Paul Farmer Memorial Resolution

On Tuesday, March 7, 2023, a coalition in the U.S. House of Representatives and U.S. Senate announced the reintroduction of the most bold and ambitious global health legislation ever introduced in Congress: The Paul Farmer Memorial Resolution;
 
Led again in the House by Representatives Jan Schakowsky, Barbara Lee, and Raul Ruiz, and for the first time in the Senate by Senators Sherrod Brown, Ed Markey, and Elizabeth Warren, this coalition is proposing what they've termed a "21st century global health strategy," based on the life's work of the late Dr. Paul Farmer. It enshrines Dr. Farmer's vision for global health equity to serve as a "north star" for global health politics for years to come. 
 
The resolution proposes a goal of conferring universal health care globally to prevent over one hundred million unnecessary deaths per decade by inflecting the flow of trillions of dollars in the global economy. After its introduction in the House last year, the resolution gained 24 cosponsors.

Dr. Farmer argued our world has more resources than at any point in history. Yet, tragically one hundred million people die every decade because they lack access to basic medical care. There's no way we stop this injustice without ensuring the poorest countries have more resources to build health systems. As Paul Farmer pointed out, poor countries have developed rich countries for hundreds of years, not the other way around. We must reverse this trend as a matter of justice. 

1. Increasing U.S. government global health spending to $125 billion per year, sufficient to: 
   • Meet around 30% of the "essential universal health care" financing gap for low- and lower-middle income countries
   • Allow the U.S. to meet the U.N. aid target of 0.7% GNI for the first time
2. Reforming global health aid to: 
   • Focus on supporting national health systems & direct funding to align with local plans and priorities, not the development industry
   • Develop new medical technologies for diseases of poverty and ensure their availability as global public goods
3. Make the global economy more fair, just, and democratic so that the poorest countries have more resources by: 
   • Democratizing the IMF, World Bank, and World Trade Organization so that poor countries have equal representation and a greater say over decisions that affect their economies and their ability to finance health systems
   • Global debt cancellation for all developing countries that need it, acknowledging these debts have often been unjustly imposed and maintained
   • Ending harmful licit and illicit financial flows from poor countries
   • Supporting global labor rights, such as a global minimum wage
4. Reparations, including award, apology, and guarantee of non-repetition of harms for: 
   • The institution of slavery, and harms of colonialism, imperialism and ecological breakdown

The Paul Farmer Memorial Resolution- An Explainer

The purpose 

This resolution will serve as a 'North Star' for global health politics for decades to come. This is a first step to raise aspirations in a new reinvigorated, decades-long push for global health equity. As an organizing tool the resolution serves as a basis for debate and discussion between Members of Congress and civil society on global health strategy. Specific legislation from each of the resolution's core pillars will emerge from this effort in the near future. 

A fundamental problem in global health is the low aspirations of people in power, borne partly out of a misunderstanding of the causes of and solutions to global health inequity. Dr. Farmer termed these chronically low aspirations as being "socialized for scarcity on behalf of others." This resolution is Congress's most serious effort to address this problem. 

Resource constraints

Over 100 million people die each decade because they lack access to basic health services, what Paul often referred to as "stupid deaths."

The spending gap to achieve essential universal health care in low- and lower-middle income countries, according to the Lancet Commission on Investing in Health, is around $350 billions per year (in 2016 U.S. dollars). Experts believe that this investment to confer essential universal health care would avert the vast majority of medically unnecessary deaths, approximately 100 million per decade.

While $350 billion seems like a large figure, it represents only 0.5% of the G20 GDP in 2021, and only 2.8% of the wealth possessed by billionaires in 2021. The problem is not a lack of resources but an unjust distribution of them. 

"Many of the poorest developing countries presently lack the tax capacity to mobilize the necessary resources to close the universal health coverage financing gap," the resolution states, "meaning unnecessary deaths will continue in these settings for the foreseeable future without external donor financing or dramatic increases in domestic tax capacity." 

