Arquivo de etiquetas: Equidade

Main Challenges of Climate Change Negotiations V

Problem-Solving Versus Negotiating

I want to talk about the, the nature of the negotiating process and more generally, the nature of the problem-solving process of the 193 governments that are party to the UN Framework Convention on Climate Change.

Let’s go back to an earlier picture, really the core of the logic of negotiation itself. Remember we talked about, in the first chapter of this lecture, the idea that negotiations are to improve the situation of all the negotiating parties relative to the business-as-usual.

951It’s to move to what we called a Pareto improving outcome. In this diagram from the business-as-usual point that is lower in possibilities for all countries to the cooperative equilibrium “C” in which both groups of countries shown in this figure are better off, and because climate change is, after all, potentially such a calamity, moving to a situation better than the one that we are facing in business-as-usual terms is evident, evidently possible. And yet, the negotiations have continuously proved to be extraordinarily difficult; that’s why we’re aiming for a real solution at COP21 that we might have thought would come in COP1 in Berlin in 1995 or COP3 as was attempted in Kyoto or COP15 in Copenhagen when it seemed that the world was coming close to making a meaningful breakthrough.

What are the reasons why it has proved so hard to go from that BAU point to the point “C”, the cooperative Pareto improving negotiating outcome?

I think that there are at least eight reasons that make climate negotiations just incredibly hard compared to almost any other kind of negotiation that one might consider, and it is worth it for us to think about those difficulties, those uncharacteristic difficulties making this issue so distinct in order to overcome these obstacles.

The first problem is that going from BAU to “C” is not an immediate process. Sometimes when you negotiate you’re better off when you get up from the table and you say, “ok we’ve made an advance”, but when it comes to climate change we’re talking about a transformation of the economy, of the energy system, of our technologies, of our behaviors stretching over decades, and we’re talking about seeing gains from that that also will show up mostly over decades and so negotiating over a very long-term process is inherently more difficult than negotiating over an outcome that gives the immediate gratification of an improvement relative to the status quo.

There’s a related but distinct second challenge and that is that when it comes to the actual improvements, that is why C is “better” than BAU, we’re not going to see those improvements for a long time, not just that it is a long time to realize the change, but the costs of action will be borne predominantly within the next two or three decades, whereas the benefits will be felt predominantly in decades to come. And so we have the costs up front, the benefits later-delayed gratification; not the simplest thing for humanity in general for any of us and certainly not the simplest thing for politicians to manage. They are immediate gratifiers to the ultimate extent; they want to win an election; they want to stay in power, so they’re looking at the short term. But, we have compressed in that negotiating diagram short- and long-term and saying that going from BAU to C is an improvement is simplifying a much more complicated situation where costs come early and gains are likely to be felt only much later.

A third problem that is obviously fundamental is that in many negotiations when you shake hands and have reached an outcome, you know clearly you’re better off, but when it comes to climate change there are enormous uncertainties, not the uncertainties that justify climate denial–this is pure anti-science—the basic science is overwhelming. But, there are uncertainties about technologies, there are uncertainties about future costs, there are uncertainties about the specific timing of climate events, there are uncertainties about the capacity to adapt to climate change rather than to mitigate climate change.

This is technically, scientifically, socially one of the most complex issues that humanity has ever faced because it’s global scale, because it goes to the heart of the economic system, because it involves a complex planetary dynamic, and these uncertainties, of course, enable doubt to be magnified, to be manufactured as has been said, into paralysis.

Of course, there is uncertainty. This doesn’t mean a failure, that we should fail to act, but it is one of the reasons why it is so difficult to act.952

The fourth element is that with the timeline and the timing and the uncertainties, the transition required in going from BAU to C is not simply stated. It is not self-evident and transparent, nor is it the product of a small number of actions.

