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Global Health Justice and Governance$

Jennifer Prah Ruger

Print publication date: 2018

Print ISBN-13: 9780199694631

Published to Oxford Scholarship Online: June 2018

DOI: 10.1093/oso/9780199694631.001.0001

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Global Health Governance Problems

Global Health Governance Problems

(p.17) 2 Global Health Governance Problems
Global Health Justice and Governance

Jennifer Prah Ruger

Oxford University Press

Abstract and Keywords

Global health institutions, including the World Health Organization and other United Nations organizations, the World Bank, the vast numbers of foundations, civil society organizations and other actors, and nations themselves have been unable to address global health problems sufficiently. Health actors have proliferated dramatically, and the global health enterprise has become kaleidoscopically fragmented and incoherent. The modus vivendi underlying the activities and interrelationships of these actors arguably works against resolving the world’s health challenges. Decades-old international problems in health governance still persist today. These problems present serious ethical questions and demand a normative theoretical foundation as we seek their solutions.

Keywords:   global health institutions, United Nations, World Health Organization, civil society, global health problems, health governance, World Bank

2.1 Global Institutions

Each of these sets of global health problems—inequalities, externalities, cross-border issues—has a potential resolution in the behavior of global and domestic actors. While the state remains the most important actor in both domestic politics and international relations, global actors, both state-based and nongovernmental, play an increasingly important role. The United Nations (UN) system itself, including the World Bank and World Health Organization (WHO), is responsible for a number of global arrangements that directly and indirectly impact the global health problems described in Chapter 1. Yet different actors have different levels of interest in these global health problems. States approach global health problems in terms of foreign policy, concerned with those that most directly affect their national interests, and are amenable to minimal interventions through bilateral action; multilateral collective action is a second choice. They focus on externalities that pose direct and dangerous threats of transmission to their own populations. Other problems, embedded in global health inequalities and cross-border issues, involve more difficult solutions such as the development and good governance of public health and health care systems.

This book presents a theoretical framework for evaluating global and domestic policies, practices, and institutions. How do they distribute benefits and burdens? What are their priorities and how are disagreements about priority setting resolved? Are these distributions and the associated policies, institutions, and practices just? Are they based on evidence of effective investments or on political priorities? Do certain diseases or conditions, such as HIV/AIDS or other communicable diseases, receive a disproportionate share of resources and consideration? If the global institutional order is not just, how might it be reformed, or gaps be filled by the creation of new institutions and policies?

Are existing institutions, along with relevant processes and rules, sufficient to address contemporary and future global health problems? Global health (p.18) governance (GHG) produces suboptimal results in both individual and population health. How can we move our world toward a more just set of global and domestic actions and arrangements?

2.2 From International Health Governance to Global Health Governance

For many decades in the nineteenth and twentieth centuries, international health was the purview of states and multilateral organizations with state members, beginning with a focus on cooperation among states to control the spread of communicable diseases—yellow fever, cholera, and the plague—to protect trade and travel. Thereafter collective action focused on specific health problems related to cross-border issues such as military victims, trade in alcohol, border-area water pollution, and, later, occupational safety and health exposures and injuries, none of which were foremost in states’ foreign policies.1 Health funding flowed between donor and recipient governments. National ministries had responsibility for health services delivery.

In 1948, WHO was established and has since advanced the rhetoric of “Health for All” and of the right to the highest attainable standard of health. Mired in powerful states’ political interests and its own ineffectiveness, however, WHO has largely failed to effectuate these ideals. A limited set of partners has coordinated effectively with WHO on global efforts like smallpox eradication, successfully eliminating the disease, and on onchocerciasis, yaws, and global immunization programs. WHO has also used the International Health Regulations (IHR) to manage international reporting and disease outbreaks.2 For some decades, the international health architecture—more recently termed “the multilateral health regime,”3 or “horizontal germ governance”4—was relatively uncomplicated, with significantly fewer actors and straightforward responsibilities. Health efforts required less coordination, because emerging and re-emerging infectious diseases did not spread globally as they do now, and WHO achievements in smallpox gave it credibility and authority; states therefore followed WHO’s lead. Advanced states applied their medical and (p.19) administrative capacities to control outbreaks and defend their borders.5 The system operated—for powerful Western states—but critics have suggested it neglected the interests of other countries.6

On another front, the Declaration of Alma-Ata in 1978, calling for universal access to primary health care, was unsuccessful. As a humanitarian effort, this approach failed to create a new international order, but rather reflected existing geopolitical concerns of powerful states and significant East–West friction in international relations. “Health for All” and international health more generally were not major foreign policy issues for powerful countries. Thus, neither the great powers nor the multilateral system gave international health significant priority.

WHO’s first decades showed that the old structures were inadequate for a swiftly globalizing planet, where national economies are increasingly interdependent and people and products move rapidly worldwide. Infectious diseases emerging or re-emerging anywhere can have repercussions everywhere, and such contagions quickly became national and global security issues. Thus began the more complex GHG era, in which new actors, programs, initiatives, and regimes have proliferated and new funding has exploded. Very often these activities are uncoordinated and their effectiveness is questionable. Multiple different regimes impacting international health have evolved in human rights, labor and trade, the environment, economic development, and humanitarianism. Only in the past several years have scholars attempted a definition of “global health.”7

Multiplying non-state actors have emerged. For example, the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) includes non-state actor representatives on its board of directors, and the revised WHO IHR includes surveillance information from nongovernmental sources. GHG’s diffuse, non-hierarchical nature is evident in the language observers use—“post-Westphalian,”8 “nodal,”9 “open-source anarchy,”10 a “regime complex,”11 and (p.20) a “complex adaptive system.”12 Non-state actors, including the media, have begun to provide information to international organizations, in the cases of severe acute respiratory syndrome (SARS) and avian flu, for example, even contradicting state actors such as China, Thailand, and Indonesia. By providing important information, non-state actors’ surveillance information incidentally has assisted WHO as it seeks to manage these global pandemics.

Disease-specific programs mushroomed particularly around HIV/AIDS (the Global Fund and Joint United Nations Programme on HIV/AIDS (UNAIDS)) and tobacco control with the Framework Convention on Tobacco Control (FCTC). Rather than building on prior UN and WHO programs, political interests created and drove new initiatives. This expansion of actors has injected new resources and ideas, different processes and principles, but it also “blur[s] lines of responsibility”13 and encourages a scramble for resources and leadership. It further challenges WHO’s role as an institution responsible for collective action, technical assistance, and normative principles. Though some claim this multiplication of actors results in enhanced cooperation, competition among non-state, state, and intergovernmental actors permeates these complex relationships.

As a result, GHG lacks any clear structure. It does not clearly delineate roles for states, UN organizations (UNOs), international organizations, civil society organizations (CSOs), and public–private partnerships (PPPs). These actors often serve simultaneously as program funders, initiators, implementers, monitors, and evaluators. As just one example: the Global Fund, financed by state governments, philanthropic foundations, nongovernmental organizations (NGOs), and corporate initiatives, disburses resources to national governments, which work with donors and CSOs to design plans, and may implement those plans with these actors’ assistance. Some argue that there is simply “no architecture of global health.”14 Others characterize GHG as three concentric circles of actors: the World Bank and WHO at the center; countries, the International Monetary Fund (IMF), and other UNOs in the next ring; and NGOs, multinational corporations (MNCs), epistemic communities (or networks of experts), and individuals in the outermost ring.15

(p.21) Indeed, GHG often seems more like a three-ring circus than three concentric circles: the operational chaos is indisputable. A burgeoning landscape of fragmented global health processes impedes an effective and efficient integration of resources, interests, and approaches to address global health problems. The WHO World Health Assembly (WHA) is now just one process for global health decision-making. In many respects the WHA is eclipsed by newer mechanisms that work bilaterally (for example, the President’s Emergency Plan for AIDS Relief (PEPFAR)), regionally (for example, the European Union (EU)), or through alternative structures (for example, Gavi, the Global Alliance for Vaccines and Immunizations; Global Fund; or the Bill and Melinda Gates Foundation). Fierce competition among actors and priorities results in end runs around national governments and the UN system. Disruptions in national planning, duplication, and waste plague GHG. If actors don’t get what they want in one venue, they move to another: failing to get favorable intellectual property (IP) protections for medicines from WHO, for example, actors simply moved to the World Trade Organization (WTO). UN agencies, too, compete for funds, so often no objective, impartial organization exists to seek the common good or agree upon global health processes. Even as non-state actors increasingly define GHG, traditional international health governance (IHG) actors prove difficult to displace and continue to dominate health governance. NGOs and PPPs can be flexible, innovative, cost-effective, and more accountable, but these actors exhibit their own dysfunctions and may create new complications even as they solve others.16

