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Appendix E
Commissioned PaPer
Global Health Governance Report
Lawrence O. Gostin*
Emily A. Mok**
I. Introduction
Global health is of primary importance to human functioning and well-being.
Yet the state of global health by many measures is dire. The dual burdens of
infectious and chronic diseases among the world’s poorest people are enduring.
Profound disparities in health and life expectancy between the rich and poor are
wide and resistant to change. And all countries, rich and poor, are at risk of pro -
nounced health hazards from the movement of people, goods, and services.
No country, acting alone, can adequately protect the health of its citizens or
significantly ameliorate the deep problems of poor health in developing countries.
The spread of disease, the importation of consumer goods, and the migration of
health professionals cannot be adequately controlled by states in isolation, but
depend on international cooperation and assistance. Globalization—the “process
of increasing economic, political and social interdependence, and global integra -
tion that occurs as capital, traded goods, people, concepts, images, ideas and
values diffuse across national boundaries” (Taylor 2002)—is changing the way
that states must protect and promote health due to the growing number of health
hazards that increasingly cross national boundaries (Dodgson et al. 2002, Lee
et al. 2002, Lee 2003). Globalization similarly demands creative solutions to
*Associate Dean (Research and Academic Programs), the Linda and Timothy O’Neill Professor
of Global Health Law, and Faculty Director of the O’Neill Institute for National and Global Health
Law, Georgetown University
**Visiting Researcher, O’Neill Institute of National and Global Health Law, Georgetown Univer-
sity, and D.Phil candidate, Centre for Socio-Legal Studies, University of Oxford.
0
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complex problems that affect the determinants of health such as in trade, human
rights, and the environment (Dodgson et al. 2002).
Despite the importance of a coherent strategy for global health, the tradi -
tional system of international health governance, which primarily encompasses
states and intergovernmental organizations (IGOs), has been unable to effectively
govern in the new global health context (Dodgson et al. 2002). Today, the inter-
national community faces a number of hard global health governance (GHG)
problems. Here, we highlight several “grand challenges,” which are vital to
the improvement of world health and the reduction in glaring health disparities
(Gostin 2008a):
• Leadership—WHO must gain the capacity and authority to establish a
clear mission, achieve objectives, and influence health-promoting activi -
ties globally.
• Harness Creativity, Energy, and Resources for Global Health—The GHG
system must create and align incentives of private/public actors and stake-
holders to promote imaginative, well-funded solutions for global health
improvement.
• Collaboration and Coordination of Multiple Players—The GHG system
must create effective partnerships and coordinate currently fragmented
funding, programs, and activities to create synergies and avoid destructive
competition among funders and service providers or, worse, with local
government and business initiatives.
• Basic Survival Needs—The GHG system must help build health systems
and infrastructures that are scalable and sustainable to meet fundamental
human needs, including sanitation, food and water, vector control, and
maternal/infant health.
• Funding and Priorities—The GHG system must gain agreement on fund-
ing levels needed to achieve key priorities, the responsibility of rich states
to devote adequate funding for international health assistance, and ensure
adequate health system capacities in poor states.
• Accountability, Transparency, Monitoring, and Enforcement—The GHG
system must create rules for accountability, transparency, monitoring
progress, and norm enforcement needed to fulfill commitments and meet
goals.
The conspicuous voids left by the traditional governance system in the face
of global health crises have prompted the creation of various ad hoc initiatives
sponsored bilaterally or by nonstate actors such as nongovernmental organiza -
tions (e.g., humanitarian organizations, industry associations, foundations, and
other private associations) and businesses (e.g., pharmaceutical companies). For
some initiatives, states and IGOs have joined forces with nonstate actors to form
public-private partnerships (PPPs) or “hybrid” organizations in an attempt to
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APPENDIX E
address global health problems such as the Global Fund for HIV/AIDS, Tuber-
culosis and Malaria (“the Global Fund”) and the International Finance Facility
for Immunisation (IFFIm).
