.4 trillion, more than all of the aid and debt cancellation funds that have gone to the continent, and much of it due to transnational corporate practices, and not simply criminality or corruption (15). There is a modicum of self-interest in this, as some estimates calculate that Canada is absorbing huge tax losses on the more than $160 billion in Canadian income parked mostly in offshore Caribbean branches of Canadian chartered banks (16).

Actions oriented towards such economic and taxation reforms by Canada would move us away from a charity model of intermittent, donor-driven aid to a structural model of global social solidarity and an equitable economic empowerment.

In sum, Canada in preparing for a post-2015 world could:

  • Continue but strengthen our commitments to maternal/child health
  • Promote our publicly-funded universal health system as an important model for expanding UHC
  • Ensure that health concerns (present and future) are fully protected in trade and investment treaties
  • Aid for trade – if trade treaties actually disproportionately benefit poorer people and countries
  • Aid for tax reform – to build the transparent and progressive tax systems developing countries need to build effective states and mobilize domestic revenues for health
  • Join and promote global systems of taxation to prevent tax evasion and illicit capital flight
  • Work with African and Latin American countries to improve their royalties on extractive industries, notably mining.


10.  Friel S., Gleeson D., Thow A-M., Labonté R., Stuckler D., Kay A. and Snowdown W. A new generation of trade policy: potential risks to diet-related health from the trans pacific partnership agreement.  Globalization and Health 2013, 9(46): 1-7.

11. See: Government of Canada, 2013. Global Markets Action Plan.

12. See:

13. See:

14. See:

15. See: African Development Bank and Global Financial Integrity, 2013. Illicit financial flows and the problem of net resource transfers from Africa: 1980-2009. [pdf] Available at:

16.  See:


Based on two plenary presentations at the 2013 Canadian Conference on Global Health, Ottawa, Canada, October 28-29.

Canada and the post-2015 world: Part I

In this post, guest blogger Ronald Labonté introduces a two-part blog series about post-2015 development goals. Discussed are their relationship to health and specific steps Canada could take to encourage a healthy and progressive transition. Labonté holds a Canada Research Chair in Globalization and Health Equity at the Institute of Population Health, and is Professor in the Faculty of Medicine, University of Ottawa; and in the Faculty of Health Sciences, Flinders University of South Australia.

In 2000 the world committed to health and a paternalistic egalitarianism, as the Millennium Development Goals (MDGs) promised reductions in extreme poverty and hunger, and measurable progress in water and sanitation, education and a host of specific health targets. There was lots to criticize in the MDGs: lack of ambition in the targets (especially for poverty), failure to consider the already surging pandemic of noncommunicable diseases, lack of equity stratifiers for the targets, huge holes in the data used to measure progress, and a resounding silence on any of the economic and political systems that were fuelling global financial speculation, transnational corporate power and gross inequities in income and wealth. Still, the MDGs galvanized some important initiatives and have chocked up some successes.

As the 2015 clock on the MDGs ticks down, there’s been a flurry of intergovernmental, civil society and social mediated consultations on what the world’s nations should commit to next. If the 2000 MDGs were a bureaucratic exercise in synthesizing what states had already more or less agreed upon during the 1990s, the post-2015 has opened the floodgates to consultation processes to such an extent that one becomes either exhausted with keeping up with the opportunities to input, or cynical about why bothering to.

Bracketing an excess of cynicism to strike a balance between realism and defeatism, this two-part blog series offers a few reflections on the competing post-2015 goal streams and Canada’s potential role within them. The first post will reflect on sustainable development goals, the UN high-level panel, and health goals in the post-2015 context. The second post will discuss aid-for-trade and aid-for-taxation strategies, and summarize how Canada can prepare for the post-2015 world.

Sustainable Development Goals

No one outside of the US Tea Party any longer insists that climate change is a left-wing environmentalist plot. (Although it would be nice if there were more left-wing environmentalists at the political and economic levels where they are needed.) The problem with these goals, an output of the Rio+10 initiative, rests with the term itself, a throwback to the late 1980s Bruntland Commission (Our Common Future) (1) and the first wave of efforts to harness economic development to environmental sustainability. Back then Canada was a leader, jumping enthusiastically on the ‘roundtables on economy and environment’ governance ideal promoted by the Commission. I recall an environmental lawyer leaving one of such meeting, complaining that the business folks around the table ‘Just don’t get it!’ To which a senior government official gently chided, ‘Oh, but they do. You see, they got the noun and you got the adjective.’

We continue to live under the illusion that, with claims of a slowly greening economy, we can consume our way out of a problem of over-consumption. We can even invest our savings on the Dow Jones Sustainability Index, feeling better that our retirement returns derive from companies deemed to be operating in a ‘sustainable’ way. We just have to pretend that there is consensus on how to measure good corporate environmentalism so that we aren’t fooled by such as Pepsi-Cola’s claim that in India it is replacing more water than it takes to supply the sub-continent with its sugary beverages (2). As for our greening economy: Why should the USA use trade rules to challenge China’s heavy subsidization of its solar and wind turbine industries? Yes, it puts the US-based industries at a competitive disadvantage, but it drives up global prices and slows diffusion of possibly important climate change reducers. Why not exclude from trade rules subsidies on all new products that reduce the human environmental footprint, a race to the top rather than a slide to the bottom?