GHG is increasingly political and decreasingly technical and scientific. The theories and methods of foreign policy and international relations are eclipsing those of science, epidemiology, medicine, and public health. In the USA, for example, the Obama administration used global health as a component of its smart power in foreign policy,17 and an Institute of Medicine Committee, co-chaired by Thomas Pickering and Harold Varmus, recommended that the USA improve internal and external coordination, increase global health financial contributions, and make global health an important component of American foreign policy.18

(p.22) 2.3 Development Assistance for Health19

Development assistance for health (DAH) a form of foreign aid, has grown massively over the past few decades. Levels of and contributors to global health financing have increased at an unprecedented pace, with an emphasis on funds for HIV/AIDS; maternal, newborn, and child health; malaria; and tuberculosis. DAH nearly quintupled from 1990 to 2012 (from $5.7 billion to $28.1 billion),20 though now may have peaked. Proliferating DAH actors now number 175-plus major global health agencies and organizations, 15 percent of which are private entities, such as the Bill and Melinda Gates Foundation, other not-for-profit organizations, and PPPs. Governments are still DAH’s largest source.

While increased aid is essential and welcome, these DAH system developments raise numerous ethical questions. The failure to demonstrate these investments’ effectiveness is a major GHG problem. Other questions: Are these resources sustainable? Are expenditures focused correctly on key priorities? Who should decide and how should these decisions be made? Who should pay and receive these funds? How might the system address the epidemiological transition in many developing countries, where increasingly prevalent non-communicable diseases (NCDs) are adding to persistent inequalities in communicable diseases? Emerging nations’ political and economic transitions also require attention as these countries claim greater independence in addressing their own health financing needs and extend their influence beyond their borders. The poorest countries depend most heavily upon DAH and suffer most from asymmetries in information and in power vis-à-vis the donor community. This context shapes global justice concerns. The debates about a post-Millennium Development Goals (MDG) and Sustainable Development Goals (SDG) health agenda have failed to analyze DAH’s issues adequately, specifically whether DAH conforms to basic global justice principles.

The existing DAH system grew out of the post-World War II period of reconstruction and decolonization in which neoliberal principles of national interests, charity, or enlightened self-interest guided foreign aid from donors to recipients within a hierarchical and asymmetric relationship. Empirical evidence on donor priorities suggests that these motivations persist today. While proposals for DAH system changes have emerged, they have focused on more practical issues and have not adequately addressed critical global justice concerns. DAH’s main problems, such as failure to enable developing (p.23) countries to help themselves, lie in its underlying values.21 Addressing ethical questions thus requires changing fundamental DAH features.

2.3.1 Foreign Aid, Public and Private

Foreign aid, a key global governance function, involves transferring goods and services or money from donors to recipients in a foreign country as a donation, grant, or favorable-terms loan. These favorable terms include lengthy repayment schedules, grace periods, and below-market interest rates. Indeed, sometimes this aid is altogether unavailable commercially. Official Development Assistance (ODA) is the term the Organisation for Economic Co-operation and Development (OECD)’s Development Assistance Committee uses. The OECD defines ODA’s main objective as the “promotion of the economic development and welfare of developing countries.”22

Donor organizations are both public and private, the latter including foundations, corporations, and other private entities. Private aid involves voluntary donations from organizations and individuals to recipient individuals and groups. Governments comprise the public sector. Public aid can be either bilateral aid, government to government assistance, or multilateral aid, whereby aid is distributed by an organization through which donors contribute funds. Government tax revenues fund public sector bilateral and multilateral aid. The largest public aid donors in terms of volume are the United States, United Kingdom, Germany, Japan, and France. Sweden, Norway, Denmark, Luxembourg, Germany, and the United Kingdom gave 0.7 percent ODA or more as a percentage of gross national income.23 The largest single multilateral agency for development assistance remains the World Bank Group through the International Development Association (IDA) and International Bank for Reconstruction and Development (IBRD).24 IDA provides zero or very low interest interest long-term loans (called credits) to the lowest income countries, and IBRD offers slightly below-market interest rates and medium-term loans to other developing countries, primarily middle-income ones. Given sufficient funds, development assistance, unlike humanitarian relief, can serve long-term goals to develop sustainable national systems.

(p.24) 2.3.2 Reasons Why Donors Provide Foreign Aid

Empirical research on donor motivations reveals multiple reasons and framings of the issue. First, while recipient need—as measured by disease prevalence, mortality rates, food security status, or a country’s overall degree of poverty—can evoke sympathetic concern and beneficence and does motivate donors to provide aid, these are not the only or dominant motivations for donor assistance, nor does altruism necessarily produce effective aid.25 Some benefit may accrue to the recipient under an altruism framing, and the recipient may be (although is not necessarily) better off with the aid than without it. But aid evaluation criteria rarely specify what type and how much benefit must result from foreign assistance. This framing does not require engaging the recipient country in determining its own needs and the best way to address them. Capacity constraints in many countries may hamper aid effectiveness, while countries with stronger policy environments may be better able to deploy foreign aid effectively.26 Enhancing competencies in recipient countries is missing from this perspective, yet capacity building is critical to helping recipients get the most benefit from resources.

Recipient merit is a second framing for development assistance, but it too is not the dominant motivation. Donors conceptualize recipient merit variously in terms of human rights, anti-corruption,27 or historical ties such as sharing a colonial past.28 Similarly, a donor country might want to aid a country with a shared culture or language. This framing in part captures the desire to rectify past wrongs that have harmed a recipient country. Yet normative criteria don’t exist against which to evaluate this type of aid. To what objective should donors direct such reparative efforts? Is restoring recipient countries to pre-harm conditions ethically acceptable or even possible?

Thirdly, some donors are motivated by development ideology, or simply follow what other countries or peer institutions do to gain credibility in the donor community. Development ideology is donor-driven, not recipient-driven. (p.25) It can focus on basic needs, poverty reduction, participatory approaches, or, as in the recipient-merit framing, on a good recipient policy environment. It can draw on development principles embodied in the OECD’s Paris Declaration (2005) and Accra Agenda for Action (2008), which stress recipient involvement and ownership. A dominant development ideology for much of the post-World War II period has been the neoliberal “Washington Consensus” with its focus on free markets. The Washington Consensus and its variants have come under significant criticism recently, even among development economists.29 Fluctuating development ideologies, which are often unsupported by empirical evidence, can do more harm than good.

Finally, empirical research overwhelmingly finds that donors provide aid for economic, military, and political reasons. Geopolitical power, regional peace and security, and trade relations are common motivations.30 Gaining economically from aid allocations is a strong motivation, especially when donors seek access to natural resources or export markets31 or to ensure contracts for their businesses in recipient countries. Security interests such as combating terrorism, ensuring a ceasefire, or supporting strategic alliances32 pervade foreign aid. Donors deploy geopolitical power to support certain regimes and thus influence regional or global affairs both bilaterally, as was done during the Cold War, or through international organizations of the UN, World Bank, or IMF.33 Analyses of the geographic distribution of aid by the World Bank and Asian Development Bank found linkages between these distributions and US geopolitical and commercial interests. UN Security Council temporary membership has been linked with greater access to IMF programs.34 These motivations reflect a neorealist and neoliberal view of international relations.

(p.26) These foreign aid frames do not recognize the moral claims of individuals or allocate moral responsibility for addressing such claims. All foreign aid cannot be assumed to be good or ethically desirable. There is good aid and bad aid, and distinguishing between them requires evaluative criteria rooted in normative theory.