And not only will weak health systems causes mass, unnecessary deaths in poor countries, but they will leave all countries vulnerable to pandemics. 

The resolution states: "weak health systems that fail to prevent unnecessary deaths also lack the staff, health facility infrastructure, and medical technologies requires for effective care delivery and thereby disease containment, thus placing all countries at increased risk of pandemic disease."

The Financing Solution

There are two ways to mobilize these resources in the near future: 

1. Increase the amount of resources for health systems flowing into countries
2. Grow the domestic tax base of poor countries so they can finance health systems into themselves

The resolution proposes to achieve these objectives, respectively, by increasing the amount of quality of global health funding and implementing global economic reforms. 

Increasing global health aid

U.S. global health aid has stagnated. The resolution states, "regular annual United States appropriations for global health increased by merely 10.6 percent to $11,300,000,000 since 2010, and have been outpaced by both inflation and the United States economic growth."

Contrary to population belief, we have room to significantly increase development spending. 

As the resolution states, "Relative to the size of the United States economy, the United States official overseas development spending is low at 0.17 percent of gross national income (GNI) in 2020, placing the United States 24th out of the 29 country members of the Organization for Economic Cooperation and Development's Development Assistance Committee, and meeting just one-fourth of the United Nations official development assistance target of 0.7 percent GNI." Six other countries have met this goal previously. 

The resolution proposes increasing global health spending from $11.4 to $125 billion annually by meeting a long-standing UN aid target, the U.S., by itself, could meet around 30% of the global financing gap for essential universal health coverage in low- and lower-middle income countries. 

Improving aid efficiency

If our goal is to build strong health systems capable of ending preventable deaths and stopping pandemics, we should be directly funding those health systems. 

The resolution argues we should reform global health delivery spending to make sure it funds public institutions in alignment with national health plans, not private contractors in the development industry. We should fund areas seldom funded in global health, like the creation of hospitals and clinics, new medical and nursing schools, and the payment of existing clinicians. 

Finally, the resolution also points out that medical technologies for diseases of poverty are rarely researcher; and medical technologies are also priced out of reach for the global poor. One use of the $125 billion in spending should also be to fund an ambitious R&D program that results in new technologies available as global public goods-- not kept away form the global poor behind patents, trade secrets, and market forces. 

Ending economic exploitation of developing countries 

The fundamental question of the resolution is: why don't poor countries have the resources to provide universal health care?

The resolution points out that the current global economic architecture siphons resources form poor countries to rich countries. And that this is by design, from the colonial period to today's governance structure of the World Trade Organization, International Monetary Fund, and World Bank. 

Still today, poor countries develop rich countries, rather than the other way around. Research from Global Financial Integrity estimates that an upwards of $2 trillion more flows out of poor countries them into them each year. That's over ten times the entire global aid budget. 

The resolution argues that the global economic harms being done to poor countries today amount to many times the $350 billion cost of essential universal health coverage.

In an era of stagnation, action on global economic justice is a smart and just way to support health systems strengthening and pandemic preparedness.

For instance, capital flight from developing countries costs them an upwards of $1.7 trillion each year. Most of this capital flight is made up of illegal financial flows and equates to around 5 times the cost of essential universal health care. Furthermore, the imposition and maintenance of unjust external debts and the resulting compound interest, meant that for 2021 developing countries had a debt service obligation of $356 billion on public and publicly guaranteed debt.

The resolution argues that if U.S. policy is to care about ensuring poor countries build strong health systems, it must also aim to stop the economic harm being done to these poor countries, which prevents them from mobilizing the domestic resources for health spending in the first place. 

The resolution lays out a variety of policy areas where the U.S. could use legal and diplomatic power to make the global economy more fair, just, and democratic. 

Reparations 

The resolution emphasizes that justice requires not only stopping the ongoing harms that maintain a postcolonial divide in the global economy and undermines the health and wellbeing of people around the world but also redress for past harms and their legacies, including the institution of slavery and harms of colonialism, imperialism, and ecological breakdown.