Canada scores very poorly on this account. Our exit from the Kyoto Accord in 2011 and our drive to become a fossil-fuel superpower have transformed Canada from a once-upon-a-time eco-leader (we were, after all, the birthplace of Greenpeace and home of the increasingly pessimistic David Suzuki) to one of the bottom-placing eco-destroyers. The potentially healthy challenge for Canada is that if the post-2015 goals achieve their mooted intent of applying to all countries, alongside the increasing anger of developing countries at the rich club reneging on its climate change commitments, we may be dragged back into accountable commitments to a greener future.

But the gravest challenge for a post-2015 sustainably developed future lies in the fallout of the Great Financial Crisis, which became the Great Recession and persists as the Great Austerity. Most domestic political attention has drifted back to conventional economics of spurring growth by re-energizing the real economy of production and consumption (jobs, jobs, jobs). This is saleable in the short-term, although the quality of new employment with respect to pay, benefits, security, and health and safety remain vexing complications under neoliberalism’s labour market ‘flexibilization’. But it grates against the reality that we cannot use conventional economics to grow incomes for a world of soon to be 9 billion producers and consumers (3). We don’t have enough of a planet to do so. Add to that our oft-proclaimed ‘time bomb’ – an aging population living longer, with demographers and politicians concerned with increasing the size of the active labour force (those aged 20 – 65 or 70) to sustain the social contract (health care, pensions and benefits) for the swelling cohort of elders. This continuous priming of the base of the demographic pyramid is simply an environmental ponzi scheme, one that only radical redistribution and economic regulation might prevent from imploding.

UN High Level Panel

The UN High Level Panel on the post-2015 goals (is there ever one called ‘low-level’?) came up with a number of useful suggestions that could partly forestall such a dystopian ponzi pyramid. These include a call for governments to regulate private finance, reform trade, crack down on illicit capital flows, stem transnational tax evasion, return stolen assets and promote sustainable patterns of production and consumption (4). Such recommendations are meatier than the Panel’s obligatory nudge to donor countries to honour their aid commitments. Been there, done that and, in Canada’s case, we don’t seem to care much. Despite our acknowledged if initially botched leadership on the ‘Muskoka Initiative’ for Maternal/Child Health, we are losing ground on our aid commitments, freezing the level of our disbursements, and restricting contributions to a smaller number of countries. Apart from issues of quantity, there are issues of quality. The 2012 Centre for Global Development’s Quality of ODA Index ranks Canada in the lower half of donors on efficiency and reducing the burdens or transaction costs of aid. We do better on fostering institutions, and are smack in the middle on transparency and learning; a middling assessment at best (5).

Returning to the Panel’s higher-level goals: Good as they are in intent, there is no operational guidance in the report. There is also too much emphasis on corporate social responsibility and partnerships between states and businesses to make global markets more just and equitable, rather than recognizing the pressing need for mandatory and enforceable market rules. It is in how we must move on the Panel’s goals that is of prime importance, which then requires an analysis of why we have these problems in the first place. As a People’s Health Movement commentary laments, none of the prevailing models for post-2015 priorities question, much less challenge, the prevailing paradigm of economic growth (6).

There is even the risk that the UN High Level Panel could reinforce some of the more egregious qualities of the prevailing paradigm. For one, it criticizes the core labour rights of the ILO-led initiative on social protection and ‘decent work’ (7) as too much of a ‘one size fits all.’ It calls, instead, for ‘good jobs’ and for ‘flexibly regulated labour markets’, an invitation to a continual reduction in labour’s power against that of capital. In sync with the World Bank and other economic development agencies, its poverty goal of ‘leave no one behind’ (commendable, depending on where one draws the poverty line) is based on the norm of ‘equality of opportunity.’ While the procedural justice inherent in this norm is important (all should be treated alike), in the game of economics it only becomes fair when all are alike when they start playing. This is patently not the case, not when fewer than 1500 people have more wealth than the combined populations of the continent of Africa and the sub-continent of India (8). Equality of opportunity only becomes fair when it is joined with a parallel commitment to equality of outcome – an ideal but measurable target – that relies on progressive tax/transfer programs within and between governments. Such a norm is unlikely to have much political traction in Canada at the moment, however, where reduced and regressive taxation have been the norm for the past decade or more. The same may be true for most of the austerity-addicted high-income countries and many of the recession-stuck middle-income ones.

What of health?

No one knows exactly how health goals in the post-2015 final list will be defined. Several of the goals from the sustainable development agenda and the high-level panel already deal with key health determinants, albeit imperfectly. The World Health Organization (WHO) is calling for completion of the 2000 health MDG’s unfinished agenda, and a ‘healthy life expectancy’ goal perhaps allowing some broader measurable target. But it seems most keen to bank on a post-2015 health goal of universal health coverage (UHC), a re-born concept still in search of consensus. The WHO defines it as “ensuring that all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need” (a nod in the direction of the heady days of the Alma Ata Declaration on Primary Health Care), with services “of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship” (9). This sounds reasonable enough, but it ducks the contentious issue of the relationship between public and private sectors in health care financing and provision. With private insurers and providers eager to carve out a larger piece of the annual $6.5 trillion health care ‘market,’ the risk is that the costly chaos now passing for Obamacare in the USA will come to define the global default position.