Despite the proliferation of actors and initiatives in the global health space,
the current approach to governance is not solving the global health crisis. Numer-
ous global health initiatives have missed or are missing their targets (e.g., WHO’s
“3 by 5” initiative and the UN Millennium Development Goals) due, in part, to
problems of governance. Furthermore, there is growing concern over the popu -
larity of short-term, narrowly focused disease programs over long-term capacity
building initiatives aimed at generalized health protection and promotion (Burris
and Beletsky 2005).
This commissioned Institute of Medicine paper addresses why the most
important global health objectives are being hindered by global health gover-
nance today. The most vital goals include improved health and longevity among
the world’s poor, maternal and infant survival, reduced health disparities, and
reduced spread of health hazards across national boundaries. First, in section II,
we review the “grand challenges” for global health that need to be addressed by
GHG. The issues highlighted are not meant to be an exhaustive list of today’s
global health challenges, but rather to assist in understanding why global health
has not progressed further and determining what needs to be done.
In Section III, we survey the range of key global health actors and the
decentralized environment within which they operate, and investigate the reasons
behind their inability to meet contemporary global health challenges. The grow -
ing overlap between institutional mandates, sectors, and laws has transformed
global health into a disorganized world of territorial actors, uneven partnerships,
and tenuously balanced multisectoral approaches. This section highlights the
need for a more coherent approach to address the broad governance challenges
of global health as a whole.
Finally, in Section IV, we explore innovative approaches to global health
governance. As the problems of global health governance continue to grow,
several prominent scholars have devised creative solutions that may help to trans-
form today’s global health situation. We briefly review their ideas and consider
how they might function in practice. These proposals represent only a start to
what clearly has to be a broadly conceived, imaginative approach to global health
governance, where innovation is urgently needed.
II. Grand Challenges in Global Health Today
Globalization has dramatically transformed how the international commu -
nity must respond to modern health hazards. As the forces of globalization (such
as mass travel, trade, industrialization, and communication) bring states closer
together, there is a newfound sense of urgency regarding the spread of disease
due to the potential for widespread and rapid dispersion. A sudden rush to address
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this issue in terms of national security has resulted in a greater focus on particu -
lar health issues, such as HIV/AIDS and biosecurity, and resulted in an influx
of narrowly focused, overlapping initiatives without a coherent sense of the big
picture of global health.
Today, many are wondering why health targets are not being reached and
what has become of the investments made. Meanwhile, a number of other criti -
cal health issues such as chronic conditions (Daar et al. 2007) and less popular
diseases of poverty (i.e., the so-called “neglected diseases”) continue to be left at
the wayside despite their significant burden on society—especially in resource-
poor countries (Gostin 2008a). Overall, there is a sense that underlying health
needs are being “obscured” by current tendencies for popular health initiatives
(Burris and Beletsky 2005).
The intractability of progress in global health can be attributed to a number
of “grand challenges” (Gates Foundation 2003). These grand challenges are 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 (Gostin and Taylor 2008). In this section, we high -
light six of the key grand challenges in relation to global health governance. We
offer more specificity regarding these challenges later in the paper. It is important
to note that all of these challenges are interconnected and, in some instances,
overlapping and a systemic approach is necessary to address these issues appro -
priately and adequately.
1. WHO Leadership
The first grand challenge relates to the lack of leadership that WHO has
exhibited in its role as the premier agency for health. WHO, despite its unique
directive to lead using an array of powerful mechanisms (e.g., treaties and regula-
tions) and legitimacy, has shied away from providing the much needed leadership
for the promotion of international health. At the same time, other IGOs have chal-
lenged WHO’s primacy in global health, such as the World Bank and WTO, using
their resource-based or political powers (Gostin and Taylor 2008). Although this
void in leadership is explained partly by structural and power dynamics at WHO,
it has nonetheless resulted in flawed implementation of and weak compliance
with WHO norms by states. Consequently, WHO needs to gain the capacity and
authority to establish a clear mission, achieve objectives, and influence health-
promoting activities globally.