2.3.3 The DAH System: Critiques and Proposals

Given these varying motivations for foreign aid, the empirical literature’s mixed results on DAH’s effects are not surprising. Some studies find that health sector aid has either no significant effect or a negative effect on health outcomes, while others find positive effects. In one study, health aid is found to have no significant effect on immunization coverage, life expectancy, death rate, or infant mortality,35 while another study finds a significant positive effect on the latter.36 Other studies have found significant positive effects of health sector aid on diphtheria-tetanus-pertussis immunization coverage in countries with low corruption control,37 of US aid for HIV/AIDS on reducing AIDS-related deaths (although aid in general did not reduce new HIV infections),38 and of aid for malaria in increasing insecticide-treated mosquito net distribution and reducing under-5 mortality in African recipient countries.39 Nor is the greatest amount of DAH consistently allocated to countries with the lowest income and highest disease burden. One study found that of the top ten countries receiving DAH (all of which are low-income countries) only four fall in the top ten in terms of disease burden, measured by DALYs (disability-adjusted life years, a standard measure).40

Criticisms of the DAH system abound and reflect varied concerns. First, the total DAH levels are considered inadequate,41 the volatility of overall health financing exacerbates recipients’ uncertainty, and DAH may actually crowd out domestic health financing. These problems undermine recipient countries’ ability to finance sustainable health systems. Second, concerns about the (p.27) locus of DAH decision-making and priority setting are long-standing issues, with donor-driven development still the dominant paradigm. Third, lack of coordination among an increasingly fragmented set of DAH actors creates and exacerbates inefficiencies in health administration, delivery, and processes in recipient countries. Fourth, DAH lacks effective accountability mechanisms to ensure that both donors and recipients are accountable, not just for the use of funds and their impact, but for the overall DAH system. While efforts have tried to include recipients in decision-making processes, coordinate donors, and hold actors accountable for performance and results, the main problem is that no clearly recognized global normative framework exists for DAH. The legitimacy and accountability of the DAH system as a whole are questionable.

Numerous DAH system reforms have been proposed in several areas. First are financing proposals in the form of international taxes (for example, airline ticket levies, billionaire and sin taxes, financial transaction taxes), financial mechanisms (Advance Market Commitments, the International Finance Facility for Immunisation (IFFIm) in support of Gavi’s immunization programs, the Global Fund’s Debt2Health program), and products in the private sector (for example, (PRODUCT)RED fundraising through product labeling). Second are coordination and accountability mechanisms in the form of sector-wide approaches (SWAps), other “One” or “Unified” initiatives (for example, “Three Ones” for HIV/AIDS, “One United Nations”), the Paris Declaration on Aid Effectiveness and the Accra Agenda for Action, the International Health Partnership, Poverty Reduction Strategy Papers (PRSPs), Health 8, and Health 4+ for maternal and child health. The third area comprises UN commissions and international laws and treaties (for example, the UN Commission on Information and Accountability for Women’s and Children’s Health, the FCTC, the Framework Convention on Global Health, Framework Convention on Obesity Control, Global Fund for Social Protection, and proposed international conventions on research and development (R&D) and on alcohol). Critics of reform-based framework conventions say they fail to provide a convincing rationale for states to pursue such reforms and lack binding obligations in international law.42

But the DAH system reform debate has not adequately considered the relationship between DAH and global justice. Reforms have focused on practical issues and have framed the DAH system within a neoliberal view. These solutions thus fail to scrutinize critically the donor/recipient hierarchy. Indeed, some have argued that the current development paradigm has created as many problems as it has sought to address.43

(p.28) 2.4 Actors and Regimes in Global Health Governance44

2.4.1 States

Many agree that states remain the primary actors with ultimate responsibility in health governance, national and global.45 The greatest single source of global health assistance remains bilateral funding, alongside the UN system,46 and even in low- and lower middle-income countries, national resources account for nearly 40 percent of total health expenditure.47 National governments’ capacity and decisions determine disease surveillance and control, despite their global implications; the Chinese government’s attempted suppression of SARS news in 2003 and China and Mexico’s handling of H1N1 years later are just two examples of national interference in these vital functions. States decide what to negotiate internationally and implement domestically.48 Member states fund organizations like WHO. Powerful states also set WHO priorities and limit permitted actions. For example, WHO’s surveillance authority has been described as what Western states allow.49 Furthermore, wealthy countries can impact health by influencing bilateral trade agreements to strengthen IP rights, limit drug access, and protect pharmaceutical, tobacco, and food industry interests. The Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS), an international pact imposing standards for IP regulation, is a prime example. Globalization purportedly breaks down national boundaries and diminishes the state’s importance, but the Westphalian model is still relevant.50 There is no global health system, as the SARS, Ebola, and H1N1 examples demonstrate, that bypasses state measures. Some observers suggest that GHG actually promotes “re-territorializations.”51

(p.29) The primacy of states is evident in other ways. Around the world, public health systems designed and operated by state governments tend to achieve health equity more effectively than private sector systems.52 Country-level efforts have also yielded major public health successes, including Morocco’s trachoma control campaign, Chile’s folic acid fortification of flour for neural tube defect prevention, and HIV/AIDS programs in Brazil and Thailand.53 And states have primary responsibility as well for the social determinants of health—those factors outside the health sphere that nonetheless affect health, such as housing, sanitation, education, economy, and the environment. The US government’s role in regulating the food industry,54 for example, is evidenced by public policy measures such as taxation on sugared beverages,55 and restricting marketing to children and the availability of junk food in schools.

Global policies in any domain will not gain significant traction without industrialized states’ support. The USA and other G8 countries arguably have considerable, even hegemonic, clout.56 By insisting on IP rights and thus limiting drug access, do the USA and EU exacerbate infectious disease threats? Do they have moral obligations in addressing those risks? Protecting other US industries—especially tobacco—also undermines global health. Should the USA use its global influence to establish a global health agreement?57 Is the G8 the logical emerging global health governor?

Finally, emerging countries, especially Brazil, Russia, India, China, and South Africa, are also assuming a larger GHG role. They are increasingly providing financial and technical assistance, examples (both good and bad) of health system development, and medical services and supplies, including generic drugs. Emerging nations are challenging trade and IP rules that hinder (p.30) drug access, and through them the developing world is finding a greater voice in the global arena.

2.4.2 United Nations Organizations

The importance of WHO and other health-related UNOs in GHG has diminished as non-state actors—PPPs, NGOs, foundations, G8, and MNCs—and their initiatives have proliferated.58 WHO inefficiency and ineffectiveness arguably contributed to the emergence of these non-state actors.59 WHO lost its purview over major diseases, for example, to the Global Fund and UNAIDS.60

Criticisms of the UN and WHO abound. In the absence of a UN “master plan” for health, UN agencies compete and duplicate efforts.61 Influence and political pressure diminish WHO’s role as the “global health conscience.”62 WHO lacks enforcement powers. It is, according to critics, too focused on the Global Fund and UNAIDS,63 technical matters and vertical programs, too bureaucratic, and insufficiently engaged with civil society.64 Furthermore, WHO plays conflicting roles as advisor and evaluator, also eroding its effectiveness.65 Some believe its private sector partnerships undermine its reliability in setting norms and standards.66 Unable to use international law in the past, it is still reluctant to use it today.67 WHO must now compete with numerous other global health actors for influence and for DAH, including recipient countries, NGOs, other UN actors such as the WTO and World Bank, PEPFAR, (p.31) MNCs, and foundations. Powerful countries have bypassed WHO in setting up new institutions and regimes such as UNAIDS, the Global Fund, the Advanced Market Commitments for vaccines, and the IFFIm.

Many of these criticisms were validated in WHO’s response to the 2014 Ebola outbreak. WHO was criticized for failing to mount an effective first response, only declaring the Ebola epidemic a public health emergency of international concern on August 8, 2014, five months after it was first reported.68 A gap is growing between the world’s view of WHO as a first responder and WHO’s view of itself as a technical, standards-setting organization.69 WHO’s budgetary issues are widening this gap. To address a US$300 million deficit in 2010, WHO chose to cut its “outbreak and crisis response” funds by 51 percent from $469 million to $228 million. Moreover, in recent years over 75 percent of WHO’s funding has come from voluntary contributions from member states and other donors, which are typically earmarked for specific priorities. This extra-budgetary funding is not WHO’s to allocate as it would choose, thus leaving its hands tied during outbreaks like Ebola or 2016’s Zika epidemic.

