Category Archives: Leadership

Performing health equity: A repeat prescription from yesteryear

In a recent paper in the International Journal for Health Equity, Berenson et al. deliver a hopeful vision of a world better able to take advantage of SDH research. Had the article been published in 2015, it would have landed in a world positioned to take full advantage of the prescription. Unfortunately, the very value frame that supports SDH interventions has fractured. They note this in the lightest way possible, citing a paper by Woolf et al. as evidence of “adverse political environments” for SDH. This characterisation completely undersells what Woolf et al. actually observed — a complete ban, a dismantling, of any research on SDH-style categories: equity, race, diversity, and inclusion. Woolf et al. provide what is close to a complete rebuttal of the point Berenson et al. seek to make.

One of the strongest conclusions from the authors is that “SDH researchers must aim to create and cultivate policy windows of opportunity by being active protagonists…” This assumes at least a world with something approaching shared values, not a world in which “social determinants” are not simply contested but openly reviled and its advocates cast as the enemy — where your notion of fairness is an attack on our cultural values, where your racial equality is advocacy for our genetic and cultural replacement. By their own adopted framework (Kingdon), policy windows rely on a conducive political context. That cannot be created by researchers and has not existed for over a decade! The current political context is not simply unconducive, it is actively hostile. If “cultivating policy windows” — something like a horticultural endeavour at the South Pole — were the solution, then climate regulation would have been resolved, and abortion laws would be universal and rights-protecting, but they are in retreat.

Berenson et al. warn against research that risks being too “technocratic and detached from real-world constraints”, that offers “descriptive documentation of inequities” without “confronting the interests and institutions that benefit from the status quo.” They will say, rightly, that they are not naive about politics — that they explicitly concede research alone cannot overcome entrenched power, and devote an entire section to asking whether the problem is politics rather than research conduct. All of that is true. But notice what the concession does in their hands. They file it. Then without any apparent guile or appreciation of irony, they propose a five-point technocratic corrective. What is needed, they say is more methodological pluralism, more multisectoral collaboration, better communication, reformed incentives, stronger “brokering institutions.” These echo the calls made in the health policy and systems research literature for at least the last fifteen years — including in several of the paper’s own citations, e.g., Rasanathan & Diaz 2016.

The paper is at its core an advocacy piece playing to an audience of the like-minded. As with so many pieces from the last twenty months, which have come out of a loose coterie of global health scholars, civil servants, philanthropists, and diplomats, it fundamentally preserves a shared delusion of global order (or its complete irrelevance) and the insights of yesterday’s science conducted under the aegis of that order. They want to preserve the findings as if they are real, but not the shared value system and international human-rights framework on which those findings — and their policy relevance — are contingent. That, finally, is the more interesting question the paper never asks: not why its fifteen-year-old prescriptions haven’t worked, but whether those contingent truths can ever reach beyond the frameworks that made them possible.

Berenson et al. call knowledge and science “a crucial bulwark to combat forces arraigned against solidarity.” But a bulwark is a defensive structure. It only matters if you still hold the ground behind it. And the ground — the shared value system, the international human-rights framework on which every one of their findings depends for its meaning — is precisely what is being overrun, and they do not seek to protect. This is the paper’s absurdity. Until universal values and rights are put back into the intellectual core, prescriptions like this one are not merely ineffective, they are complicit. They sustain the fiction that the problem is technique rather than the loss of the framework that made the technique meaningful. They keep wanting to refill the gas tank after the bandits have stolen the engine.

A New Global Health Architecture: Maximising Health Returns

There have been a number of opinion pieces, resets, and declarations on what is needed in a new Global Health Architecture. These have been authored by diplomats, former Prime Ministers and Presidents, Multi-lateral agency staff and former staff, Philanthropies and peak bodies on what is needed in a new global health architecture. They have appeared in prestigious peer reviewed journals, on corporate websites, and here, I have attempted to synthesise the core messages and draw them together into an aggregate position that can help national governments action some of the ideas.