2. Harness the Creativity, Energy, and Resources for Global Health
The second grand challenge is the need for the current international system
of states and IGOs to harness the creativity, energy, and resources of other actors
and stakeholders for global health. It is well understood that nonstate actors, such
as civil society, foundations, and private enterprises, play an increasingly impor-
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APPENDIX E
tant role in global health, but their role and obligations remain unclear. Businesses
can offer great benefits for the health of the global community, for example, by
innovations in pharmaceuticals, vaccines, and medical devices; producing and
selling healthier foods and safer products; and creating healthier and safer places
to work. Philanthropists can provide much needed resources for urgent and endur-
ing health needs, as well as imaginative ideas for how to serve the health needs
of poor people. And civil society has demonstrated the capacity for helping those
within their communities and advocating for social change.
The GHG system needs to devise a means to create incentives, facilitate,
coordinate, and channel the activities of these nonstate actors. It needs to enhance
health-producing activities and discourage harmful ones. How, for example, can
the GHG system increase the involvement of the nonhealth sectors (e.g., food,
energy, and transportation) and encourage them to think in health-conscious
ways? It has even been suggested that WHO, or another international entity, could
“monitor, evaluate, and rank corporations on their degree of ‘health responsibility,’
much the way that companies are ranked on their ‘greenness’” (Bloom 2007).
Public-private partnerships (PPPs) have served as a primary means for engag-
ing private industry in health initiatives in order to leverage industry strengths
in research and development, product manufacturing, and product distribution.
At the same time, private industry can benefit from the opportunities offered by
engaging in such work. For example, PPPs offer pharmaceuticals the ability to
obtain subsidies for research and assistance in clinical trials, as well as good PR
for entry into drug markets (Buse and Walt 2002). This arrangement, however,
could result in conflicts of interest between the pharmaceutical’s corporate strat -
egy and PPP objectives. Overall, the GHG system needs to find a way to create
and align the incentives for private/public actors and stakeholders to promote
imaginative, well-funded solutions for global health improvement (Buse and
Harmer 2007).
3. Collaboration and Coordination of Multiple Players
The third grand challenge is the need for collaboration and coordination
among the multiple players in global health. A number of actors, beyond the tra -
ditional state-centric governance system, now occupy the field of global health.
This has resulted in rampant problems of fragmentation and duplication in the
sea of funding, programs, and activities that span the global health domain. Such
problems have crippling effects at the national level where “[developing coun -
try] governments looking to tackle health problems . . . face a bewildering array
of global agencies from which to elicit support” and, in consequence, typically
results in overburdening the health ministries with “writing proposals and reports
for donors whose interests, activities, and processes sometimes overlap, but often
differ” (Bloom 2007, IDC 2008).
Related to fragmentation among the current proliferation of actors is the
growing competition between international NGOs and local service providers
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(e.g., governments, business and community based organizations) for funding and
human resources (Garrett 2007a). It is feared that this encroachment of interna -
tional actors upon capable actors at the local level will hinder efforts at greater
country ownership1 and control. When well-funded NGOs create AIDS clinics or
other services on the ground, they are often able to offer more lucrative salaries
and far better working conditions than local providers. This can drain public or
private initiatives in the host country, making it even more difficult to provide
sustainable services.
Rather what is needed is a system of governance that fosters effective part -
nerships and coordinates initiatives to create synergies and avoids destructive
competition at all levels—international, national, and local (Rosenberg et al.
forthcoming). Several recent efforts at coordination and harmonization among
actors have been launched, such as the “Health 8” and the International Health
Partnership,2 but it remains to be seen whether these initiatives will achieve their
goals (International Health Partnership 2007, NORAD 2007, IOC 2008).
4. Basic Survival Needs
The fourth grand challenge pertains to meeting fundamental human needs
through the development of scalable and sustainable health systems and infra -
structures. Meeting fundamental human needs lack the glamour of high-technol -
ogy medicine or rescue, but their value is the significant potential for impact on
health because they deal with the major causes of common disease and disabili -
ties across the globe. These needs are essential to restoring human capability and
functioning, which one of us has termed “basic survival needs” (Gostin 2008a).