We’re talking about transformation of the core of the energy system. We’re talking about changes of land use on a global scale. We’re talking about changes in agriculture that engages hundreds of millions of people around the world. There is nothing simple about this. We’re talking about an enormously complex process of change even if we could agree fully on what needs to be done and how to do it, we would then, and we will, I hope, face the challenge of implementation that itself will prove to be one of the most daunting aspects of this whole issue.

The fifth aspect that makes this so hard is the, the little fib that is shown in the simple diagram of going from BAU to C. I’ve drawn that picture of two symmetric negotiators, and the improvement is also symmetric. The arrow points up on a 45 degree line from, from the origin of the, of this graph. In other words, the countries are sharing equally, and it’s pretty easy to define in this simple diagram what equal means, but there is nothing equal about the status of the countries that are at the table.

There are huge, powerful asymmetries around the table. Some countries are fantastically rich and others are desperately poor. They have very different points of view. The rich countries often think, “we can impose a solution on the poor”, and the poor countries think “why are we even here being asked to do something when the rich have caused the problem and have the means to solve the problem.” There are big differences in how countries are feeling the advent of anthropogenic climate change.

The small island states know, they know in their gut their country could absolutely disappear under the waves. With rising sea levels, countries are threatened with their very survival, the case of some of the small island states.

Some of the big, northern, more temperate zone economies, Canada or Russia, may feel a little bit warmer, well, maybe not all bad; we’re a pretty cold climate much of the year. The sense of peril may not be felt, may not even be as dramatic as is experienced in an island or in a dryland country or in a tropical setting.

Countries really differ by the nature of the damages and harms, though it is absolutely the case no country will be able to stand-alone in a world profoundly perturbed and disrupted by large-scale climate change. Countries also differ, of course, tremendously in the ownership of energy resources, especially fossil fuels. Some countries are fossil fuel-rich, and they are typically saying, “we plan to use those fossil fuels, thank you”. Other countries don’t have fossil fuels; maybe they even have vast renewable alternatives and they’re saying, “stop the fossil fuels. Let’s move to alternative form of energy”. It’s easier for them to say that, more convenient. Not only do they not feel the lobbying pressure from the owners of the fossil fuels, but for countries that don’t have their own fossil fuel resources, the alternatives look more promising and more secure.

This are just some of the very strong asymmetries that make negotiating more difficult, that make defining a fair or focal bargain that says “yes that’s the point on which we should all agree”–a more daunting task.

953This comes to another point, what is fair? If we were all the same and symmetrically placed around the table, fair would be quite obvious. If a group of individuals is dividing the cake, and there’s no other reason, in terms of division, to do otherwise, you try to divide the cake in as close to equal pieces as possible. But, because of the asymmetries, every country has its own standard vision of what’s fair.

Poor countries talk about fairness in terms of wealth and poverty. The highly vulnerable countries, like the small island states, understandably, talk about fairness in terms of impact of climate change. The fossil fuel-owning countries talk about fair in terms of the right to use their own resources. Other countries talk about fair in terms of an equal allocation of the atmospheric space for greenhouse gas emissions, and so on.

These are all aspects of fairness, and the fact that there are so many different perspectives, of course, means that reaching an outcome–not that it’s impossible because countries could all say, “even though we differ in our moral judgments, ethical judgments, sense of fairness, we’re all better off at the following point”, but it does make it harder to find that point.

Then, as we discussed in the case of the Prisoner’s Dilemma, there’s a huge problem of trust. “Okay, we could agree, but how do I know you’re really going to carry that out. I have to go back to my parliament or my congress or my party and explain what I’ve committed to and they’re going to say, ‘you committed that when the others are not really going to follow through.'”

This is a standard problem of any kind of agreement. In an arms agreement, the peace negotiators may come home to find huge objection by saying, “you have entrusted our country on the basis of a promise that will not be fulfilled by the others.”

So, the whole question of finding a binding solution, one that can be monitored, one that can be verified is a part of negotiations.

Here just as it has long been a major part of arms limitation agreements and other kinds of geopolitical negotiations. And then the eighth point is, of course, very particular, powerful interests. Some of these interests are enormously concentrated. Some of the big oil companies, of course, face almost an existential question, “if we’re going to have a 2-degree C limit, what happens to us?