It starts with the contemporary global health landscape, which is increasingly defined by structural fiscal contraction, evolving geopolitical priorities, and the imperative to sustain health systems performance under conditions of constrained financing. In this context, legacy colonial models of development assistance—characterised by externally driven priorities, fragmented delivery channels, and open-ended commitments—are no longer fit for purpose. A transition toward more efficient, sovereign-aligned frameworks can deliver health at scale across well segmented population groups.

At the center of this transition is a reassertion of national sovereignty. Low- and low-middle income countries have historically been analysed through the lens of deficit-based models—most notably income, poverty and other World Bank style development indicators. In a context of increasing financial constraint and projected stagnation or decline in economic growth, that approach invites systemic failure.

A better alternative is an analysis of countries through the lens of asset-based models and indicators. This shift allows for a reorientation from needs-based allocation towards strategic engagement, in which financially flexible partners align with nationally defined priorities to co-develop fully costed health pathways. Such pathways provide end-to-end cost visibility, improving efficiency and accountability and enabling the precise calibration of health investments against projected returns. The well-established link between health improvement and economic productivity can be operationalised as part of national investment cases.

This reorientation will motivate a shift away from traditional sovereign lending, with its associated conditionalities, as the dominant financing modality. While sovereign lenders have played a critical role in expanding access and supporting system development, their balance sheets are increasingly constrained. Capital markets offer emerging mechanisms to complement sovereign financing in targeted areas where risk can be appropriately structured and priced. Through structured asset-pooling within and across countries, these mechanisms can enhance risk absorption and expand resource mobilisation. Over time, they may progressively relieve pressure on sovereign financing, enabling health systems to access more diversified funding streams while reducing exposure to fiscal volatility. This, in turn, may lessen reliance on sovereign conditionalities and allow national governments greater implementation flexibility.

Operationalising this shift requires the development of a coherent investment architecture. One approach is the development of Population Equity Units (PEUs), which serve as the foundational analytical and financial entities within national systems. These units can be aggregated into stratified Demographic Asset Classes, reflecting variations in projected lifetime contribution, health system utilisation, and responsiveness to intervention. The introduction of such classifications enables a more granular understanding of where investments are likely to generate the greatest returns for national governments alongside the highest health-valued gains.

To support decision-making across this architecture, a Health Returns Value Index (HRVI) can be employed. The Index would provide a standardised metric for comparing Population Equity Units based on anticipated health outcomes relative to cost. This facilitates outcome-weighted health investment prioritisation, ensuring that limited resources are allocated in a manner consistent with maximising aggregate health systems performance. Importantly, such an Index would allow for dynamic recalibration over time, as demographic, epidemiological, and economic conditions evolve.

Within this framework, national health systems can be conceptualised as Health Equity Portfolios. These portfolios comprise a diversified set of Population Equity Units across multiple Demographic Asset Classes, each contributing differently to overall system yield. Standard portfolio management principles can then be applied, including allocation, rebalancing, and risk mitigation. High-performing segments—those demonstrating strong alignment between investment and realised outcomes—can be prioritised for sustained or increased capital allocation.

Conversely, Population Equity Units falling below defined marginal value thresholds may require structured reassessment. In such cases, mechanisms for managed transition, including consolidation or phased divestment, can be introduced to preserve portfolio efficiency. These processes should be governed by transparent criteria and embedded within broader national planning frameworks to ensure predictability and stability.

The potential integration of capital markets provides an opportunity to further enhance the flexibility of this model. Population Equity Units can be progressively bundled into tradable instruments, including outcome-linked bonds and equity participation vehicles. These instruments allow external sovereign and market investors to assume a share of the financial risk associated with health investments, while aligning returns directly with measurable outcomes. In doing so, they create a direct linkage between system performance and capital flows, reinforcing incentives for efficiency and innovation.