Basic survival needs include sanitation and sewage, pest control, clean air and
water, tobacco reduction, diet and nutrition, essential medicines and vaccines, and
functioning health systems for the prevention, detection, and mitigation of disease
and premature death. By focusing on these needs, the international community
could dramatically improve prospects for the world’s population. A number of
the needs are laid out in international agreements. Three of the eight MDGs, for
1 According to a recent U.K. International Development Committee report, developing countries’
“ownership” of their own development effort is a key aspect of aid effectiveness (IDC 2008).
2 The “Health 8” refers to the group of eight major international health-related agencies (i.e., WHO,
World Bank, GAVI, UNICEF, UNFPA, UNAIDS, the Global Fund to fight AIDS, Tuberculosis and
Malaria, and the Bill and Melinda Gates Foundation), which meet informally to discuss ways to
scale up services and improve health-related MDG outcomes (International Health Partnership 2007,
NORAD 2007). The International Health Partnership (IHP) is an effort that was launched in 2007 by
some donor countries “to improve the coverage and use of health services—whether through public
or private channels, or through non-governmental organisations—in order to deliver improved out -
comes” related to the health-related MDGs and universal access commitments ( Lancet 2007, Ooms
et al. 2008, International Health Partnership 2007). The International Health Partnership has also been
a topic of discussion by the H8 and led to an interagency coordination process and common workplan
known as IHP+ (for IHP and related initiatives).
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APPENDIX E
example, are health-related: child mortality, maternal health, and reducing the
burden of infectious diseases (UN Dep’t of Int’l Econ. & Soc. Aff. 2006). The
UN Economic & Social Council finds that basic survival needs are a core com -
mitment of the right to health, including immunization, essential medicines, food,
potable water, sanitation, disease prevention and treatment, primary health care,
and health education (UN Comm. on Econ., Soc. & Cultural Rights, General
Comment 2000).
Building enduring health systems is critical to population health. Such health
systems require sound infrastructures and human resources, which would give
countries the tools to safeguard their own populations. Poor countries need to
gain the capacity to provide basic health services themselves. Health system
capacity has the added benefit of improving world health by significantly reduc -
ing the potential for disease migration to other countries and regions. Local
capacities empower health professionals to prevent, rapidly detect, treat, and con-
tain health hazards before they spread out of control (WHO 2000). Unfortunately,
as discussed in the next grand challenge, the priority placed on addressing basic
survival needs and building health systems by international assistance tends to be
low. The GHG system must find a way to redress this critical problem.
5. Funding and Priorities
The fifth grand challenge relates to the skewed priorities in international
funding. Currently, a significant amount of funding is directed towards “specific
diseases or narrowly perceived national security interests” that have been placed
high on the global health agenda by a small number of wealthy donors (such as
OECD countries, the Gates Foundation and the Global Fund) (Garrett 2007b,
Gostin and Taylor 2008). As a result, funding tends to be diverted from the larger,
systemic approaches, such as building stable local systems to meet basic survival
needs (Prakongsai et al. 2008, Waddington 2004).
In priority setting, a stronger cooperative approach needs to be taken between
donors and recipient countries in defining and advancing developing country
health agendas (Bloom 2007). Proper resource allocation based upon attainment
of basic survival needs, support for basic infrastructure and capacity building, and
cost-effective interventions have the potential to make donor funding go further.
And, it is important to prioritize funding in light of its potential for health impact
over a substantial period of time—e.g., 10 to 15 years (Levine 2008). The Disease
Control Priorities Project (DCPP) is an illustration of a current effort to assist
developing countries with the improvement of their health systems. The DCPP
provides technical resources to inform policy making on topics such as the cost-
effectiveness of different health-improving interventions and cross-cutting issues
crucial to the delivery of quality health services (Laxminarayan et al. 2006).
