The Transformation of Global Health Governance

C. McInnes, A. Kamradt-Scott, K. Lee, A. Roemer-Mahler, S. Rushton, O. Williams

• Publisher: Palgrave Pivot
• Year: 2014
• Print ISBN:
  9781137365712
• eBook ISBN:
  9781137365729
• Topic: Política y relaciones internacionales
• Subtopic: Industria farmacéutica, biotecnológica y sanitaria

The authors examine how health governance is being transformed amid globalization, characterized by the emergence of new actors and institutions, and the interplay of competing ideas about global health. They explore how this has affected the governance of specific health issues and how it relates to global governance more broadly.

1

Global Governance and Health

Abstract: This chapter discusses the relationship, in an age of globalisation, between global health governance and the governance of individual health issues such as HIV/AIDS, pandemic influenza, tobacco control and access to medicines. It does this within the context of changes to global governance more generally. It proposes a new way of envisaging this relationship, which captures the evolving political dynamics. In particular the chapter identifies a narrative of transformative change in global health governance based on three elements: the globalisation of health; the emergence of competing visions of global health governance; and the changing institutional landscape.

McInnes, Colin, Kamradt-Scott, Adam, Lee, Kelley, Roemer-Mahler, Anne, Rushton, Simon and Williams, Owain David. The Transformation of Global Health Governance. Basingstoke: Palgrave Macmillan. DOI: 10.1057/9781137365729.0005.

Introduction

In early 2007, Indonesia’s Minister of Health, Siti Fadilah Supari, announced her country’s decision to stop sharing its samples of the H5N1 influenza (‘bird flu’) virus with the World Health Organization (WHO). What appeared at first sight to be a fairly innocuous, technical decision, sparked a major diplomatic crisis. Since 1952, the WHO has been identifying circulating strains of the influenza virus to allow the development of vaccines and warn of novel strains with the potential to become pandemic. Central to this is the manner in which samples of the influenza virus are shared on a systematic and regular basis, from 135 recognised National Influenza Centres located in 105 areas, to one of six regionally distributed WHO Collaborating Centres. Here they are analysed to determine which strains are in active circulation and whether a new strain may be emerging (WHO, no date). Virus sharing was therefore widely accepted as a global public good, where mutual interests had produced global norms and institutions to mitigate the potential human and economic costs of influenza.

In this context, the Indonesian decision not only appeared to undermine an example of an effective global regime, but also came at a time when fears of a highly pathogenic influenza pandemic were high, and Indonesia was among the countries seen as a highly likely source of such an outbreak. The general reaction, especially from the United States, was extremely hostile, portraying Indonesia’s actions as reckless and threatening to global health security. Siti Supari, however, argued that virus samples were being passed on, without Indonesia’s knowledge or permission, to private pharmaceutical companies to develop highly lucrative vaccines. Moreover, despite widespread recognition that Indonesia could potentially be the front line of an influenza pandemic, and therefore in greatest need of vaccine supplies, the price set by pharmaceutical companies lay beyond the means of most Indonesians. Further, patent protections had been taken out by companies on the avian influenza virus itself, and Material Transfer Agreements concluded between WHO and pharmaceutical companies, without the consent of those countries providing virus samples. Supari claimed that this practice was ‘obviously unfair and opaque’ (Supari, 2007). Indonesian fears appeared vindicated in 2009–10 when, during the ‘swine flu’ (H1N1) pandemic, high-income countries received privileged access to the relevant vaccine, regardless of who was most at risk from the virus or which governments had provided virus samples to manufacture the vaccine (WHO, 2007a; Fidler, 2010a; Knox, 2011; Sinha, 2011).

Although the Indonesian virus sharing crisis was eventually resolved in 2011, what the crisis appeared to confirm was that the traditional view of international health cooperation had been transformed. Historically seen as a largely technical arena focused on such tasks as developing guidelines for ‘best practice’, agreeing common nomenclature and supporting capacity building in healthcare delivery, it was now characterised by a greater diversity and, on many issues more divergent, range of interests and perspectives. International health cooperation is now known as global health governance (GHG), a term suggesting a qualitative shift from intergovernmental relations to a more complex global assemblage. Crucially, this sense of transformative change in governance, widely constructed as a consequence of globalisation (for example: Cockerham and Cockerham, 2010; Harman, 2012), was not limited to health, but was sensed more widely within the international system.

This first chapter sets out the concerns of this book and its underpinning approach. It begins by discussing global governance, allowing us to begin to interrogate the relationship with GHG. It then discusses the emergence of GHG as a distinct subject of study and practice. This allows us to locate our work within this developing subject area, before outlining the framework of analysis adopted (what we term the ‘three transformations’ in GHG). The book then proceeds to apply this macro-level framework to four case studies, each focusing on a particular issue widely constructed as central in and to the narrative of global health. These four issues balance the traditional focus in GHG on infectious and communicable disease, with more recent concerns over non-communicable disease and distributive justice issues, and the appropriate and necessary governance responses to each.