What happens to our multi-gazillion dollar capitalization in the marketplace? How will investors value us?” What will happen, asks the CEO, to my wealth, to my income, to my pension, to my position? And, put it the other way, some of these interests are extraordinarily powerful. They’re major political powers in their country, and they are able to shape the political discussion and the national negotiations.

And, of course, individual countries around the table also can play that role. It’s probably the case that if there’s a vast consensus about what to do, to unanimity, will not be the rule. But if any of the major countries–China or the United states or India or the European Union–say, “No way!” that makes a deal extraordinarily difficult, and so individual countries can play a pretty decisive role in blocking an agreement even one that has been agreed by dozens and dozens of other countries.

you might say, “that’s pretty exhausting”, and it has been exhausting because we have gone through 19 Conferences of the Parties. We’ll have the twentieth in Lima in December and the twenty-first in Paris in December 2015 and still no breakthrough. But, it may be in part because we have been looking at this whole issue in the not quite correct way.

If the negotiations are viewed as a largely zero-sum game that “I can’t make a concession because you’re going to get the big prize” or “you do more, I do less” or “you pay for it, I don’t pay for it” or “you have your historical responsibility, I don’t have to participate”; when it’s viewed as one versus the other, then all of these problems that I have discussed are brought to the fore.

If, however, the sense of the discussion around the table were somewhat different starting from the point “we are collectively in a mess; it is a horrendous problem facing everybody in the world, and we’re all in this together”, then the spirit of these discussions could be quite different. And I would compare this in the following way. One might view this as a poker game. Each negotiator is holding their cards, looking across the table. The US negotiator is looking at China; “what are they doing? What are they promising?” The Chinese negotiator is looking back at the US and casting a glance over to the European Union. Each side is wondering who is going to take the pot; how are we going to divide this?

But a quite different view would be the same group around the table; the men and women’s sleeves rolled up saying, “My God, what are we going to do? This is a horrendous problem. We’ve got to figure this out.” So it would be less of a poker game and more of an intense brainstorming and problem-solving; the kind of thing you’d see in a movie as world leaders get together pondering what to do about the asteroid coming towards the earth or the alien space invasion that suddenly unites all of humanity into a common force because the problem is external, shared by everyone, and requiring creativity, fortitude, bravery, brainstorming, far-sightedness.

And yet another analogy that I find very important and compelling is the idea of an orchestra; brainstorming, sleeves rolled up and trying to figure this one out. An orchestra is trying to make beautiful music together.

In other words, trying to implement a solution. The solution could be a wonderful symphony or the solution could be deep decarbonization. Now, one might immediately ask, “if it’s an orchestra, if the world’s to make beautiful music together, where’s the conductor? How is this going to be brought about?” And that in recent years is drawn my attention to a phenomenon known as the conductor-less orchestra. Here, you’re looking at Olin conductorless orchestra. They are a chamber orchestra playing beautiful music together; well worth listening to on Youtube. There’s no conductor. There is no single individual. There is, however, a score.

They all have the score in front of them. They’re playing to the same sheet music. That I believe is the closest analogy, at least that I can come up with, to what we ought to be doing. We do have the same sheet music; we have the 2-degree centigrade limit. We know what we need to do in terms of the global performance. We could have in front of everybody’s stand the respective deep decarbonization pathways that each country is playing its music, is pursuing its own designed deep decarbonization pathway. There is no single conductor, but in the aggregate, the music makes sense; it does keep the world safe.

So I believe that we are too much thinking of poker players, too little thinking of the brainstormers or the conductorless orchestra, and when it comes to the poker playing what really worries me is that the players around the table are not only looking at their hands, actually all of their cards are blank. They don’t know what’s on their cards or what’s their national interest.