But despite its many flaws, the world continues to look to WHO as the obvious global health governor; real alternatives don’t exist. Many believe WHO is uniquely positioned to organize disease surveillance,70 and alone combines legal authority, public health expertise, and mandate.71 And in the face of WHO’s budgetary weaknesses,72 many argue for strengthening it financially and politically, giving it enforcement powers and a stronger mandate, rather than creating or enhancing alternative institutions.73 Overall, numerous observers think multilateral UNOs and WHO, as more neutral forums than bilateral arrangements, should play a greater role in globalization.74 Theoretically, the UN and WHO, as public sector entities, are more (p.32) objective, more equitable, and less subject to corporate influence and bottom-line compulsions. On the ground, of course, the picture is not nearly so convincing. And WHO’s need now to compete with other actors for influence and DAH dollars challenges its normative neutrality and scientific integrity.

2.4.3 Economic Organizations and Coalitions: World Bank, World Trade Organization, G8, and G20

Global economic organizations have extended their reach beyond economics and development into health governance in recent decades. The WTO trade regime, with its impact on drug access and health services and on major risk factors such as tobacco, food safety, unhealthy diets, and, by extension, NCDs, has expanded the WTO’s role in health affairs. Some have argued for greater involvement by the health community with Doha Round negotiations and the WTO above and beyond the typical IP focus.75 The WTO is becoming increasingly important in GHG.76 (Though the WTO has a major impact on GHG, an in-depth analysis of it is beyond this book’s scope.)

The World Bank, recognizing the importance of health to development, has also asserted a major role. The Bank is well positioned to stress health system strengthening (HSS) and financing and to provide technical and policy advice. With superior resources, it has challenged WHO’s agenda-setting role in health since the 1990s, especially in poor countries.77 But some still call on the World Bank to offer more effective leadership,78 support WHO functions,79 collaborate with WHO to lessen free trade’s negative health effects,80 and address global public goods.81 The World Bank’s critics charge it with undemocratic and pro-privatization policies,82 opaque and (p.33) inefficient management,83 and a narrow focus on performance rather than outcome and impact evaluation.84

Some observers have discussed the G8 nations as a potential global health governor,85 or one of last resort,86 suggesting this coalition could be GHG’s “emerging centre.”87 The G8’s membership is task-oriented, builds public–private collaborations, and works from shared values.88 These assets, coupled with its intragroup accountability,89 might make G8 more effective than other global institutions. Essentially an informal network, however, G8 may lack the organizational capacity to lead GHG as a “global health apex institution,”90 and questions arise as to whom this coalition is accountable. Still, the influence of its members could be an asset,91 and this government network can be a mechanism for achieving global governance results.92 The G8 also has greater flexibility in its work, operating outside constraining global health bureaucracies. Soliciting funds for specific work is also more ably accomplished through G8 auspices than, for example, by WHO, given the coalition’s access to its own national financial and human resources. The Global Fund, for example, was a G8 project. But these powerful countries are likely to pursue their own interests first. Despite the concerning global effects of smoking,93 the G8’s inaction on tobacco, and its inadequate redistribution efforts,94 have revealed its priorities.

(p.34) Perhaps the G20, an expanded G8, could take a role. It is an intergovernment group whose member governments have authority and accountability to their populations; it represents more than 60 percent of the global population; participants are chiefly finance ministers with access to funding. And it is a “broadly representative leaders-level grouping.”95 However, the G20’s 2009 summit was virtually silent on the poverty and suffering resulting from the 2008 world financial meltdown. Some doubt that the G20 can deliver fundamental reforms;96 still, arguments for global cooperation among the G20 and broader community are building.97

2.4.4 Civil Society Organizations and Nongovernmental Organizations

Conventional wisdom suggests that NGOs and CSOs can be more flexible, democratic, cost-effective, and expert in accessing remote communities, and thus can outperform governments as service providers.98 NGOs have been involved in many proven successes in global health. The Task Force for Child Survival and Development; Bangladesh Rural Advancement Committee; Carter Center; Clark, Gates, and Hassan II Foundations; Helen Keller International; and the International Trachoma Initiative are just a few. NGOs, rather than governments, receive much of PEPFAR’s funding. Some argue that CSOs give voice to and empower aid recipients,99 particularly the poor, helping them grasp issues and define negotiating positions. NGOs turned a spotlight on drug access during the WTO Doha Round;100 many think they helped propel the FCTC negotiations.101

But others challenge the conventional wisdom.102 Time and experience have revealed NGOs’ own pathologies. They compete amongst themselves for donor funding, turf, and attention; adverse effects on program design, (p.35) implementation, and interorganization coordination result.103 Ideology sometimes drives NGO priorities and can diminish effectiveness—religious beliefs, for example, obstruct condom use and promotion104—though real needs often overcome ideology on the ground.105 CSOs receive funding not just from civil society, but also from states and businesses, and therefore reflect those interests.106 Though they often claim to represent the public interest, NGO and CSO actors are not elected, and one does not necessarily know whom they represent or to whom they are accountable. NGO service delivery also bypasses and can undermine elected governments; and higher NGO salaries can cause health-worker brain drain, thus damaging public sector organizations.107 Beyond these varied issues, some observers question the whole notion of a global civil society.108

2.4.5 Public–Private Partnerships

The emergence of PPPs has raised hopes of bringing together civil society with the public and private sectors to correct market failures. Many believe that private sector management skills, abundant financial and in-kind resources, an innovative culture, and efficiency equip PPPs to be uniquely effective.109 They are also, arguably, unavoidable in some contexts: the private sector “own[s] the ball”110 in drug R&D, for example. Merck’s ivermectin donation and Pfizer’s trachoma programs are among successful PPPs. Studies show that PPPs can reduce disease at low expense.111 They also typically target the most menacing diseases and the neediest countries.112

But skeptics suggest that PPPs place the risks on the public sector while the private sector reaps profits, and that corporations use PPPs to burnish corporate (p.36) images and expand markets.113 Because PPPs involve specific companies and industries, they tend toward vertical programs with their attendant problems. Nor do they particularly target poverty: they have excluded impoverished countries with big populations, for example, or countries with unpopular governments or inadequate infrastructure.114 PPPs are often opaque and unaccountable, untethered to lines of responsibility.115 Northern actors tend to dominate; the Global South has been underrepresented,116 though that imbalance has begun to shift.117 PPPs may also weaken governments and multilateral organizations, by distorting the public sector’s normative focus. And they can compromise international organizations’ values and thus their norm- and standard-setting authority.118

2.5 Where Global Health Efforts Succeed

The global eradication of smallpox throughout the 1970s, under IHG, was one of the most noteworthy global health successes. WHO coordinated and member states implemented eradication programs. Help came from donor governments such as the USA, the Soviet Union, and Sweden, and from Wyeth Laboratories’ invention of the bifurcated needle. Fourteen years after the program began in 1966, smallpox was officially declared eradicated.119 More recently, success stories under GHG show that the multiplication of new actors does not preclude effective work. National governments, international organizations, CSOs, the private sector, and individuals have collaborated fruitfully. WHO’s African Programme for Onchocerciasis Control, begun in 1995 to eliminate river blindness in central, southern, and eastern Africa, exemplified these collaborations. It included the governments of nineteen African (p.37) countries; twenty-seven donor countries, institutions, and foundations; more than thirty CSOs; and more than eighty thousand rural African communities that distributed the medication locally.

