Michael Marmot and Paulo Buss*
“The economy is not delivering the security and widely shared prosperity expected by large parts of our societies. Among the failings of the current economic model are rising inequality, financial instability, increasing personal insecurity, and slowing economic growth,” writes Martin Wolf in his new book The Crisis of Democratic Capitalism.1 To the failures that Wolf lists, we would add increasing health inequalities in many societies and the climate emergency.
The current state of the world and the crisis of democratic capitalism provide ample reasons to be gloomy—if not panicked. But, ever hopeful, we see positive signs of change. COP27 may have fallen short of what is needed to achieve net zero greenhouse gas emissions, but the global community, at last, is taking the climate emergency seriously. The move to wellbeing economies is welcome. Six countries—Canada, Finland, Iceland, Scotland, Wales, and New Zealand—have formed the Wellbeing Economy Alliance, and the WHO Regional Office for Europe recently held a high level meeting of member states on the wellbeing economy. After years of discussion, the United Nations Human Rights Council is close to adopting a binding resolution on “the right to development” which, if respected and implemented by developed countries, could bring important benefits to countries that have been left on the sidelines for decades, particularly through the concepts of duty to cooperate and not to create obstacles for the development of other countries. It creates ways of monitoring and evaluating the implementation of the right to development with the formation of a conference of countries party to the treaty and measures to punish those who violate this right. Gary Gerstle, historian of the United States, writes in his book The Rise and Fall of the Neoliberal Order2 that unbridled faith in free markets and the Washington Consensus (a set of 10 economic prescriptions) have been found wanting. It may have risen as the dominant approach to economics and politics from around 1980, but now it has fallen. The question now is what will replace it.
The final report of the WHO Council on the Economics of Health for All—Health for All at the Centre of our Economies and New Economic Thinking—provides further grounds for hope of a new and much needed way forward.3 The council goes beyond much current economic thinking in important ways. Firstly, its credo is that health is not an instrument to some higher goal such as wealth, but is an important human right in itself. “Alongside a healthy and sustainable environment, human health and wellbeing must be the ultimate goal of economic activity,” writes the council’s chair, Mariana Mazzucato, in her preface to the report.
Secondly, the phrase “health for all” came into wide usage with the 1978 Alma Ata Declaration.4 Although the declaration had much to say about the social determinants of health, the dominant message was that health for all was to be achieved through primary healthcare. This has evolved into universal health coverage. Universal access to high quality healthcare is a vital social need, but by itself will not deliver health for all. As the WHO commission on social determinants of health made clear, health inequalities arise from a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics.5 The first two of these are the direct focus of this new report and, if the approach laid out were to be followed, the result would be good politics.
Thirdly, “economics of health for all” is global in its approach. “It is evident that the three great crises of our time—health, inequality, and the climate emergency—are profoundly interconnected, and none respects national borders,” says the report. These three great crises must be tackled together.
Fourthly, according to the report—and a clear outcome of what has just been outlined—the role of government is not simply to deal with market failures. A free market fundamentalist might depart from orthodoxy sufficiently to acknowledge that the inequalities, or environmental damage, that come with unbridled markets do need some rectification and governments might be the appropriate actors for this. Economics of Health for All proposes that the public and private sectors should combine, with the common good as their goal. The four groups of recommendations in the report—valuing, financing, innovating for, and strengthening capacity to deliver health for all—are the ways to achieve the common good of greater health equity and a viable planet.
There may be specific examples of innovations in the healthcare sector, but these should be developed with the common good as a central focus. More generally, one way forward is given by the Wellbeing Economy Alliance. The WHO council cites doughnut economics as another. This new way of economic thinking, proposed by Kate Raworth, focuses on eliminating global poverty and living within the world’s natural resources, showing the need to tackle social needs within the limits imposed by protecting the planet.6
The report clearly states that continuing with the neoliberal economy will not solve the problems of inequality and climate change, or tackle health as a fundamental human right. Health for all must be seen as a long term investment and not as a short run cost. To achieve greater health equity and deal with the climate emergency, action is needed by the whole of government striving towards the common good.
1. Wolf M. The crisis of democratic capitalism.Penguin Random House, 2023.
2. Gerstle G. The rise and fall of the neoliberal order.Oxford University Press, 2022doi:10.1093/oso/9780197519646.001.0001.
3. World Health Organization. Final report of the WHO council on the economics of health for all. May 2023.
4. World Health Organization. Declaration of Alma-Ata. International Conference on Primary Health Care; 6-12 September.
5. Commission on the Social Determinants of Health. Final report of the Commission on Social Determinants of Health. 2008.
6. Raworth K. Doughnut economics: seven ways to think like a 21st-century economist.Penguin Random House, 2017.
This article was originally published in The BMJ.
*Michael Marmot is the director of UCL Institute of Health Equity, UK; Paulo Buss is the coordinator of Fiocruz Global Health Center.