A complementary development is the introduction of rating systems for Demographic Asset Classes. Drawing on established methodologies from financial markets, population segments can be assigned standardised ratings based on projected return profiles and risk characteristics. AAA-rated population segments—those with high expected returns and low variability—can be prioritised for long-term investment, while sub-investment grade cohorts may be subject to targeted de-risking strategies, including controlled exposure limits, selective disengagement, or phased reallocation of resources. Rating migration over time provides an additional feedback mechanism, enabling continuous optimisation of the Health Equity Portfolio, including downgrade-triggered reallocation where required.

One of the strategic advantages of this approach for national governments is the reconceptualisation of equity. Rather than being treated as a purely distributive principle, equity can be operationalised as a function of participation and alignment with system performance requirements. Under this model, Population Equity Units hold differentiated positions within the national portfolio, reflecting their contribution to and benefit from collective investment. This ensures that resource allocation remains responsive to both system performance and evolving demographic realities.

Institutionally, the framework aligns with a broader functional redefinition of global health actors. Multilateral organisations, including normative bodies, can focus on establishing standards, developing metrics such as the HRVI, and convening stakeholders across sectors. Implementation and operational decision-making are devolved to national and regional entities, consistent with the principle of subsidiarity. This division of labour reduces duplication and enhances system coherence.

Financing flows, in turn, become more targeted and time-bound. Development assistance becomes progressively redundant, reducing exposure to sovereign conditionalities, and financing is repositioned as catalytic capital, supporting transitions toward domestically anchored and market-enabled systems. Global public goods—such as surveillance, research and development, and epidemic preparedness—remain appropriate areas for sustained collective investment, given their transnational nature and positive externalities. Nonetheless, they would need to demonstrate measurable impact on the Population Equity Units, and a positive return on investment.

The proposed model is not without complexity. The introduction of new instruments, metrics, and governance arrangements requires careful design and sequencing. Data systems must be strengthened to support accurate classification, valuation, and monitoring of Population Equity Units, with the resulting data architecture constituting a high-value analytical asset class in its own right, potentially suitable for managed service provision or structured private participation. Regulatory frameworks must evolve to accommodate novel financing mechanisms while safeguarding system integrity. Capacity building at national and subnational levels is essential to ensure effective portfolio management.

The risks of inaction, however, are far greater. Persisting with fragmented, input-driven, and fiscally unsustainable models will undermine both efficiency and impact. By contrast, a transition toward a maximally efficient, return-oriented framework offers the potential to sustain and enhance health outcomes despite resource constraints.

The convergence of fiscal pressure, institutional reform, and financial innovation creates a significant opportunity to re-engineer the global health architecture around principles of equity, efficiency, alignment, and sustainability. Through the structuring of Population Equity Units, the deployment of the Health Returns Value Index, and the gradual mobilisation of capital markets, it is possible to construct Health Equity Portfolios that are resilient, adaptive, and performance-oriented. Such an approach ensures that, even under conditions of constrained financing, health systems can continue to deliver measurable value at scale for national governments.

Health system sustainability is preserved through disciplined alignment of investment with demonstrable population value.

A Crime Boss is not a force for good

When US forces kidnapped Nicolás Maduro in Caracas last week they acted illegally. They broke multiple international laws. The President of the United States publicly declared that he cannot be held to account. He is not constrained by the law, he said, he is (un)constrained by his personal (im)morality.

There is no doubt that Maduro was a brutal and repressive dictator, and a majority of the people of Venezuela wanted democratic change. They had voted for it in 2024. Did Donald Trump and the United States act morally in removing this man from power?

Consider three scenarios:

Scenario 1: An honest passerby sees a thug beating an elderly person. She tackles the thug and saves the victim.

Scenario 2: A Mafia Boss sees the same assault. He notices the thug’s expensive gold bracelet, tackles him, steals the bracelet, and the elderly person is saved.

Scenario 3: An honest passerby witnesses the assault but is too frightened to intervene. She calls a known Mafia Boss for help. He tackles the thug, steals the bracelet, and the elderly person is saved.

Only Scenario 1 deserves praise. The passerby acts from virtuous motives and achieves a good outcome. But what of the Mafia Boss?