Polio and guinea worm eradication and lymphatic filariasis elimination campaigns have likewise brought together many national, international, non-profit, and corporate players, including WHO, Pan American Health Organization, United Nations Children’s Fund (UNICEF), US Centers for Disease Control and Prevention (CDC), Gates Foundation, Carter Center, Merck, and DuPont, in successful programs.120 Dramatic global declines in measles since 2000 are the fruit of regional campaigns undertaken by national governments and entities such as WHO, UNICEF, US CDC, and American Red Cross.121 The PARTNERS project on multidrug-resistant tuberculosis (MDR-TB) is a collaboration among Partners in Health, its sister Peruvian group Socios en Salud, US CDC, WHO, the Task Force for Child Survival and Development, and national governments. It demonstrated that MDR-TB treatment could be successfully scaled up in resource-poor settings, and WHO integrated MDR-TB into its TB policy as a result.122

Diverse actors can provide more of the elements necessary for good global health performance—adequate and sustained funding, political leadership and commitment, technical expertise, innovation, and managerial and logistical skills.123 Partners with common interests and complementary skills can surmount competing agendas, conflicting requirements, and turf disputes if they develop mutual trust; agree on goals, measurements, and strategies; and establish an appropriate collaborative structure.124 Third parties can also foster international cooperation: the Carter Center brought the Dominican Republic and Haiti together to eliminate malaria and lymphatic filariasis as part of its larger International Task Force for Disease Eradication.125

Still, the challenges in global health far exceed the successes. Meeting these challenges continues to vex GHG. Though the MDGs and SDGs offer a basis (p.38) for cooperation, the absence of either a universally accepted coordinating body or a unified vision for global health thwarts best efforts to solve global health problems.

2.6 GHG: Major Issues and Challenges

2.6.1 Approaches to Global Health Challenges: Vertical and Horizontal

Most efforts to address health challenges today are either vertical and selective (disease-specific) or horizontal and comprehensive such as broad-based HSS and development. WHO’s 1978 Health for All initiative exemplifies the horizontal approach; current global health initiatives tend to be vertical. Some are calling for a “diagonal” third way.126

Vertical efforts show results: performance and outcomes are readily measurable. Assessing results in horizontal programs, on the other hand, is more difficult and takes longer. And where the absence of disease is the measure of success, population-based preventative efforts are at a disadvantage in demonstrating results. These broader systemic efforts are also more likely to become unmanageable. Donors therefore tend to prefer vertical programs. Many of global health’s proven successes have emerged from vertical programs: examples are smallpox and polio eradication; onchocerciasis, trachoma, TB, measles, and Chagas disease control; and guinea worm reduction. Some believe vertical projects are “what works” in global health programming.127

But the vertical approach has evident failings. Critics argue that many vertical programs exhibit and exacerbate global health’s enduring governance challenges—poor coordination, duplication and waste, short-term funding, unsustainability, and inadequate performance assessment. Further, laser focus on specific diseases constructs a hierarchy in which certain ailments like HIV/AIDS receive extraordinary attention while other conditions go untended.128 Vertical programs drain human and material resources away from population-wide preventative functions. The vertical approach also ignores broader equity issues and the socioeconomic determinants of health. Other critics argue that vertical programs are technocratic and skewed in favor of some populations while neglecting others.129 They can overlook investments in broader health (p.39) systems necessary to their own success.130 Vertical programs might also distort national health priorities; some argue they reduce states’ policy autonomy.131 On the other hand, some observers believe that in countries with weak health systems, a logical first step is funding disease-specific programs, in hopes that they will foster health infrastructure development as a second stage.132

Overall, an emerging consensus supports action on health care, public health systems development, and universal coverage, increasingly acknowledged as essential to improving health, precisely because systems failings are thwarting vertical program objectives and achievement of the MDGs133 and SDGs. Observers are arguing for strong commitments, funding, and technical support for developing health infrastructure, ensuring access, and addressing inadequacies in human resources and data systems.134 The lack of data systems is a considerable global concern, particularly in the areas of global child health.135 The World Bank’s role in these endeavors is receiving particular attention. Many believe WHO’s focus on developing health systems driven by primary care is essential for meeting developing countries’ health challenges.136 Still, despite reported successes in the 1980s in Mozambique, Cuba, and Nicaragua, the horizontal approach’s potential remains “largely unexploited.”137 Strategies for building a strong health system vary, and a clear choice remains to be seen.138

Some have proposed a diagonal approach,139 which deploys vertical intervention measures to drive horizontal HSS. This approach allocates resources to improve health system components relevant to specific diseases burdening a (p.40) given country.140 GAVI-HSS, an initiative from the Gavi alliance in 2006, embodies the diagonal approach, seeking to improve immunization by strengthening health systems.141 Health ministries in participating countries identify health system weaknesses where GAVI-HSS help is needed. Research into the program so far supports developing an HSS approach starting with specific programs.142

2.6.2 Health: A Multisectoral Issue

Increasingly, scholars and policy-makers recognize that health is a multisectoral issue, connected to other sectors, especially in a globalizing world.143 Integrating health into broader policy-making requires greater coordination across sectors to ensure coherent policies protecting health interests.144 For example, the globalization of unhealthy diets and sedentary lifestyles exacerbates NCDs such as cancer, heart disease, and diabetes.145 Tobacco’s spread to developing markets and its importance for many developing economies (for example, China, Turkey, Zimbabwe) worsens the NCD threat.146 Wealthy philanthropists such as Michael Bloomberg and Bill and Melinda Gates have supported global anti-tobacco campaigns,147 but individual and environmental factors also affect NCDs, requiring multisectoral action and partnerships, beyond the work of any one organization.148

(p.41) The health–trade nexus is particularly challenging. Economic globalization and trade liberalization have both positive and negative potential for health. They can promote NCDs and limit access to drugs and health care technologies.149 But globalization and trade can also spur economic growth, essential for health systems development and sustainability.

Incentives for R&D, pricing, and IP rules can all affect drug access. Most pharmaceutical R&D occurs in developed markets and targets health conditions affecting those countries’ populations; poor countries lack the spending power to make immense R&D investments worthwhile to private industry.150 Profit-driven R&D neglects tropical diseases because the developing countries they affect are unlikely to yield sufficient return on investments.151 The Drugs for Neglected Diseases initiative (DNDi),152 and orphan drug acts in the USA, Japan, and the EU, attempt to promote more equity in R&D.153

When drug prices are too high, often the result of IP rules, they limit access.154 Large price differences exist between countries where drugs are patented and thus subject to IP protection and those where generic versions are available.155 On the other hand, when pricing in wealthy countries subsidizes lower prices in the developing world, this international price discrimination can foster greater access—if separate markets are maintained and accepted politically. Parallel importing and compulsory licensing, allowing the import and manufacture, respectively, of generic products, can also improve access. But pharmaceutical companies and interest groups in rich countries oppose developing countries’ attempts to use these instruments. Some of these opposing actions fail (South Africa and Brazil, for example, successfully fought off pharma attempts to limit generics), while others have succeeded in curbing generics’ manufacture and importation.156 But whether (p.42) drug patents actually limit access to essential medicines is an unresolved question. Some argue that most drugs that WHO considers “essential” are not patented,157 that drug companies often do not patent formulas even when they could, and that in practice, patents do not limit access to certain therapies—antiretroviral treatment in Africa, for example.158 In this view, the fundamental problem is that individual states have not established a right to essential medicines, a problem that revising IP rules would not solve.