Funding needs to be provided at adequate and predictable levels that are
scalable to needs. Such needs exist at both the international and national level, as
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WHO is highly dependent on Member States for financial resources to carry out
its functions and developing countries need funding to build capacity. A prob-
lem with current funding approaches is that there is no method of holding rich
states accountable to provide sufficient and stable international health assistance
to states that lack the capacity. For example, developed countries have not even
fulfilled their pledges made in 1975 of giving 0.7 percent of gross national income
(GNI) per annum on overseas development assistance (ODA). More than 30 years
later, their real contribution has only recently risen to reach a high of 0.33 percent.
In general, the GHG system must gain agreement on funding levels needed to
achieve key priorities, the responsibility of rich states to devote adequate funding
for international health assistance, and ensure adequate health system capacities
in poor states. Figuring out innovative ways to ensure adequate and enduring
levels of funding, and agreed-upon priorities, will be vital in ensuring that poor
countries gain the capacity to deal with everyday health threats, as well as public
health emergencies.
6. Accountability, Transparency, Monitoring, and Enforcement
Finally, the sixth grand challenge pertains to the need for greater transpar-
ency, accountability, monitoring, and enforcement in meeting global health goals.
Accountability in global health has been problematic. WHO and other IGOs are
officially accountable to their Member States, but “they often lack detailed and
realistic targets for health outcomes or for the intermediate actions they take to
promote health” (Bloom 2007). States themselves tend to enter into voluntary,
rather than binding, commitments towards health and it is difficult to hold them
accountable under such weak mechanisms. Other actors, such as civil society,
foundations, and corporations, report to an array of different interest groups and
cannot be held accountable for their failures or shortcomings.
At the same time, there is insufficient transparency both with respect to IGO
and state decision making. Transparency, literally truthfulness and openness to
view, has no fixed meaning, but most definitions include the following overlap-
ping features: open governance, free flows of information, and civic participa -
tion. These are values that support accountability and are widely believed to be
hallmarks of good governance.
Monitoring and enforcement in global health are similarly problematic.
While there have been increased efforts to build “monitoring and evaluation” sys-
tems to track the progress of various health initiatives, the lack of an enforcement
mechanism generally leaves things at a voluntary level for the actors involved.
Reliance on voluntary practice can be unreliable and unstable unless there are
adequate incentives to drive performance. All in all, the GHG system needs to
adapt by creating rules for accountability, transparency, monitoring progress,
and norm enforcement for the fulfillment of commitments and achievement of
goals.
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APPENDIX E
To conclude, these six “grand challenges” represent some of the critical fea -
tures needed in a coherent system of global health governance. To ensure effective
and well-functioning health systems in poor countries, and to meet basic survival
needs, the international community, in partnership with host countries, must
invest in health system infrastructure. It is not simply the amount of money spent
that is important, but how those resources are invested and used. This requires a
structured approach that sets priorities, ensures coordination, and monitors and
enforces results. Accomplishing a system of coordinated and effective interna -
tional aid will require political will and a system that unifies the myriad efforts
of states, IGOs, NGOs, businesses, and private foundations. On top of all of this
is a need for clear and strategic leadership. As the next section indicates, current
global health governance efforts have not been able to accomplish these goals,
and a fresh approach is badly needed.
III. The Inadequacy of the Current Approach to Global Health Governance
As highlighted by the six grand challenges, the advancement of global
health requires leadership, coordinated global health actors, priorities, basic
survival needs, and accountability, transparency, monitoring, and enforcement.
Unfortunately, as this section will illustrate, the current approach to global health
governance has not been able to meet these needs. A central, and actually inher-
ent, problem to the current approach is the lack of leadership in global health.
Leadership unifies actors. It also sets the direction for priorities and has the
potential to drive basic survival needs to the fore. At the same time, it can help
align incentives and engage in monitoring and enforcement.