In Scenario 2, he performs a superficially right action (stopping an assault) but for entirely immoral purpose (theft). The victim benefits, but this is incidental to the Mafia Boss’s criminal purpose. Most moral traditions recognise this distinction. We praise people for their character and intentions, not merely for producing beneficial side effects. A surgeon who saves a patient primarily to steal their jewellery hasn’t acted virtuously, even though the patient survives.

The Mafia Boss might deserve some credit for not making things worse—he could have ignored the victim or joined the assault. But “not being as bad as possible” isn’t praiseworthy. At most, we might say: “How fortunate his greed led him to intervene”—but this concerns lucky consequences, not moral worth.

Scenario 3 adds complexity. The passerby achieves a good outcome she couldn’t manage alone, but she’s complicit in the theft by knowingly involving a criminal. This is the classic “dirty hands” dilemma: when achieving good outcomes requires morally tainted means.

Now apply this to Venezuela.

We are in Scenario 2 (possibly Scenario 3) territory. Trump’s own words reveal his motives with startling clarity. “We’re going to be using oil, and we’re going to be taking oil”, he told the New York Times. “We will rebuild it in a very profitable way”. He repeatedly emphasised making money for the United States, settling old scores over nationalisation (“they took the oil from us years ago”), and has already begun negotiating with American oil executives.

The pattern of decisions confirms this. Rather than recognising María Corina Machado—the Nobel Peace Prize-winning opposition leader whose party won Venezuela’s 2024 election—Trump works with Maduro’s former vice president, a regime loyalist. Why? Because “she’s essentially willing to do what we think is necessary to make Venezuela great again,” Trump said, meaning granting American companies renewed access to Venezuela’s oil industry. There’s no timeline for elections, no commitment to Venezuelan self-governance. “Only time will tell”, Trump said when asked how long US control would last. “I would say much longer” than a year.

The stated justifications—drugs, migration, terrorism—don’t withstand scrutiny. Venezuela accounts for minimal drug trafficking to the US. The intervention followed months of pressure focused squarely on oil: sanctions, blockades, and seizing tankers.

This is Scenario 2. An authoritarian leader is removed—arguably beneficial for many Venezuelans—but primarily to facilitate resource extraction. The relief for Venezuelans is incidental to the core objective.

The Mafia Boss deserves no praise for saving the elderly person whilst stealing their bracelet. He should be prosecuted for the crime he committed. Donald Trump should be prosecuted for his crimes—Congress has the power.

The crimes of the leader

When is an entire nation guilty of the crimes of its leader?

In the aftermath of World War II, there was considerable discussion about the collective responsibility of the German people for the horrific actions of the Nazis. By the mid-1950s, it was almost impossible to find a German who had ever been pro-Nazi—everyone was against it from the start. Whether it was from shame, fear of association, or cognitive dissonance, they would have you believe there was only ever a handful of Nazis and their supporters in Germany.

The truth hardly needs defending. The great majority of Germans knew what the Nazi Party stood for. The last free election held in pre-war Germany was in November 1932, when the Nazi Party won 33% of the vote. The March 1933 election, when the Nazi Party won 43% of the vote, was held after the Reichstag fire and in the presence of significant political intimidation. Before the last free election, the German people knew Hitler. He was openly anti-Semitic, anti-communist, and anti-democratic. In the 1920s, he compared Jews to germs, stating that diseases cannot be controlled unless you destroy their causes. By 1925, he had argued for the special entitlement of Germans for Lebensraum and the conquest of Slavic lands in Eastern Europe. He attempted a coup and established a paramilitary force.

Almost immediately after he won the March election in 1933, he established the first concentration camp (Dachau) for any social and political undesirables. He was also openly anti-Roma and Sinti, and anti-Catholic.

The tendency towards everything that followed historically was there for all to see. What responsibility did the German people have in 1933 to resist? What about ‘34, ‘35, ‘36, ‘37, … ‘45? In 1945, actual membership of the Nazi party was at its highest, about 10% of the population. When were the German people collectively responsible for their government’s actions?