Along with inequitable access to drugs and health services, the research gap is another major health inequality: although the developing world suffers large parts of the global disease burden, a small fraction of research expenditures specifically targets that burden. This gap resists remediation both because the private sector has little market incentive to make the investments and because developing countries lack the capacity to conduct and access research.159 Technological and scientific advances such as genomics, nanotechnology, and proteomics in developed countries are likely to widen the gap even more.160 Augmenting research capacity in developing countries, information sharing to improve knowledge access, and fair global rules to direct technology toward the health needs of the poor could help bridge this divide.161

Another trade–health nexus with implications for developing countries appears in the WTO General Agreement on Trade in Services (GATS). GATS aims to liberalize trade in health services, and foster market competition and privatization. The impact on health and health care is unclear. GATS criticisms are numerous, charging that it helps MNCs to extend their reach,162 and that health services privatization will cost more, generate inequitable two-tiered systems, widen health gaps, and obstruct universal access.163 Others worry that progressive liberalization will only bring more privatization of health systems and health care provision, thus hindering development of public health services and limiting future government options in health system design.164 GATS could also worsen the brain drain problem as workers (p.43) move from the public to the private sector and from developing to developed countries.165

The relationship between the trade and health sectors has been the focus of much debate, particularly about the strength of the world trade system as compared to the global health system. The global system for trade is more formalized and unified with legal, enforceable obligations, and thus is more powerful and effective than GHG with its “unstructured plurality.”166 Countries are willing to join the WTO and adhere to its rules since their economic success depends on participation in an effective international trade system. By contrast, WHO lacks enforcement power and bases its authority primarily on technical expertise.167 WHO, with the WHA and external financing, must deal with diverse actors with minimal reciprocal obligations. Though WTO proceedings and policies impact health, WHO has limited access to trade commissions, where business representatives outnumber health officials. And while trade policy impacts health, adequate systematic assessment and monitoring of these impacts does not occur. GHG lacks a unified vision, further compromising health’s standing vis-à-vis trade. Some advocate coordination between trade and health to achieve policy coherence:168 WHO can bring its scientific and technical capacities to bear in assisting countries as they study, negotiate, and draft trade laws.169 For example, WHO can help them understand the health impacts of trade policy and the effects of global brands marketing. It could push harder to effectuate the FCTC,170 and to monitor large-scale agricultural production. Others argue for direct transnational corporation regulation to protect health from international commerce effects.171

Health intersects with other sectors as well. Health ties into development, and links to extreme poverty and other development indicators. WHO argued for incorporating health more into PRSPs and SWAps,172 and health has become a significant component of the World Bank’s global economic role. Yet large-scale development projects often proceed without adequately (p.44) assessing their health effects.173 Growing economic prosperity is important, but heedless development that damages air or water quality harms rather than benefits health. Development has other potential health impacts—worker exploitation, the use of harmful chemicals in agriculture, threats to animal health and meat, and the loss of biodiversity to sustain life—to which global health efforts must attend.174

2.6.3 Neoliberalism and Global Health

Neoliberalism is a broader theme underlying health’s multisectoral connections and globalization’s health impacts. Neoliberalism seeks global economic liberalization, market competition, privatization, and the pursuit of efficiency. Its application has health impacts. Infectious disease outbreaks multiply during human migrations believed to be associated with economic globalization.175 Economic growth, foreign direct investments, and urbanization affect NCD mortality rates.176 Although open trade can promote economic growth and poverty reduction, it also produces both winners and losers. Equitable health care does not necessarily result from liberalization;177 devolving responsibility for health to the individual level, when health’s determinants are also global and national, does not necessarily improve health.178

Some scholars note that international institutions such as the IMF, WTO, and the World Bank promote a neoliberal agenda,179 favoring capital and overriding national democratic institutions. Their tools—structural adjustment programs (SAPs), debt repayment arrangements, and PRSPs—have failed, according to observers, to account for the social, health, and economic costs of (p.45) adjustment.180 They charge that health care suffers from policies such as spending cuts and user fees,181 designed to reduce government health expenditures. Indeed, some would exempt health spending from international financial institutions’ fiscal restraints, because neoliberal globalization “simultaneously maximizes the need for social intervention,” and minimizes the political and strategic options available to achieve the public good.182

Neoliberalism pursues efficiency and consumption at the cost, some believe, of equality.183 Clarifying which countries and which citizens within each country benefit or suffer under neoliberal agendas will help assess neoliberalism’s impacts. A literature review of empirical studies of SAPs’ consequences for health, for example, found both positive and negative effects.184

2.6.4 Country and Local Capacity and Ownership

When short-term orientation and uncoordinated efforts undermine health programs, complicate national planning, and strain national and local resources, recipient countries and local communities suffer. Local ownership better represents and addresses local needs,185 and community health improves when communities have greater control over local programs.186 Local ownership and engagement in global health initiatives are key to development and sustainability,187 and governments in poorer countries have funded and led proven successes in global health.188 They have contributed, for example, to recent successes against guinea worm, onchocerciasis, and malaria.189 The WHO Healthy Cities initiatives, first launched in 1986, (p.46) exemplify efforts to foster local ownership in certain contexts.190 Other key elements are country leadership, harmonization, and the alignment of global health initiatives with national plans.191 Efforts targeting country ownership and coordination include the Paris Declaration on Aid Effectiveness,192 PRSPs, UNAIDS’ “Three Ones” initiative,193 GAVI-HSS, Committee C of the WHA,194 and the International Health Partnership and related initiatives. Still, barriers exist to local and national ownership of projects. Financial and human resources capacities might be insufficient.195 Key stakeholders might or might not be included. Regulating activities of better-resourced actors is challenging for poor countries,196 and some country governments are incompetent and/or corrupt. Donors’ reluctance to give up pet initiatives and long-standing procedures also thwarts country ownership.197 Strengthening local and country capacities and ownership is a major task.

2.6.5 Research Gaps in Global Health Governance

Knowledge deficiencies about governance itself also undermine GHG. The global health community might well have an insufficient evidence base for the most important global health tasks—strengthening health systems and improving public health. Many global health initiatives lack an evidence base. Interventions to improve health among the poor are often untested,198 particularly as to whether specific interventions can successfully move from one geographic context to another.199 Developing more knowledge about interventions’ (p.47) costs and effectiveness is essential. What works and does not work in health policy design and implementation also requires more study.200 Research on the effectiveness of private sector contracting and its impact on the poor;201 biotechnology relevant to disease, agriculture, and the environment;202 and GHG institutions and processes is also important. Improving treatment adherence among patients with limited literacy and numeracy also needs further study,203 given the need for complicated HIV/AIDS treatments in some of the world’s poorest places. More fundamentally, norms must be established for allocating resources across health needs.204 If global health research is to maximize usefulness, it must both address priority health needs and contribute to policy formulation.

2.7 Global Health Governance’s Key Problems Persist

The most striking GHG theme is the persistence of its key problems. With the exception of proven successes in global health, primarily in disease-specific programs, the international problems in health governance Charles Pannenborg listed in 1979 still persist today.205 In 1979, IHG weaknesses included: (1) lack of coordination between donor governments, NGOs, and recipient countries; (2) confusion of norms and activities due to different ideas regarding health rights and obligations; (3) lack of coordination between WHO, World Bank, other UNOs, and multilateral organizations; (4) lack of national health plans in recipient countries, or plans that do not provide for donor coordination; (5) donor neglect of recurrent expenditures; (6) donors’ short-term orientation, ignoring middle- and long-term commitments; (7) tying health aid to donors’ or recipients’ foreign policies or to purchases of supplies from donor countries; and (8) criteria of “self-reliance” and past performance, (p.48) channeling aid away from the most needy countries. Why these problems persist, and how to solve them, are core questions that this book addresses.

Today, one of the most salient issues remains the lack of coordination among donors and between donors and recipient governments.206 GHG’s proliferation of initiatives, funding sources, and actors has exacerbated this problem. Many donors lack long-term commitment,207 and issues of accountability and sustainability as well as performance-based evaluations persist in distorting program design, implementation, and the choice of funding recipients. Furthermore, donor economic, political, and strategic self-interests continue to determine bilateral health aid.208 Multiple competing principles associated with different regime clusters and associated processes in global health lack coherence and generate overlap, redundancies, and conflicts. Enumerations of these problems are routine, yet GHG solutions remain elusive after nearly four decades. And now, with the scope and complexity of the social determinants of health and the effects of globalization overwhelming state and non-state actors, bringing coherence and coordination to countless unconnected players is increasingly difficult.

