The contemporary history of global governance for health

Until recently, GGH has not captured significant international attention. Part of the reason may be that much of the global health landscape was for decades uncrowded, with several leading institutions and dominant themes, which could largely be examined on their own terms—for instance WHO and primary health care (the Declaration of Alma-Ata) and the World Bank (structural adjustment). Governance could largely be understood through a relatively limited set of institutions and approaches. This relatively simple understanding of global health, and its governance structures, is no longer true.

Beginning in the 1990s and accelerating in the 2000s, the global health landscape expanded swiftly. The number of actors proliferated, with bilateral agencies, nongovernmental organizations (NGOs), partnerships, foundations, corporations, and new multilateral institutions such as the Global Fund and GAVI. AIDS came to dominate the global health landscape, while the Millennium Development Goals (MDGs) drew particular focus to maternal and child health. The burden of non-communicable diseases rapidly grew in developing countries. Globalization gathered speed, contributing to the faster international spread of disease, while increasing the impact on health, trade, migration, and the environment. International funding for health grew exponentially, although funding is still outpaced by need. Health systems moved up on the global health agenda, while primary health care, the social determinants of health, and universal health coverage commanded renewed attention.

Non-state actors (such as NGOs, foundations, and partnerships), not the traditional subject of international law, have come to the fore. The roles of intergovernmental institutions that have dominated the field of global health have been in flux or in retreat, while some have questioned the leadership of the WHO. As other legal regimes have matured, some have encroached upon global health’s territory. They have even collided with efforts to address principal global health challenges, as most prominently evidenced in the tension between international intellectual property and access to essential vaccines and medicines.

Global governance is struggling to catch up, to effectively respond to this changing environment. Across much of the global health landscape, binding international health law may appear secondary, or simply absent, with notable exceptions such as the Framework Convention on Tobacco Control and International Health Regulations. In domains occupied by several bodies of law, such as where health and trade intersect, there is no consensus on a hierarchy of regimes that could resolve conflicts. Seeking to fill the void and resolve these tensions are ad hoc arrangements with less obvious connections to international law. The ‘soft law’ of non-binding instruments and structures have emerged as more relevant approaches for governing a sometimes-chaotic global health landscape, such as the Paris Declaration on Aid Effectiveness, the International Health Partnership, the Global Fund, the WHO Global Code of Practice on the International Recruitment of Health Personnel, and the Doha Declaration on the Trade-Related Aspects of Intellectual Property Rights (TRIPS) agreement and public health.

Meanwhile, innovative proposals to re-order the global health landscape to lead to better health appear at odds with traditional views of international law. Local and national priorities must drive actions for better health, ‘bottom-up’ approaches rather than the seemingly ‘top-down’ imposition of international law. Treaties typically take years to negotiate, and years more still to come into force, a timescale that may appear to be eons in today’s world full of pressing health needs. Furthermore, international law is notoriously difficult to enforce. Are the answers to what is widely agreed to be flawed and outdated global governance for health structures to be found in international law, or elsewhere? Would a more organic, less structured set of processes be more responsive and better able to meet the complex, fast changing challenges of global health?

Global governance for health, including international law, has the potential to dramatically improve global health. It can bring effective governance to presently poorly governed parts of the global health landscape. Developed astutely, especially if backed by social movements, international law and GGH can provide a frame that is sturdy yet flexible, constructed of human rights and social justice, shaped by community needs and priorities.

Seeking to learn from its present strengths and weaknesses, we will offer a vision of how effective governance can respond to today’s global health needs, shape far more efficient institutions and structures, close health inequities, and manage emerging challenges. We hope to inspire confidence

– and the aspiration – to engage in the further development of GGH, to help unleash its power, and to pursue the ideals behind it.

Global governance for health: A definition and differentiation

The United Nations system has focused attention on GGH, acknowledging that the concept ‘is increasingly being challenged by new realities of an interdependent world and that there is an urgent need to make the global health architecture more effective, efficient, and responsive, in order to, inter alia, bring more coherence to the delivery of health outcomes and enhance health equity.’ (6) Indeed, the Ministers of Foreign Affairs of Brazil, France, Indonesia, Norway, Senegal, South Africa, and Thailand, founding members of the Foreign Policy and Global Health Initiative, argued in September 2010 that ‘[f]oreign policy areas such as security and peace building, humanitarian response, social and economic development, human rights and trade have a strong bearing on development and have an important interface with health.’ (7) The United Nations, moreover, has specifically linked health and foreign policy, urging member states to ‘consider health in the formulation of foreign policy making … to contribute better to creating a global policy environment supportive of global health.’ (8)

What does ‘global governance for health’ mean, and how can it be differentiated from similar concepts such as international health law generally and ‘global health governance’ in particular? We define GGH as the collection of norms, institutions, and processes that collectively shape the health of the world’s population. It encompasses structures at the international level, such as the norms created by major treaties in the health (e.g. the International Health Regulations and Framework Convention on Tobacco Control) and related sectors (e.g. TRIPS and the Kyoto Protocol); the international organizations that affect global health (e.g. WHO, World Bank, and World Trade Organization); and global decision-making bodies and processes (e.g. the World Health Assembly and Global Fund grant-making process).