In many ways, the question is unfair. How can a Bavarian farmer bear the same responsibility as a concentration camp commandant? Those who joined the party, served in the Einsatzgruppen, or otherwise actively participated in Nazi crimes must bear a more direct criminal and moral responsibility. What of the civil servants? What of those who made sure the infamous trains ran on time, delivering millions to their deaths? What is the moral calculus associated with the flow of benefits—direct and indirect—from the persecution of others, such as cheap farm labour from concentration camps, a new home, more job availability, etc.?

The night of 9 November 1938 was Kristallnacht—a pogrom against Jews throughout Germany and Austria. Over 1,400 synagogues were burned, thousands of Jewish businesses were destroyed, Jewish homes were ransacked, and dozens were killed in the streets. The violence was public, visible, and undeniable. Evidence suggests that many Germans—perhaps most—disapproved of the brutality and destruction. But this disapproval remained private and passive. There were no mass protests, no general strikes, no widespread efforts to shelter Jewish neighbours. The gap between private discomfort and public acquiescence reveals something crucial about collective responsibility: moral squeamishness without moral courage is functionally equivalent to complicity. After Kristallnacht, no German could claim ignorance of the regime’s violent intentions. The persecution was no longer bureaucratic or hidden—it happened in city centres with flames visible for miles. If it hadn’t before, Kristallnacht was the moment when passive opposition became morally insufficient, when continued participation in or acceptance of the Nazi system—even by those who privately disapproved—became a choice that enabled everything that followed.

What does resistance look like? Rolling and continuous general strikes, protests, refusal to deliver to, repair, or assist the state apparatus. It is painful; it will result in loss of liberty, loss of property, and, probably, loss of life. Resistance starts with the most, not those with the least. It will fracture families and friendships.

Where Americans have resisted the Trump administration, they have used polite institutional resistance—lawsuits, protests, opinion pieces, and letters to the editor—all of which assume the system can contain someone who fundamentally doesn’t operate within its rules. It’s the equivalent of Germans relying on Weimar constitutional mechanisms to check Hitler after 1933. The Supreme Court has essentially unleashed a criminal President, because by definition, he cannot commit a crime, and he is only enjoined after he has turned a criminal act into a de facto reality. You cannot un-ring the illegal bells he rings.

That’s an outrageous parallel, you say. Donald Trump is no Hitler. And I agree. Donald Trump is a greedy, narcissistic kleptocrat. And in the name of the American people, he has committed international crimes. He has supported genocide. He has ordered the extra-judicial killing of scores of people. He has threatened allies with invasion. He has had people imprisoned without due process. He has had people tortured. He has destroyed the multilateral system. He has put troops on the streets of US cities. He has attempted (it remains to be seen if he succeeds) to subvert the electoral system. He has compelled universities and multi-billion-dollar corporations to bend to his will. He and his family have stolen and extorted billions.

But whether Trump is Hitler is not the question. The question is: when do the American people bear collective responsibility for their leader’s actions? Like the German people in 1933, they knew their leader when they elected him in 2024—and unlike Hitler, they gave him a majority of the votes (not just the Electoral College). When they voted for him, they knew he did not follow the law. They knew he used violence to take what he wanted. They knew he was racist. They knew he pursued his personal interests above any greater good. They knew he was driven by vanity.

Where the German people opposed passively, the American people have resisted institutionally, at a time when institutions do not constrain power. Both groups chose mechanisms of resistance that enabled the regimes they oppose. Both nations bear collective responsibility for their leaders’ actions.

Postscript. Democracies offer their citizens a get-out-of-jail-free card. We elect a new leader, and we are absolved. We held the previous regime accountable and cast them out. Our sins are forgiven. I have always found it a slightly uncomfortable moral maneuver, but I do understand it.

In 2020, Americans could claim they had corrected their mistake. They voted Trump out. Democracy worked. They could also seek comfort in the fact that he failed to win the popular vote. Yes, he won the Electoral College vote, and that is a flaw in our system, but as a people, we rejected him. Then they voted him back in—with full knowledge of what he had done, who he was, and what he would do. The absolution was a lie. The accountability was performance. And the collective responsibility deepens.