2.7.1 Summary of Global Health Governance Problems

In sum, several key problems vex GHG. First, hyperpluralism and fragmentation produce incoherence, disorder, and inefficiency; no single regime governs health. Two, blurred lines of responsibility undercut accountability and compliance, making it hard to hold actors—including the WHO—responsible. Three, the proliferation of new actors with divergent interests increases competition and reduces incentives for long-term, prevention-oriented investments in health, health care, or public health systems. Four, uncertainty reigns about normative principles and processes guiding global health in the absence of a genuine agreement on common goals and procedures. Five, key components of global health analyses and planning are lacking: a master health plan, an analysis of global health problems, policy solutions that include an evidence base for their effectiveness and cost-effectiveness, and a global health strategy with global health priorities. Six, powerful countries and institutions exercise excessive political influence, control finances, and manipulate decision-making, and injustice results. Seven, credible compliance and dispute resolution mechanisms are lacking. Eight, inadequate global (p.49) standards and rules, other than the IHR, fail to govern the system effectively. Finally, a façade of ethics whose content is charity, not justice, conceals narrow self- and national political interests, operating under the prevailing rational actor model. The current approach is reactive with an ex post or after-the-fact orientation. GHG needs an alternative approach that is proactive, preventative, and ex ante oriented. Addressing health problems after they become global pandemics, as in the 2014 Ebola and 2016 Zika crises, is ineffective and in fact unconscionable in the suffering it fails to avert; it is the wrong approach to global health.

The relatively few success stories notwithstanding, overall the state of GHG points to continuing, decades-old problems of insufficient coordination, the pursuit of narrow national and organizational self-interest, inadequate recipient participation, and sheer lack of resources. Both state and non-state actors continue to oppose governance reforms that would constrain their pursuit of their own interests.

The world needs a new way forward, and shared health governance (SHG) provides a conceptual and operative framework. As a theoretical approach to GHG, SHG calls for developing a shared vision of health and health provision by amalgamating values among global, national, and local actors. Such shared understanding aims to foster agreement on goals and strategies to promote program design, coordination, implementation, and evaluation. SHG is compatible with different framings of health, and can potentially bring the frames together. SHG also advances health agency for all; involving affected but marginalized groups in national and global health initiatives is critical for addressing aid recipients’ needs effectively and for reining in powerful industry and national interests. The global community should recognize health as an entitlement, the realization of which will require voluntary resource redistribution from rich to poor, in order to narrow the vast and unjust gaps in health and health services. Actors internalize public moral norms for equity in health and commit to meeting the health needs of all.

SHG envisions an institutional structure for the reduction of global health injustices and greater realization of health equity. While different policy realms touch on health, and health’s expansive policy relevance for multiple sectors is important, a unified global health infrastructure is crucial. But though health is broad and multifaceted, a complicated regime complex is not necessary at either the domestic or global level. Successful health governance is focused on preventing people from getting sick and injured and then on treating them as efficiently as possible. Effective prevention and treatment come from creating and sustaining integrated, rational, and harmonized structures, as in many national contexts. A major focus of global and national health systems should be control of health issues that occur every day in human lives and on managing infectious and chronic conditions with limited (p.50) resources. Building and sustaining national and local public health and health care systems that interface with integrated global health systems should be the foundation.

The current global system, including WHO, is inadequate. Effective governance demands new solutions, a framework for solving global health problems. Scholarly investigations in this area have been as uncoordinated and fragmented as the global health architecture itself. GHG has been framed in dissimilar ways, as an issue of national security, human security, human rights, and global public goods.209 Global health’s increased political prominence in international relations has led powerful state and non-state actors to use health even more as a political tool for geostrategic purposes, and has decreased their willingness to cede control to other bilateral and multilateral actors, including WHO. The Gates Foundation, for example, is now viewed by many as more powerful than WHO in global health. Emerging nations act no differently. Public health and health policy actors are sidelined or politicized in these processes. The current characterization of GHG’s purpose in terms of global security,210 global commerce, global preparedness, response, individual rights, its constitutional outlines,211 and even philanthropy serves the interests of powerful state and non-state actors. This multiplicity of frames has failed to provide a sufficient basis for strong domestic public health and health policy, to ground a sustainable global health policy, or to motivate a commitment to global health justice.

2.8 Why a Theory of Global Health Justice and Governance?

The literature has been essentially untethered to a theorized framework able to illuminate and evaluate GHG in accordance with moral values. Global and national responses to health problems must derive from ethical values about health: ethical claims have the power to create greater understanding and commitment; to motivate; to delineate principles, duties, and responsibilities; and to hold actors morally responsible for achieving common goals. Since addressing inequalities requires redistributing societal benefits and burdens (p.51) more fairly, there is a need for theories of justice to define the obligations of institutions and actors.

Critical ethical issues confront us as we seek to develop a moral vision that addresses global health’s most confounding problems. What are the moral consequences of global health? Is health a special global good, and if so, what are the moral implications for domestic and global actors and institutions? Why are global health inequalities, externalities, and cross-border problems a matter of justice—or are they? How do we measure global health inequalities? What ethical challenges do these global health issues pose? What is the moral justification for trying to reduce them?

Questions of justice across state boundaries have sparked penetrating academic and policy debate. How do those questions relate to global health—or do they? Do global health issues imply global egalitarianism or do more limited theoretical approaches, such as limited globalism or extended nationalism, provide a better approach for global health? Do global-level health justice duties exist? If so, how do we identify and define them? What duties and responsibilities attach to global and state actors, and to what degree? Does global health justice require global health government? What does reducing global health disparities require? Do states have special obligations for their citizens’ health? If so, how do states weigh these special duties against general duties? Is national self-determination inviolate when governments fail their own citizens? May global institutions coerce national governments when they neglect their populations’ health? What role, if any, do international and domestic law and human rights play in global and domestic health? Can we find a universal consensus on health? What distributive principles (equality, priority, sufficiency) apply to global health? How much priority do disadvantaged groups merit?

Despite well-known theories of global justice and more recent work in global health ethics, theorists have neglected to offer relevant theoretical insights into global health inequalities, externalities, or cross-border problems. This lack of a theoretical foundation for global health has resulted in skeptics and realists who question whether universal moral standards exist and if a normative framework is required to take action. Are there, or can there be, globally shared values and priorities in global health, and if so, which are central? Addressing such questions precedes understanding our obligations to shape the conditions for all to be healthy. Global and domestic institutions, groups, and individuals need a theoretical foundation on which to build a more just world.

This book offers a foundation, the provincial globalism/shared health governance (PG/SHG) line of reasoning, grounding it in capability theory. Ethical principles underlying this approach include the intrinsic value of health to well-being and equal respect for all human life; the importance of health for (p.52) individual and collective agency; assessment by measuring the shortfall from the health status of a reference group; and the need for a disproportionate effort to help disadvantaged groups. Global actors and institutions have responsibilities and roles, as do individuals. An essential first step in redressing wrongs, to the extent that wrongs exist, is exposing the wrong and “making explicit the values on which proposed action is based.”212 In the PG/SHG view, allowing individuals to die prematurely and suffer unnecessary morbidity when the global community could create the socioeconomic conditions necessary to support health is unjust. This deprivation-oriented view calls for identifying the most deprived within and between countries by disaggregating health outcomes. It also urges policy-makers to monitor progress and thereby supplement, rather than displace, the typical tracking of changes in average health. Global and national efforts could then focus on improving opportunities for health in disadvantaged groups. This view would not abandon attempts to improve average health or to improve the health of groups that reside in the middle of the ill-health spectrum. But in supporting universal health coverage (UHC), the PG/SHG view addresses conditions that undermine individuals’ capabilities, including those particularly prevalent among disadvantaged groups, such as tuberculosis, malaria, and AIDS. UHC between and within countries depends on the moral values that underlie health policy at the state213 and global level. This approach also stresses that alternative global and national structures and behavior must be voluntary and self-imposed.

Global health justice and ethics also raise a number of issues related to the allocation of moral responsibility in global health: Who is responsible, and thus accountable? For what are they responsible and accountable? Principles of allocation and the competing views that underlie them include important and divergent rationales. One idea uses causality for harm to determine responsibility for remediation. Justice and governance in this view would entail determining a harm, demonstrating its cause, and assigning moral responsibility for remediating it. The challenge of proving causation, however, makes assigning responsibilities difficult. A second rationale is connectedness to others and partiality: justice extends to the citizens of a given state who share a common identity, and state boundaries mark the limits of obligation. A third rationale rests on functions and capabilities. Allocation of responsibilities depends on required functions and the roles, abilities, and effectiveness of actors and institutions in alleviating global health inequalities, addressing (p.53) externalities, and remedying cross-border problems. The PG/SHG perspective parcels out respective roles and responsibilities at the global, state, local, and individual levels based on functional requirements and needs, identifying actors and institutions, their obligations, and how they are held accountable. Institutions and actors perform core functions, functions required to protect and promote human’s health capabilities, particularly central health capabilities, meeting health functioning and health agency needs. This view acknowledges concurrent general duties toward foreigners and special duties toward fellow nationals. It also recognizes that our impartiality toward fellow human beings and our partiality toward those with whom we share circumstances, such as statehood, are compatible rather than mutually antagonistic.