What can they be doing? They don’t necessarily know because they haven’t made the analysis of a deep decarbonization pathway. They may think they’re defending their national interest, but how can you know the national interest unless you have investigated the real benefits and costs of alternative pathways, and alas, that has not happened. And one of the reasons that has not happened is that the players around the table are not quite the right players. That chamber orchestra would not be quite so interesting if every musician was playing a violin. It’s the mix that’s crucial to get the right music, but who’s at the table? The table is the government.

Of course, it’s the diplomats; they are not technologists; they are not engineers; they are negotiating very much from the point of view “don’t make concessions, have the other country make concessions.” Not, “how are we going to get carbon capture and sequestration working more rapidly?” Who should be around the table for this kind of problem solving and implementation? Well, the politicians should be there; they represent the governments that put the public policy into place but also the technologists, the engineers, the scientists who can say carbon capture and sequestration–this can be done if we can overcome the following technical obstacles. Or look at the possibility for energy storage with this technology if we can just push it over the boundary to commercialization then we’d all have much more running room.

The companies should be there as well. Both the established companies and the startups. Now, you might think if the companies are there that’s all lobbying, but I actually want the companies pulled to the table. What are the oil companies doing outside saying, “This isn’t our responsibility.” Just making huge amounts of money, lobbying behind the scenes perhaps to slow things down but not being at the table. When recently some of the big oil companies, Exxon Mobile and others, said, “We don’t believe in the 2-degree Celsius as a feasible goal.” I think that is pure moral hazard or immoral behavior. It’s not for a company, which is a major emitter and a beneficiary of inaction, to decide by itself what’s feasible or not; it has to be there exercising responsibility and indeed following public policy.

And citizens more generally need to be at the table, and that’s why I am going to emphasize shortly in the final lecture the role of global goals that are clear, that are succinct, that are understandable by everybody; this is not a technocrat adventure; it’s not a political insiders game; it’s not a business deal or a lobbyist’s dream; this is a citizen’s issue of the first-order of importance for the world. In the DDPP itself, in our Deep Decarbonization Pathway Project, as Emmanuel Guerin described to you, we had our own brainstorming and negotiating and thinking and working together across 15 countries, we realized, even as a group of strongly motivated, environmentally conscious, determined to help fight climate change group, it’s not easy to get to 2 degrees C; it’s going to require a huge effort even in the modeling itself, much less in the actual implementation.

Even within a project, therefore, you see that the brainstorming, the idea that we need to find our way, step-by-step together to meaningful solutions applies. And that needs to be the spirit around the table as world leaders from business, civil society, government, academia, technologists help to find a path forward. In the next lecture, I’ll talk about how we could help to make the negotiating process fit that purpose and do so in time for success in COP21.

Why Did Some Countries Advance While Others Remained in Poverty? III

The Role of Culture: Demography, Education, Gender

We’re making a differential diagnosis of why countries get stuck with their bad economic performance. We’ve looked at, how poverty traps can hold poor countries in a grasp preventing them from making the basic investments to move forward. We’ve looked at how physical geography, the presence or lack of fossil fuels. That the proximity to or distance to the coast.

431The nature of the climate system. Can shape economic development. Very often, people turn first to culture as the explanation, of why some places are ahead, and others behind. It’s often quite glib, because,rich people like to say, we’re rich because our culture is better, rather than to say, we’re rich because we have lots of energy resources, good coastal proximity, and a healthy climate. And rich people often like to blame poor people for their problems, say, well, they’re lazy, they’re not working very hard. And throughout history, places that were once poor and they became rich were known quote unquote as lazy places, during their period of poverty. And then once they became rich, their culture was used to explain their hard working ethos. So culture can be a bit of an optical illusion. A little bit to easy sometimes, as an attribution or a cause of a countries conditions. And we should remember that cultural phenomena, people’s beliefs and attitudes, their views towards appropriate roles in society. Change over time as well. SO culture isn’t a fixed monolit. I believe culture has a role, however, though not as big a role as sometimes thought. And we should focus on those atributtes of a societies values, its norms, Its attitudes. As ways that can be promotive or barriers to sustainable development. I want to focus on three. One is on demography and population. The second on education. And the third, regarding gender[1]. When we look at the population challenge, a good place to start is this world map of the fertility rate. The total fertility rate in a country, and you’ll recall Measures on average the number of children that a woman will have during her lifetime. It looks at the age-specific fertility rates for women in a society, and then says, if women age 20 to 25 on average have this many children, women age 25 to 30 have this many children, and so forth, Then on average over the course of a woman’s lifetime reproductive years, an average woman in this society would have this number of children. What the world map shows, is the tremendous variation in our world today in the total fertility rate. In many parts of the world, especially the high-income world today, fertility rates are below two.