Without clear leadership, current priorities have been skewed towards popu-
lar, disease-focused initiatives and away from basic survival needs. A prolifera -
tion of actors with “little or no formal mandate in health” has entered the global
health domain and, in general, they have not worked well together. Despite the
creation of novel financing mechanisms, such as the Global Fund, funding levels
continue to be missed as separate mechanisms are adopted (e.g., PEPFAR). Over-
all, accountability is questionable and enforcement has been nonexistent.
This section points out the inadequacies in the current approach to gover-
nance. First, it identifies the reasons behind the lack of global health leadership by
the World Health Organization. It goes on to consider the proliferation of players
in global health, through a look at several prominent actors (i.e., the World Bank,
PEPFAR, the Gates Foundation, and the Global Fund), and presents some of the
key criticisms regarding each of their approaches. Finally, the section concludes
with a look at four emerging areas of overlap with the health sector and what the
overlap means for GHG in terms of synergies and tensions.
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THE U.S. COMMITMENT TO GLOBAL HEALTH
A. The Lack of Leadership by the World Health Organization
Leadership is vitally important to achieve vital objectives in global health.
Individuals and organizations that take leadership can effectively influence the
activities of multiple actors to establish a clear mission and achieve objec -
tives. In the global health field, the United Nations established the World Health
Organization (WHO) to exercise leadership. The WHO has in many ways been
an admirable organization advancing world health, but it has failed to live up
to expectations in its leadership role. The fault is not entirely its own, but the
vacuum in leadership over the years has significantly impeded progress on the
key parameters of global health.
The WHO, the UN specialized agency for health, was established in 1948
and includes 193 member states. The WHO Constitution envisioned an agency
that would act as the “directing and coordinating authority on public health” (Art.
2) and endowed it with extensive normative powers to proactively promote the
attainment of “the highest possible level of health.” These powers include the
adoption of conventions (Art. 19), the promulgation of binding regulations (Art.
21), and the recommendations (Art. 23), and monitor national health legislation
(Art. 63).
The WHO’s treaty-making powers are noteworthy. The agency can adopt
binding conventions or agreements which, unlike normal treaties, affirmatively
require States to “take action”—submitting the convention for ratification and
notifying the Director General of the action taken and State’s reasons within 18
months (WHO Constitution, Art. 19 and 20). The WHO also possesses quasi-
legislative powers to adopt regulations on a broad range of health topics—e.g.,
international epidemics; the safety, potency, and advertising of biologicals and
pharmaceuticals; and a nomenclature for diseases, causes of death, and public
health practices (WHO Constitution, Art. 21). WHO regulations, unlike most
international law, are binding on Member States unless they proactively “opt
out.” Once adopted by the World Health Assembly (WHA), the regulations
apply to all WHO member countries, even those that voted against it, unless the
government specifically notifies WHO that it rejects the regulation or accepts it
with reservations.
WHO’s binding normative powers, therefore, are extraordinary. It possesses
the authority to oblige States to take health treaties seriously by submitting them
to a national political process and informing the international community of the
result. Its regulatory powers are even more far-reaching, as States can be bound
by health regulations without the requirement to affirmatively sign and ratify.
States, moreover, have ongoing duties to make annual reports to the agency of
actions taken on recommendations, conventions, and regulations (WHO Constitu-
tion, Art. 62).
Despite these impressive powers, modern international health law is remark -
ably thin—two of the three existing international health instruments predate the
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APPENDIX E
agency. The WHA, at its first session in 1948, adopted World Health Regulation
No. 1, Nomenclature with Respect to Diseases and Causes of Death, which
formalized a long standing international process on the classification of disease
(WHO 1990). By providing standardized nomenclature, the regulation facilitates
the international comparison of morbidity and mortality data. The Nomenclature
Rule was modest at onset, but it subsequently became merely advisory, now
known as the International Classification of Diseases. The Rule is, therefore,
technical, rather than normative, and recommended rather than obligatory.