The theoretical basis of this book is social constructivism. As Onuf (1989) argues, the social world does not exist independent of observation but is one of our own making, and that the ideas we use in observing and understanding the social world also shape that world. This does not mean that the material world is of no concern, but rather that the material and ideational interact with each other:

Constructivists hold the view that the building blocks of ... reality are ideational as well as material; that ideational factors have normative as well as instrumental dimensions; that they express not only individual but collective intentionality; and that the meaning and significance of ideational factors are not independent of time and place. (Ruggie, 1998, p. 33)

Therefore, we do not deny the importance of material factors in shaping GHG. Rather, we add to this the manner in which health and health issues are socially constructed (by language and other means), within a specific context of time and place, and through this construction possess meaning.

The transformation of global governance

The origins of the transformation in global governance are often identified as lying in the emergence of neoliberalism and free market capitalism as the dominant economic ideology in the 1980s and 1990s. Although not all forms of global governance are manifestations of neoliberalism, these ideas formed a powerful engine for subsequent changes. In particular, boosted by the end of the Cold War, these ideas established a global rationality legitimising a series of policies and empowering certain institutions such as the World Bank. Recognition in time of the failings of neoliberal policies such as structural adjustment, however, led ‘not [to] a rejection of neoliberalism, but a recognition of the need for a greater institutional embedding of neoliberal rationalities, in particular by paying greater attention to the mechanisms of governance and securing the social conditions by which free markets could better operate’ (Joseph, 2012, pp. 95–6). Thus, neoliberalism provides an economic structure and rationalisation for a set of global norms, policies and institutions, which establish particular forms of global governance. For Cammack (2004) and others, this variant of neoliberalism is deeper than its earliest manifestation, as it involves the reconfiguration of states, institutions and social policies, as well as private actors’ forms of authority, by means of the transmission of ever wider sets of policy prescriptions and templates from the global level downwards.

This book argues that the transformation in global governance should therefore not be seen solely in economic terms, important though these are. Rather a series of simultaneous, and sometimes linked, developments contributed to a wider sense of change in the 1990s. The ending of the Cold War affirmed not only the dominance of neoliberal economics, but also opened up new possibilities for a diverse range of actors to play a more effective role in international relations based upon a shift in authority from states to global institutions with common and often ostensibly progressive norms (for example: Annan, 2000; Wheeler, 2001; Bellamy, 2009). For commentators such as Rosenau, however, this shift in the basis of authority was more complex and multi-faceted, involving multiple levels: from the subnational, through the state, to the transnational and global. Moreover, both Rosenau and Clark identified the concurrent phenomena of globalisation and fragmentation. Global change therefore appeared to them, not as a unidirectional progressive transformation in international relations, characterised by top-down developments, but as a series of changes pulling in sometimes very different directions. Using the term ‘global life’, Rosenau suggests that global governance is better understood as a change in an individual’s political horizons to incorporate the global (Clark, 1997; Rosenau, 1992, 1995, 1997).

Related to the above was a growing sense of the development of global civil society – social movements with transnational perspectives and interests, often seen as progressive forces promoting humanitarianism, rights and democratisation, or as key social mechanisms for giving voice to individual’s political interests in a globalised polity (see for example: Lipschutz, 1992; Falk, 1995; Held, 1996). Improved communications from the 1990s on, also allowed ideas to be more widely shared – constructing what Webster (1995) termed the ‘information society’ – leading not only to the sharing of norms but also to the greater development of global epistemic communities. If, however, global civil society is conceived as, by and large, ‘grassroots’ movements impacting on global society and governance, then others identified the importance of global elites, not only in establishing their own epistemic communities, but also as capable of shaping policies and practices outside of traditional governmental structures. Perhaps the most important example is the World Economic Forum held at Davos, Switzerland, but others included philanthropic enterprises such as the Bill and Melinda Gates, Clinton and Rockefeller Foundations. Avant, Finnemore and Sell (2010) also identify the emergence of ‘global governors [who] are authorities who exercise power across borders for purposes of affecting policy. Governors thus create issues, set agendas, establish and implement rules and programs, and evaluate and/or adjust outcomes’ (p. 2). For Avant et al., they are not only important as agents of global governance, but the character of their interactions is also an important feature of the international system.

The sense of transformative change has therefore emerged from multiple directions, and with different stresses being given to the lines of force and agency at play in global governance. But what is also apparent is that the result, in terms of what global governance is, lacks focus and meaning. Although the loosening of the grip of states on international relations is common to all of the transformations identified earlier (see also Scholte, 2000), what replaces it is less clear. Most fundamentally, ‘it is not clear whether [global governance] really does refer to the governance of the world on a global scale, or of whatever governance there is taking place in the world’ (Joseph, 2012, p. 90). Although clearly more than a ‘worldwide tilt from states to markets’ (Hewson and Sinclair, 1999, p. 5), there is no consensus about what this diverse set of changes to actors, norms and procedures actually means. Held and McGrew (2003) argue that it represents a shift from states to regimes; Avant et al. suggest a change in agenda setting, rule-making, implementation and monitoring (2010, p. 14); Rosenau (2006) suggests the emergence of a multi-centric globalised space, where political agendas are set and different rule systems collide; whereas others points to the emergence of new transnational networks (for example: Risse-Kappen, 1996; Keck and Sikkink, 1998).