432That means that each woman, on average, is having fewer than two children. It means, since half the children are boys and half the children are girls, On average, each woman is having less than one daughter. Or, if you say, 10 women, in total would be having fewer than 10 daughters. You can see that when fertility rates are below two. So, that, on average, each mother is not replacing herself in the next generation with a daughter. Statistically speaking that the population would tend to, be stable or declining. When the total fertility rate is above two, then the population would tend over the longer term to increase. So, if in high-income world on this map we see total fertility rates below two. We also see in some of the worlds poorest countries in notably in Africa and in parts of South Asia, total fertility rates above four and many rural areas in low income tropical Africa we have total fertility rates above six.

That is a pooe household would, on average, the woman would be having six or more children. This tremendously effects economic development because with very large populations of young children, poor families Have a very difficult time providing the basics for all of their children, maybe just the eldest son is able to go to school and the girls are married at a young age or working the fields about proper education and that means that in the next generation those young girls will grow up without the literacy and the skills that they need. To help their own lives their own children and the national economy to be productive. So countries that had made, a transition from high fertility rate to low fertility rates, have tended to have an advantage in economic development. Countries that have still today very high fertility rates tend to have much lower economic growth. To a certain extent, this is a matter of income itself. It’s not really a matter of culture. Poorer families, living on farms tend to have more kids. And have less access to family planning to contraception, the girls don’t have access to schools and don’t go to school and are married young and begin having children at a very young age, but to some extent at least fertility rates also reflect culture, lets look at one example of a society that move rapidly, From high fertility rates to much lower fertiliity rates.

433That’s China. They did that by and large through a government policy known as the One Child Policy. And while it’s been very controversial, notice the implications of this policy. What has happened, in a very short period of time. Family size has come down rapidly and parents have invested intensively in their one or sometimes two children. And so that within one generation, the levels of education, health, nutrition of Chinese young population has soared. This played an enormous role in China’s very rapid economic development. So some places by virture of culture, politics, of history, have still very high fertility rates. Other places have made a rapid transition. To lower fertility rates. And the record shows very clearly that those countries experience faster economic growth, better health for the children, and higher educational attainments. Over time this fertility rate shapes the population dynamics. Whether the population is rising or declining in overall size, and the age distribution of the population shown here by the age population pyramid so called, what these pyramids show, are the numbers of boys and girls or men and women at various ages,uh showing the age structure of the population If you look at Japan’s population, for example, in 1950 when fertility rates were still rather high, The number of children at the bottom of the pyramid was much larger than the number of their parents, and far larger than the number of the grandparents. By 2005, the shape of that pyramid had changed considerably.