World Health Regulation No. 2, the International Health Regulations (IHR),
dates back to a series of international sanitary conferences held in Europe dur-
ing the second half of the nineteeth century to address the transboundary effects
of infectious diseases. The sanitary conferences had little to do with improving
health in developing countries. Rather, they reflected the national interests of
European powers to prevent the importation of devastating tropical diseases
(Howard-Jones 1975). The legal and diplomatic work begun by the international
sanitary conferences eventually produced the International Sanitary Regulations
(ISR), which the WHA adopted in 1951 and which were renamed the IHR in 1969
(Fidler 2005). Before the IHR was fundamentally revised in 2005, they applied
only to cholera, plague, and yellow fever—the same diseases originally discussed
at the first International Sanitary Conference in Paris (1851) (WHO 2005).
Not unlike the original ISR, the revised IHR was motivated by the potentially
drastic economic and security consequences of fast moving infectious diseases,
in this case hemorrhagic fevers, SARS, avian influenza, and bioterrorism. The
IHR’s primary focus is on “public health emergencies of international concern,”
defined as “a public health risk to other States through the international spread
of disease” (WHO 2005, IHR Art. 1). The IHR, therefore, historically and politi -
cally, was intended to prevent transmigration of disease, rather than to improve
health in poor countries. To be sure, the revised IHR is far more expansive and
bold than its predecessors, but it is unlikely to do the work that is needed in global
health—namely, to dramatically improve the plight of the world’s least healthy
people (Fidler and Gostin 2006).
The WHO did not create a health convention until 2003, when the WHA
adopted the Framework Convention on Tobacco Control (FCTC) (WHO 2003).
The FCTC declares the bold objective of protecting present and future generations
from “the devastating health, social, environmental and economic consequences
of tobacco consumption and exposure to tobacco smoke” (Art. 3). It adopts
multidimensional strategies, including demand reduction, supply reduction, and
tort litigation (Taylor and Lariviere 2005, Taylor and Bettcher 2000). Although
a laudable achievement, the FCTC is almost sui generis because it regulates the
only lawful product that is uniformly harmful. The FCTC was politically feasible
because the industry was vilified for denying scientific realities, engineering
tobacco to create dependence, engaging in deceptive advertising, and targeting
youth, women, and minorities (Brandt 2007, Mehl et al. 2005).
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THE U.S. COMMITMENT TO GLOBAL HEALTH
health. Overall, there are a variety of innovative ways to address the inadequacy
of the current approach to GHG and a bold change needs to be adopted soon.
V. Health in a New Political Era
Today, we stand before a number of critical challenges in global health.
This paper highlighted how the historical lack of leadership by WHO, despite its
immense powers, has significantly impeded the international governance of health
and opened the door to a proliferation of actors in the global health domain. Now,
an array of nonhealth IGOs, bilaterals, nonstate entities, and GPPPs dominate the
field. While these actors have introduced a number of creative ideas and a vast
sum of new resources to tackle global health’s most difficult problems, they have
also brought a new set of problems to global health in the form of misaligned
priorities, heavily skewed funding, service duplication and competition, and
unsustainability. Meanwhile, global health must contend with a variety of emerg -
ing external forces such as trade, environment, and foreign policy. The overlaps
between the health sector and these other fields hold the potential for tensions
and synergies that need to be managed.
At the same time, fundamental health needs continue to be neglected and
health systems remain weak. Nonstate actors, especially at the local level, are
not being sufficiently harnessed through partnership. Transparency and account -
ability needs to be greater, and the monitoring and enforcement of commitments
should be introduced. GHG needs to resolve the current imbalances and bring
a greater sense of coherence to the “big picture” of global health. In addition,
WHO must find a way to assert itself in this new global health environment. An
innovative approach to GHG is sorely needed, and we reviewed a few creative,
initial proposals on this subject. All in all, a dramatic change to the current GHG
system is critical and the international community must be prepared to confront
each of the grand challenges with clarity of purpose.
