Editorials

Global public goods and health Richard D. Smith1

Health improvement requires collective from them by many people, there is no study finds that, while the concept has as well as individual action, and the health commercial incentive for producing them, important limitations, for some areas of of poor populations in particular requires since enjoyment cannot be made condi- health work it can offer guidance in the collective action between countries as well tional on payment. With national public financing and provision of global health as within them. Initiatives such as the goods, the government therefore programmes. In these areas it provides a Global Fund to Fight AIDS, Tuberculosis intervenes either financially, through such framework for collective action at the and Malaria reflect a growing awareness mechanisms as taxation or licensing, or global level, demonstrates the advantages of this fact. However, initiating, organizing with direct provision. But for global public for the rich in helping the poor, and and financing collective actions for health goods this is harder to do, because no provides a rationale for industrialized at the global level presents a challenge global government exists to ensure that countries to use national health budgets to existing international organizations (1). they are produced and paid for. The central to complement traditional aid (as seen The concept of ‘‘global public goods’’ issue for health-related GPGs is how in the Polio Eradication Initiative (9)). (GPGs) suggests one possible framework best to ensure that the collective action Overall, the GPG concept will be for considering these issues (2). In this necessary for health is taken at the increasingly important as a rationale and expression, ‘‘goods’’ encompass a range international level. a guide for public health work in an era n of physical commodities (such as bread, Globalization of travel, changes in of globalization. books and shoes) but includes services technology, and the liberalization of trade (such as security, information and travel), all affect health. Communicable diseases 1. Drager N, Beaglehole R. Globalization: changing the public health landscape. Bulletin of the distinguishing between private and public spread more rapidly, often in drug-resis- World Health Organization 2001;79:803. goods. Most goods are ‘‘private’’ in tant form (4), environmental degradation 2. Kaul I, Faust M. Global public goods and health: the sense that their consumption can be reduces access to clean air and water, taking the agenda forward. Bulletin of the withheld until a payment is made in and knowledge of traditional and modern World Health Organization 2001;79:869-74. exchange for them, and once consumed health technologies is increasingly pa- 3. Kaul I, Grunberg I, Stern MA, editors. Global they cannot be consumed again. In tented and thus made artificially excludable public goods: international cooperation in the 21st century. New York: Oxford University contrast, once ‘‘public’’ goods are provided (5). However, discussion of GPGs to Press; 1999. no one can be excluded from consuming date has typically been broad-based and 4. Smith RD, Coast J. Antimicrobial resistance: them (they are non-excludable), and one multisectoral (for instance on the envir- a global response. Bulletin of the World Health person’s consumption of them does not onment, international security and trade Organization 2002;80:126-33. prevent anyone else’s (they are non-rival agreements), and most of the discussion 5. Thorsteinsdo´ ttir H, Daar A, Smith RD, Singer in consumption)(3). For example, no one within the health sector has been focused P. Genomics — a global public good? Lancet 2003;361:891-2. in a population can be excluded from on medical technologies (3, 6, 7). 6. Kaul I, Conceic¸a˜ o P, Le Goulven K, Mendoza RU, benefiting from a reduction in risk of This has left many questions unan- editors. Providing global public goods: managing infectious disease when its incidence is swered (8). For example, is health itself globalization. New York: Oxford University reduced, and one person benefiting from a GPG? To what extent does my (national) Press; 2003. this reduction in risk does not prevent health depend on your (national) health? 7. Macroeconomics and health: investing in health for economic development. Report of the anyone else from benefiting from it as well. How many of the actions necessary to Commission on Macroeconomics and Health. Global public goods are goods of this global health — communicable disease Geneva: World Health Organization; 2001. kind whose benefits cross borders and control, generation and dissemination of 8. Smith RD, Beaglehole R, Woodward D, Drager N, are global in scope. For example, reduc- medical knowledge, public health editors. Global public goods for health: a tions in carbon dioxide emissions will slow infrastructure — constitute GPGs? What health economic and public health perspective. global warming. It will be impossible to contribution can the GPG concept make Oxford: Oxford University Press; 2003. 9. Aylward B, Acharya A, England S, et al. Achieving exclude any country from benefiting from to fulfilling these needs? Is international global health goals: the politics and economics this, and each country will benefit without financing for these GPGs best coordi- of polio eradication. Lancet (forthcoming). preventing another from doing so. Simi- nated through voluntary contributions, larly, the eradication of infectious diseases global taxation systems, or market-based of global scope, such as smallpox or polio, mechanisms? Does the concept of GPGs provides a benefit from which no country undermine or support concepts of equity is excluded, and from which all countries and human rights? will benefit without detriment to others. The first large-scale study of the However, these attributes of public application of the GPG concept to the goods give rise to a paradox: although health sector examines questions such as there is significant benefit to be gained these, and has just been published (8). The

1 Senior Lecturer in Health Economics, University of East Anglia, Norwich NR4 7TJ, England (email [email protected]).

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