Japan had reduced its fertility rates. Partly as a result of culture, partly as a result of economic development, partly as a result of public policy. And so now the number of children were actually fewer than the number of parents because the fertility rate had come down below two. And the whole age structure, therefore, wasn’t a broad pyramid with a big, big base of young children. But was now much more similar in numbers of population at all ages. By the middle of this century, because of the continuing low fertility rate, the population age structure will be an inverted pyramid. Few children, many more older people. And that’s how the transition occurs when fertility rates come down. Most of today’s very poor countries have that big base pyramid. Huge numbers of very young children to be supported. How are they going to be educated? How are they going to get the healthcare and the nutrition that they need? Only if today’s high fertility countries are able, through matters of public policy, cultural attitudes, and so forth to help reduce those fertility rates. And the best way is through the voluntary choices of, households who decide to reduce the number of children so that they can invest more per child and help raise healthy and better educated children, unless that happens, then the problems of the large numbers of children outnumbering their parents will continue to make very difficult the economic development of the poor countries. Another cultural phenomenon involved attitudes towards education. Some poor societies even in a state of great poverty, by tradition, by culture, focused a huge amount of effort and attention on literacy. Korea is one such country. Korea even when it was impoverished in the middle of the last century had a very high literacy rate, and there was always great attention in Korea’s modern history to broad based literacy. Well that’s a cultural attitude as well as a government policy. And it’s done very well for Korea since the middle of the century and the terrible Korean war that took place and devastated so much of Korea. In South Korea, we’ve seen some of the most successful economic development every attained, some of the fastest economic growth And with a rather widespread prosperity. A huge part of that has been facilitated by this continuing commitment to broad based, high quality education. And indeed this shows up in international test scores. What you’re looking at here are the rankings on International testing, in science and math. Where is Korea? Right at the top. It’s not the richest country in the world, but it is right at the top ranks number one or number two, definitely in almost every, test and cateogry, within the top few countries in educational performance. This reflects not only public investments in education, but it reflects parental support for their children, urging their children to excellence. It reflects a culture that has long strongly valued education, and thereby made it possible for Korea to become a world leader in technology. And one of the fastest growing countries in the world. A third cultural attitude, that deeply influences patterns of economic development, are attitudes towards women. Do women have rights? Are women participating in the labor force? Do women face massive discrimination? So, gender equality or inequality also has, political aspects, but culture plays a significant role. Once again, as with fertility and as with education, there are big differences around the world. In attitudes towards gender equality in attitudes towards women, even in the physical safety of women from violence. One can see the many, many ways that this influences economic development. There’s probably not a society in the world where women still do not face at least some discrimination. It took Tremendous political effort, social mobilization, and a lot of courage of women to break through this discrimination even in places today that we  view as close to gender equality if not fully there. But there are many parts of the world of course where women still face profound, profound barriers. To their economic participation, to their political particiiaption to hteir role in society. What are the consequences of that? A society that tries to run on half its brain power on half its human capabilities, block the role of women. In problem solving, in economic leadership, in a political role. A country that’s running on only half its human resources is bound to fall behind countries that are empowering all of their citizens, women and girls as well as men and boys. Countries where young girls may have one of two years of schooling, but then because lack of interest, lack of budget, lack of family attention and effort, are forced to drop out of school, marry young, start having children young, do not have the productivity to participate in a modern economy.

Face a tremendous amount of poverty and suffering themselves. And by dint of that are likely to be raising children in poverty as well. Now, this is an area where there have been huge changes, fortunately, in the right direction. Over the last 30 years but by no means uniformed. Look at this wonderful picture of the rowandan parliament, it may surprise you to know that rowanda’s parliament is not only more than half  omen, but has the highest porportion of women in it’s parliament in comparison with the rest of the world. And women’s participation in politics has soared in Rwanda and it is rising in other parts of the world, though still with the huge inequalities and still a tendency towards men dominating. Political power. In Rwanda you can see the wonderful benefits of this turn towards women’s empowerment.  and Rwanda has made astounding progress in reducing child mortality. It’s making big progress in improving education. Social conditions have improved dramatically. And while there are many factors that are contributing to Rwanda escaping the poverty trap, the role of women in the parliament in my opinion has played a significant role, Not only are, these women powerful role models for young girls in Rwanda, and I think Rwanda’s success. In light of this experience is a very powerful nessage for countries that are still lagging behind. Don’t try to develop with only half of your citizenry. Take the lesson that a country that is mobilizing all of its citizens, its girls, women, as well as its. Boys and men, is a country that’s going to have more success in the 21st century


Economia da Saúde e Equidade – (Saúde Global VI)

O primado da equidade na Saúde Global é uma questão do senso comum, tal como o é a ligação entre o crescimento económico ou o desenvolvimento e a existência dum sistema de saúde eficiente. Neste pequeno texto procuramos abordar a relação existente entre a economia e a saúde pública (global) e pensar de que forma é que a equidade se refleta no desenvolvimento duma Saúde Global.