This is a debate in which Canada could aggressively insert its own comparatively positive experience with a universal, single-payer and mixed provider system. Canada’s national health insurance risk-pool and legislated public administration creates one of the fairest, most efficient and most accessible health care models on record (excepting Cuba). Sure, it has warts: wait-times, gaps in coverage, encroaching privatization. But compared to the American model, and to the dual public/private models dominating Latin America (which most countries in that region are trying to transform into a more public system), the warts on Canada’s system become mere cosmetic pimples.


1. Our Common Future, Report of the World Commission on Environment and Development, World Commission on Environment and Development, 1987. Published as Annex to General Assembly document A/42/427, Development and International Co-operation: Environment August 2, 1987.

2. See:

3. Sustainable Development Commission, 2009. Prosperity without growth: the transition to a sustainable economy? London: UK Sustainable Development Commission.

4. High Level Panel on the Post-2015 Development Agenda, May, 2013.

5. See:

6. See:

7. International Labour Organization (ILO), 2011. Social protection floor for a fair and inclusive globalization [online]. Report of the Advisory Group chaired by Michelle Bachelet convened by the ILO with the collaboration of the WHO. Geneva: ILO. Available from:—dgreports/—dcomm/—publ/documents/publication/wcms_165750.pdf

8. See my last blog:

9.  See:


Based on two plenary presentations at the 2013 Canadian Conference on Global Health, Ottawa, Canada, October 28-29.



Better Governance to Improve Health

In the context of the recent World Conference on Social Determinants of Health, guest blogger Amir Attaran discusses the role of governance in improving the health of societies. Amir Attaran is a professor and Canada Research Chair in Law, Population Health and Global Development Policy at the University of Ottawa.

(Originally published in Portuguese in O Globo (Rio de Janeiro) on 19 October 2011)

If you are over 40 years old and reading this, consider yourself lucky, because historically you should be dead. Just two centuries ago, and for millennia before that, human life expectancy was half of what it is today. For doubling our lives, we must thank medical and public health science, and the legal and economic governance of modern, liberal societies.

But medicine and public health science are now close to a plateau, where life expectancy increases more slowly, at greater expense. As people live longer, lifestyle choices—diet, exercise—produce obesity, cardiovascular disease, diabetes, and cancer. In an ageing population, long life increasingly is not healthy life.

These transformations demand us to reevaluate the methods of using science and medicine to cure disease, and instead to ask how the governance of societies can prevent disease. Well before 2050, when the most typical Brazilian will be a woman over 80 years of age, societies must reorganize themselves so all their members can lead healthy lives. That means the governance of liberal societies, which formerly improved our health, now must adapt not to destroy our health.

This week in Rio, the World Health Organization is holding the World Conference on Social Determinants of Health, hosted by the Government of Brazil. It is a very important event: the first of its kind. Appropriately the agenda emphasizes governance over science or medicine. Governments need persuading that health is a good reason to use the controls of law and taxation –controls all governments possess to nudge society’s direction justly and not tyrannically –both to improve absolute health outcomes of all society, and relative health outcomes between the powerful and weak.

Not all governments accept this version of liberalism, and worse, many use the controls to destroy health rather than to improve it. Governments legislate agricultural subsidies of fast food (so a fatty burger and a sugary cookie are cheap) but do not legislate agricultural subsidies of slow food (so comida caseira and fruit are expensive). Or governments invest in highways to vast suburbs where the relatively wealthy must drive, but not safe downtowns where all of us can walk safely. What to legislate or what to tax are difficult choices, but with governance like this, is it any wonder that more people suffer obesity and hypertension which can kill them?

What worries me most, as a professor in both science and law, is that the unsurpassable influence of governance on health is either appreciated by too few, or too frightening to many. In many countries, even rich ones with universal health care systems like the UK, a distance of 10 kilometers or less separates neighbourhoods where for social reasons lifespan differs by 10-20 years (in Rio, 12.8 years). Yet governments avoid using the legal and economic controls. Even the WHO, which should know better, avoided mentioning “law” or “tax” once on the official agenda. Instead its agenda touts fuzzy goals like “Promoting participation and community leadership” – an irony because at WHO headquarters in Geneva, even NGOs which are officially recognized by WHO are not allowed participation in working groups. Thus even the WHO is not setting a good didactic example or leading by example.

Brazil has many social problems, but is trying hard and setting a better example that many so-called “advanced” countries. Recently in the British medical journal, The Lancet, our research team pointed to laws in Brazil which help procure cheaper medical supplies—a law that even Canada, my country, lacks. Good governance in Brazil means social services are increasing and income inequality is declining, while in Canada social services are declining and income inequality is exploding. It is not only symbolic that Brazil’s Vice-President and two Ministers will attend the conference, but Canada sent no Minister and only bureaucrats without authority.