Global governance for health encompasses the dynamic relationship between global structures and forces and those at regional, national, and sub-national levels: how they inter-relate and influence norms, institutions, and processes at all levels, including at the community level. GGH also includes how, in turn, more local structures affect global structures and processes. For example, virtually all states have infectious disease laws, which must comply with the International Health Regulations. The International Health Regulations, in turn, also feeds into national and local structures, for example, by mandating capacity building with international cooperation and assistance.

Scholars sometimes use ‘global governance for health’ interchangeably with ‘global health governance,’ but the former term is broader and therefore more desirable. ‘Global governance for health’ refers to the broader governance system’s influence on health outcomes, including multiple sectors such as health, trade, food, labour, human rights, and the environment. ‘Global health governance,’ on the other hand, refers to the narrower form of governance that is encapsulated by the boundaries of the health sector. Notably, the recent statement of the seven foreign ministers of the Foreign Policy and Global Health Initiative used the term ‘global governance for health’ (7).

Rules play a critical role in global governance for health. Such rules can range from legally binding agreements (e.g. public international law relating to human rights or trade) to non-legally binding instruments such as declarations, codes of conduct, and memoranda of understanding (e.g. WHO Code of Practice), through to institutional bylaws (e.g. the organizational structure of the Global Fund or GAVI Alliance). Understanding, applying, and shaping the law are therefore central to the task of formulating more effective GGH. These international legal instruments, in turn, are implemented through and otherwise influence laws and legal structures within countries, effects that are also central to understanding the idea of GGH.

Governance does not operate in a vacuum, but is shaped by multiple forces, including politics (globally and nationally), power dynamics (between and among countries of the global North and South), the influence of vested interests (e.g. corporations) and economic power (e.g. the Gates Foundation), security interests (human security and more traditional security interests), changing circumstances (evolving disease burdens and the many changes driven by globalization), knowledge and learning (lessons from how present structures are affecting global health), and values (e.g. human rights and global ethics). Civil society-led social movements, which are of particular importance in the quest for social justice, powerfully shape governance.

A comprehensive understanding of GGH and of how to wield this potentially powerful tool as a source for better health for all and for health equity, requires sophisticated reflection on the ‘grand challenges’ that face the global health system, and the inability of the current architecture to meet the critical needs of the world’s least healthy people.

The grand challenges of global governance for health

The intractability of progress in global health can be attributed to a number of ‘grand challenges’–the enduring, hard-to-solve obstacles that persist in the political, legal, economic, and social contours of the current international landscape and prevent the achievement of global health with justice. Here, we briefly discuss six ‘grand challenges’ in relation to GGH, which are vital to the improvement of world health and the reduction in glaring health disparities (9).

The future of GGH

The current approach to GGH has been inadequate. Fundamental health needs continue to be neglected and health systems remain weak. Non-state actors, especially at the local level, are not being sufficiently harnessed through partnerships. The global health landscape has been marked by fragmentation, lack of coordination, and undermining host country ownership of programmes. Transparency and accountability have been poor, and monitoring and enforcement of commitments are almost non-existent. The WHO has yet to assert itself in this new global health environment. Many of these seemingly intractable problems could be solved through innovative governance.

Whether or not Harald’s dream of a Framework Convention on Global Health comes to fruition, JALI will transform global health. It will launch a consensus building process, involving research and extensive, inclusive consultations, to address questions that respond to what we view as the core obstacle of global health equity. Governments have failed to develop the policies and devote the resources needed to more fully apply the substantial body of technical health knowledge, thus enabling all people to have their essential health needs met. JALI will therefore systematically and rigorously examine the questions of what health services are guaranteed to every person under the right to health, what state responsibilities are to their own populations and to those of people beyond their borders in securing the right to health, and what GGH is needed to ensure that all states live up to their mutual responsibilities. We believe that these questions are central to reforming global governance for health so that it is organized to dramatically reduce health inequities.

The time is ripe for reimaging the health responsibilities of states, as the 2015 deadline for the MDGs is looming, and the post-MDG global health framework is yet to be developed. A global health agreement that captures health responsibilities and reforms GGH to enable states and the global health community to effectuate these responsibilities could be attractive to countries of both the global South and North because of the mutual benefits that would come from this approach. For example, it would lead to more predictable global health funding aligned with country strategies, increased domestic health investments that provide wealthy countries the prospect of reducing assistance in due course, and greater capacity to protect everyone from public health emergencies. Such an agreement is not out of reach.

Perhaps most significantly, JALI will transform global health through a global ‘bottom-up’ campaign. Civil society and governments in the South are demanding a fair share of health goods and services, and the alignment of power structures with the compelling aspirations of the world’s least healthy people. A shared common vision of global social justice and realizing the human right to health can unite health advocates from a multitude of perspectives – AIDS advocates and child health advocates, food advocates and safe water advocates, health system strengthening advocates and advocates for health research. This united health advocacy front, with demands for accountability from people’s own governments and from the international community, has the potential to turn into a social movement with broad popular support. Such a force will itself be an important chapter in the development of global governance for health.