A questão da equidade é um tema que vale a pena pensar em primeiro lugar. Em 1999, quando foram estabelecidos os ODM, as questões da Saúde e do acesso à saúde foram separadas em vários objetivos: A Saúde das grávidas, das crianças, a redução da pobreza, o combate à má-nutrição. Todas elas constituem determinantes para diminuir a mortalidade e assegurar uma maior igualdade entre os seres humanos. Quando hoje estamos a avaliar os resultados dos ODM, temos que reconhecer, que em relação aos vários objetivos previstos nos ODM se registaram avançao consideráveis. Mas também temos que reconhecer que ainda há lugares (espaços) onde há problemas. Ou melhor, onde os indicadores não diminuíram de forma tão acentuada. Ao mesmo tempo também podemos verificar, que mesmo no interior de espaços onde se registaram fortes diminuições das taxas de incidência dos problemas a resolver, existem grupos dentro de espaços (regionais ou nacionais9 onde essa diminuição também não é tão intensa. Em suma nestes quinze anos foram atingidos bons resultados através duma diminuição significativa dos macro indicadores. Contudo, entre os mais pobres e nas regiões mias pobres do mundo, a tendência de diminuição é menor, verificando-se mesmo em alguns casos algum aumento.

Como é que estas questões podem ser resolvidas no âmbito dos ODM, ou dos futuros ODS. Uma das questões que está na agenda de discussão é a relação entre a equidade e o desenvolvimento, seja da economia, seja dos sistemas de saúde pública.

A equidade tem sido fundamentalmente abordada como a procura de uma ausência nas disparidades no acesso aos sistemas de saúde. Contudo, a questão da equidade deverá passar a ser colocada, não em termos de acesso ou cobertura do sistema de saúde, mas como uma das questões chave na construção dos determinantes sociais na resolução dos problemas da Saúde Global. Equidade não é apenas uma questão de existência do sistemas ou da sua acessibilidade, é também uma questão que implica a redução das desigualdades sociais.

O desenvolvimento económico é tradicionalmente visto como a solução para resolver os problemas dos sistemas de saúde global. Há uma convicção que aumentando a riqueza num dado território, essa riqueza se distribui pela sociedade, sendo aplicada na resolução dos seus problemas sociais. No entanto, como podemos verificar a partir das análises sobre os indicadores de saúde nos países mais desenvolvidos, não basta trabalhar sobre os indicadores para resolver os problemas da saúde global. Nos países mais desenvolvidos é necessário atuar sobre os determinantes sociais.

Durante muito tempo considerou-se, por exemplo, que bastava aumentra o PIB num país, para isso se reflectir no aumento da esperança média de vida. E efectivamente isso acontece até certo ponto, considerando-se uma valor médio entre os 3.000 e 5.000 U$. A partir dessa valor o impacto do crescimento do PIB tende a ter uma menor relação no aumento da esperança de vida. No entanto, a curva de crescimento tende a ser ligeiramente superior nuns países do que noutros. Nos países onde se verifica uma menor distância entre os mais ricos e os mais pobres, a tendência para o crescimento da curva é maior do que nos países onde a diferença entre ricos e pobres é mais acentuada. No caso do Japão, onde a distribuição da riqueza nacional é mais equitativa, a esperança de vida é maior, do que nos Estados Unidos, onde essa distribuição é menor. Significa isso, que, nos EEUU a esperança de vida é maior nos mais ricos do que entre os mais pobres. Há uma evidência sobre o impacto da distribuição de riqueza na sociedade.