The importance of the above for this book is four-fold. First, it demonstrates the contested nature of global governance – there is no set agreement on what it is and who it is for. Second, the sense of transformative change is clear and rooted in the narrative of globalisation. Third, this transformation in global governance is far more than increases in the speed and intensity of inter-state exchanges. These form a part of the transformational narrative, what may be described as a horizontal axis linking states. For example, bilateral aid programmes, such as the US President’s Emergency Plan for AIDS Relief (PEPFAR), form an important element of the patchwork of GHG. However, this is only part of the story. A vertical axis embracing actors ‘above’ the state (for example, international organisations) and ‘below’ (for example, civil society organisations) is also part of this new narrative. Finally, the transformation of global governance opens up implications for its relationship with global health, and specifically with global health governance, and the governance of specific health issues such as HIV/AIDS or pandemic influenza. In particular it suggests a multi-level governance framework involving governance of specific issues, of health and of other policy sectors, within an overall context of transformed global governance.

Health and global governance

Few analyses to date have either identified or discussed this multi-level nature, most implicitly assuming a nested relationship similar to Figure 1.1. In this relationship, the governance of specific health issues forms part of GHG, which in turn is part of broader global governance. The picture is one of a coherent relationship between multiple levels (for example: Fidler, 2010b; Frenk and Moon, 2013). However, this simplifies the often multi-sectoral nature of the policy world and narratives surrounding it. Thus health issues can affect macro-economic performance and vice versa; environmental issues can affect health; trade policies can affect both health and the environment. This suggests that the governance of these issues is similarly multi-sectoral. Rather than a nested approach, a Venn diagram may be a more appropriate representation of the interaction across various sectoral governances within an overall narrative of global governance (see Figure 1.2). This may also be repeated at the level of individual health issues. Thus, for example, the governance of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) may find areas of overlap with access to medicines. The overlapping nature of this model adds complexity, but continues to suggest a mutuality of interests through the overlapping nature of these relationships reflected in the governance of sectors and issues. Following on from previous work (McInnes and Lee, 2012a), however, we see these relationships as characterised as much by conflict as by cooperation, with different sectors pursuing their own agendas which may or may not align with others, and which may change over time. Moreover this conflict is not only between, but within sectors. Thus, within GHG, there may be conflict over the allocation of resources or priority given to specific health issues, as seen for example in the debate over ‘AIDS exceptionalism’ (Smith and Whiteside, 2010). It is tempting therefore to replace Figure 1.2 with a ‘bumper car’ model where, at both the sectoral and issue levels, different governances ‘bump’ into each other (see Figure 1.3). But this suggests that governance is marked by an ongoing series of conflicts over issues and agendas, which ignores the potential of cooperation. Moreover the model poorly reflects the manner in which interests may change over time. Our approach, therefore, is one which resembles a kaleidoscope of continually changing patterns where some issues and sectors occasionally overlap, for mutual benefit, and on other occasions may bump into each other. The key analytical question therefore becomes one of understanding when, within this kaleidoscope of cooperation and contestation, do interests, ideas and institutions offer the potential for effective GHG? What circumscribes the prospects for GHG, and what drives its potentialities?

FIGURE 1.1 Nested global governance

FIGURE 1.2 Global governance as overlapping interests

FIGURE 1.3 The bumper car model

The emergence of global health governance

GHG shares the sense of transformative change and uncertainty over meaning described earlier for global governance more generally. Like the broader field of global governance, GHG began to garner scholarly interest with the end of the Cold War (for example: Lee, 1992). Part of this was due to the removal of the constraints imposed by the Cold War’s narrow agenda, allowing new issues to emerge (McInnes and Lee, 2012b); and part was due to increased fears of emerging and re-emerging infectious diseases which, for the first time in generations, appeared to place high-income countries, as well as low to middle-income countries, at increasing risk (Garrett, 1996; Price-Smith, 2001, 2002). A key development in the literature has been to broaden the idea of GHG away from a focus on the technical competencies of international institutions, and their ability (or lack of) to deal with emerging global issues, and towards a more politicised view of the relationship between the growing number of actors involved. GHG therefore became more than simply what the WHO and other global health institutions could and should do, to a more complex question of how these institutions related to other actors in responding to the globalisation of health (Dodgson et al., 2002; Harman, 2011a; Kay and Williams, 2009).

The literature on GHG therefore does not solely portray ...

Table of contents

• Cover
• Title
• 1  Global Governance and Health
• 2  HIV/AIDS
• 3  Pandemic Influenza
• 4  Tobacco Contro
• 5  Access to Medicines and the International Patent Rights Regime
• 6  Conclusion: The Transformation of Global Health Governance
• Bibliography
• Index