As this paper sought to elucidate, many of the seemingly intractable prob -
lems in global health could be addressed through improved global health gov -
ernance. Leadership; harnessing creativity, energy, and resources; collaboration
and coordination; meeting basic survival needs and health systems capabilities;
prioritizing funding; and accountability, transparency, monitoring, and enforce -
ment are some of the key grand challenges that the GHG system must address.
And, yet, what is the role of the United States in terms of overcoming the current
grand challenges? With the recent election of Barack Obama as President, atten -
tion has turned towards the implementation of campaign promises and there are
several notable global health policies (Gostin 2008b). For example, these policies
include (Bristol 2008a, 2008b):
• Increasing the capacity of health systems to deliver HIV/AIDS
treatment.
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APPENDIX E
Launching a “Health Infrastructure 2020 Plan.”8
•
• Changes in PEPFAR, including an additional $1 billion over five years
towards the HIV/AIDS epidemic in Southeast Asia, India, and Eastern
Europe.
• Greater U.S. funding and support toward multilateral programs (including
the Global Fund to Fight AIDS, Tuberculosis and Malaria and the UN
Millennium Development Goals).
• Reforms in U.S. foreign assistance, including the doubling of yearly for-
eign assistance to $50 billion by 2012 and 100 percent debt cancellation
for the world’s heavily indebted poor countries.
It is hopeful that these policies indicate a change from the prevailing unilateral
approach taken by the United States and, perhaps, will bring our country into
greater alignment with other donor countries possessing effective aid programs
(Bristol 2008a, The One Campaign 2008). Though the current economic climate
raises some concerns about the immediate feasibility of these ambitious policies,
the opportunity for the incoming administration to change the U.S. approach
towards global health should not be neglected in the near term.
The Obama administration should still strive to shift the United States away
from an approach of “exceptionalism” and demonstrate its “willingness to engage
positively with the rest of the world” on global health (Rechel and McGee
forthcoming). As a starting point, for example, there needs to be a change in
U.S. foreign assistance from ideological approaches that have undermined or
obstructed international health efforts (e.g., HIV prevention programs 9) toward
policies that “favor realism and reliability” (Levine 2008). The Obama admin -
istration could also show its global commitment to health through several other
measures, which include the adoption of a new U.S. position on climate change
(e.g., ratify the Kyoto Protocol), the reversal of health care worker “brain drain”
from developing countries (e.g., build a supply of skilled workers domestically
and limit international recruitment), and the promotion of fair trade for develop -
ing countries (e.g., remove obstacles for poor countries in accessing essential
medicines and vaccines and developing domestic health and safety protections)
(Rechel and McGee forthcoming, Gostin 2008b).
While these near-term changes would signal greater U.S. support for global
health, the six “grand challenges” discussed earlier in this paper require a broader
and deeper level of commitment to a dramatic change in governance for the long
8 The “Health Infrastructure 2020 Plan” has been described as “a global effort to work with develop -
ing countries to invest in the full range of infrastructure needed to improve and protect both American
and global health” (Bristol 2008a).
9 Key examples of detrimental policies under the Bush administration include the “block[age] of
funds for needle or syringe exchange programmes . . . in countries with injection-driven epidemics”
and an “obsession with abstinence-only approaches . . . [in countries] where the epidemic is driven
by sexual contact” (Rechel and McGee forthcoming).
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THE U.S. COMMITMENT TO GLOBAL HEALTH
term. In the past, the United States has been resistant to global health governance,
refusing to ratify vital treaties or work cooperatively. It could make a genuine dif-
ference by agreeing to fair terms of cooperation through international agreements
and partnerships. Effective global health governance could dramatically improve
life prospects for millions of people and diminish our collective vulnerabilities.
Ultimately, this is an ideal for the Obama administration to pursue for the U.S.
commitment to global health.
Acknowledgments
The authors thank Morgan Rog and Abiodun Baiyewu of the O’Neill Insti -
tute for National and Global Health Law at Georgetown University for their
research assistance and early contributions on the topics of environment and
foreign policy in this paper.
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