Even the idea of global justice is controversial. Indeed, some theories deny altogether any claims of justice in the global realm. Chapter three assesses major theoretical perspectives on global justice and examines their implications for the existence, scope, and assignment of global health justice duties. Chapter four then lays out the main analytical components of PG. (p.54)


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(8) Aginam, “Between Isolationism and Mutual Vulnerability,” 308.

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(13) I. Kickbusch, “The Development of International Health Policies: Accountability Intact?” Social Science and Medicine 51, no. 6 (2000): 979–89.

(14) B. Bloom, Dean of Harvard University’s School of Public Health, cited in J. Cohen, “The New World of Global Health,” Science 311, no. 5758 (2006): 162–7.

(15) N. Drager and L. Sunderland, “Public Health in a Globalising World: The Perspective from the World Health Organization,” in A. F. Cooper, J. J. Kirton, and T. Schrecker, eds., Governing Global Health (Burlington, VT, and Aldershot: Ashgate Publishing, 2007), 67–78.

(16) For an introduction to global health governance, see S. Harman, Global Health Governance (Oxford: Routledge, 2012), and for a description of the evolution of global health governance, see J. Youde, Global Health Governance (Cambridge: Polity Press, 2012).

(17) M. Otero, Smart Power: Applications and Lessons for Development (Washington DC: American University, 2010).

(18) H. Varmus, “U.S. Commitment to Global Health,” David E. Barnes Lecture in Global Health, US National Institutes of Health, 2008.

(19) This section stems from J. P. Ruger, “Ethics of Development Assistance for Health,” Hastings Center Report 45, no. 3 (2015): 23–6.

(20) IHME, Financing Global Health 2012: The End of the Golden Age? (Seattle: IHME, 2012).

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(22) OECD, Glossary of Statistical Terms: Official Development Assistance (Paris: OECD, August 2003).

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(172) WHO, Health and the Millennium Development Goals (Geneva: WHO, 2005).

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(174) C. Corvalan, S. Hales, and A. McMichael, Ecosystems and Human Well-Being: Health Synthesis (Geneva: WHO, 2005); M. Parkes and P. Horwitz, “Water, Ecology and Health: Ecosystems as Settings for Promoting Health and Sustainability,” Health Promotion International 24, no. 1 (2009): 94–102; M. Jay and M. G. Marmot, “Health and Climate Change,” The Lancet 374, no. 9694 (2009): 961–2.

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(178) P. E. Farmer, B. Nizeye, S. Stulac, and S. Keshavjee, “Structural Violence and Clinical Medicine,” PLoS Medicine 3, no. 10 (2006): e449; W. Hein and L. Kohlmorgen, eds., Globalisation, Global Health Governance and National Health Politics in Developing Countries: An Exploration into the Dynamics of Interfaces (Hamburg: Deutschen Ubersee-Instituts, 2003).

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(188) Levine et al., Millions Saved.

(189) G. T. Keusch, W. L. Kilama, S. Moon, N. A. Szlezák, and C. M. Michaud, “The Global Health System: Linking Knowledge with Action—Learning from Malaria,” PLoS Medicine 7, no. 1 (2010): e1000179.

(190) T. Hancock, “Healthy Cities and Communities: Past, Present, and Future,” National Civic Review 86, no. 1 (1997): 11–21; I. Kickbusch, “Global + Local = Glocal Public Health,” Journal of Epidemiology and Community Health 53, no. 8 (1999): 451–2; R. J. Lawrence and C. Fudge, “Healthy Cities in a Global and Regional Context,” Health Promotion International 24 (Suppl. 1) (2009): i11–8.

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(193) UNAIDS, “The Three Ones” in Action: Where We Are and Where We Go from Here (Geneva: United Nations, 2005).

(194) I. Kickbusch, W. Hein, and G. Silberschmidt, “Addressing Global Health Governance Challenges through a New Mechanism: The Proposal for a Committee C of the World Health Assembly,” Journal of Law, Medicine, & Ethics 38, no. 3 (2010): 550–63.

(195) Caines et al., Assessing the Impact.

(196) L. Kumaranayake and S. Lake, “Regulation in the Context of Global Health Markets,” in Health Policy in a Globalising World, ed. Lee, Buse, and Fustukian, 78–96.

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(198) P. Buekens, G. Keusch, J. Belizan, and Z. A. Bhutta, “Evidence-Based Global Health,” Journal of the American Medical Association 291, no. 21 (2004): 2639–41.

(199) J. J. Furin, H. L. Behforouz, S. S. Shin, J. S. Mukherjee, J. Bayona, P. E. Farmer, et al., “Expanding Global HIV Treatment: Case Studies from the Field,” Annals of the New York Academy of Sciences 1136 (2008): 12–20.

(200) N. Szlezak, B. Bloom, D. Jamison, G. Keusch, C. Michaud, S. Moon, et al., “The Global Health System: Actors, Norms, and Expectations in Transition,” PLoS Medicine 7, no. 1 (2010): e1000183.

(201) R. England, Experience of Contracting with the Private Sector: A Selective Review (London: DFID Health Systems Resource Centre, 2004).

(202) P. A. Singer and A. S. Daar, “How Biodevelopment Can Enhance Biosecurity,” Bulletin of the Atomic Scientist 65, no. 2 (2009): 23–30.

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(204) S. Moon, N. Szlezák, C. Michaud, D. Jamison, G. Keusch, W. Clark, and B. Bloom, “The Global Health System: Lessons for a Stronger Institutional Framework,” PLoS Medicine 7, no. 1 (2010): e1000193.

(205) C. Pannenborg, A New International Health Order: An Inquiry into the International Relations of World Health and Medical Care (Alphen aan den Rijn: Sijthoff & Noordhoff, 1979); G. Walt, A. Spicer, and K. Buse, “Mapping the Global Health Architecture,” in Making Sense of Global Health Governance: A Policy Perspective, ed. K. Buse, W. Hein, and N. Drager (New York: Palgrave Macmillan, 2009), 74–113.

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(208) P. Hirvonen, “Stingy Samaritans: Why Recent Increases in Development Aid Fail to Help the Poor,” Global Policy Forum, August 2005: 14–28.

(209) For more on various global health frames, see C. McInnes, A. Kamradt-Scott, K. Lee, D. Reubi, A. Roemer-Mahler, S. Rushton, et al., “Framing Global Health: The Governance Challenge,” Global Public Health 7(Suppl. 2) (2012): S83–94.

(210) For ethical issues and political consequences related to the international security frame, see S. Elbe, “Should HIV/AIDS Be Securitized? The Ethical Dilemmas of Linking HIV/AIDS and Security,” International Studies Quarterly 50, no. 1 (2006): 119–44; and S. Elbe, Virus Alert: Security, Governmentality and the AIDS Pandemic (New York: Columbia University Press, 2009); and whether this frame leads to better international health policy, see S. Elbe, Security and Global Health (Cambridge: Polity Press, 2010).

(211) D. P. Fidler, “Constitutional Outlines of Public Health’s ‘New World Order’,” Temple Law Review 77, no. 247 (2004): 247–90.

(212) M. Whitehead, G. Dahlgren, and L. Gilson, “Developing the Policy Response to Inequities in Health: A Global Perspective,” in Challenging Inequities in Health, ed. T. Evans, M. Whitehead, and F. Diderichsen (New York: Oxford University Press, 2001), 308–23.

(213) U. Reinhardt and T. Cheng, “Sick around the World,” Frontline, November 10, 2007.