Em “The Spirit Level” de Key Pickett e Richard Wilkinson” abordam a questão da equidade nas sociedade e do impacto sobre a distribuição da riqueza na fomação dos indicadores sociais. Nas sociedade mais desiguais os diferentes indicadores sociais e os determinantes sociais dão indicações de que há um esforço social que é canalizado para apoio aos mais pobres e para a resolução de problemas que a desigualdade gera. O sistema de saúde global reflecte esses problemas sociais, em questões de saúde, saúde mental e mesmo obesidade.

O Relatório sobre o Desenvolvimento Humano , de 1993,  ou o Relatório da OMS sobre a Macroeconomia e Saúde , de 2001, demonstram que a Saúde não e apenas um produto do desenvolvimento, mas que existe uma relação bidireccional entre os dois e que existe uma relação entre a equidade nas sociedades e a sua capacidade para alcançar melhores níveis de desenvolvimento económico.

É evidente que é necessário que se invista no crescimento económico para aumentar a riqueza social que permita canalizar recursos para os sistemas de saúde pública. Mas o inverso também é verdadeiro. È necessário investir nos sistemas de saúde pública para potenciar o crescimento económico. Melhorar a vida e a saúde das pessoas é aumentar os ativos da sociedade. Com mais ativos há possibilidade de produzir mais riqueza.

A demonstração de que sociedades mais iguais tem desempenhos na saúde publica mais elevados é também a demonstração de que o crescimento global da economia também é assegurado por sociedades mais iguais. A construção de sociedades mais equitativas é uma prática que deve ser incluída nos determinantes sociais dos sistemas de saúde global.

A ideia de equidade social está também ligada à ideia de sociedades mais justas. Sociedades mais justas, durante muito tempo, foram pensadas como sociedades que desenvolviam igualdade de oportunidades. Assegurando, pensava-se, o acesso aos sistemas de saúde, de educação ou outros serviços sociais, cada uma dispunha de condições para construir o seu caminho. Sendo certo que entre os seres humanos há quem aproveite melhor as oportunidades que num dado momento estão disponíveis, não deixa de ser verdade que a sociedade não pode pensar que a questão da equidade se resume a assegurar um mesmo ponto de partida. Na verdade, no processo de desenvolvimento há grupos socias que são marginalizados e excluídos. São pessoas que estão em dificuldades para aproveitar as oportunidade. Ora, no processo de desenvolvimento todos são úteis. Quem não participa nos processos sociais de forma ativa, constitui um entrave ao desenvolvimento do conjunto. Dessa forma, a questão da justiça social deve também pensar na equidade horizontal e na equidade vertical.

Equidade horizontal, relaciona-se com o conceito de igualdade para todos. Tratamento igual para todos e acessibilidade para todos. A equidade vertical, parte da necessidade de desenvolver acções específicas para grupos específicos da sociedade. O processo de desenvolvimento coloca certos grupos em desvantagens que devem ser compensadas através de ações. Todos devem participar. É necessário das acesso a todos, mas também é necessário que todos tenham oportunidades de ter acesso. Assegurar a participação de todos nos processos, é uma ação do sistema global de saúde, mas também dos demais sistams sociais, como por exemplo a educação, a habitação, o saneamento e a cultura.

Em suma não basta criar condições de acesso universal. É também necessário criar oportunidades de acesso universal, com condições ajustadas a cada grupo. A construção de serviços de saúde adequados é uma forma de trabalhar os determinantes sociais que os indivíduos necessitam para agir. Não é apenas a acessibilidade que interessa atingir, mas a capacidade dos indivíduos de agirem. De se tornarem autónomos. E de desempenharem o seu papel na sociedade.

Por fim, ainda nas questões sobre a equidade, é também necessário assegurar uma equidade intergeracioanal. Não basta nos dias de hoje, usar os recursos disponíveis para resolver os problemas de hoje, sem pensar nos recursos que as gerações futuras necessitam para resolver os seus problemas. A equidade não é necessário apenas entre a sociedade, mas também entre gerações.