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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 worldâs 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. Globalizationâthe âprocess 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 boundariesâ (Taylor 2002)âis 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 OâNeill Professor of Global Health Law, and Faculty Director of the OâNeill Institute for National and Global Health Law, Georgetown University **Visiting Researcher, OâNeill Institute of National and Global Health Law, Georgetown Univer- sity, and D.Phil candidate, Centre for Socio-Legal Studies, University of Oxford. 0
0 THE U.S. COMMITMENT TO GLOBAL HEALTH 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 âgrand challenges,â which are vital to the improvement of world health and the reduction in glaring health disparities (Gostin 2008a): â¢ LeadershipâWHO must gain the capacity and authority to establish a clear mission, achieve objectives, and influence health-promoting activi - ties globally. â¢ Harness Creativity, Energy, and Resources for Global HealthâThe GHG system must create and align incentives of private/public actors and stake- holders to promote imaginative, well-funded solutions for global health improvement. â¢ Collaboration and Coordination of Multiple PlayersâThe 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. â¢ Basic Survival NeedsâThe 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. â¢ Funding and PrioritiesâThe 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. â¢ Accountability, Transparency, Monitoring, and EnforcementâThe 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 âhybridâ organizations in an attempt to
0 APPENDIX E address global health problems such as the Global Fund for HIV/AIDS, Tuber- culosis and Malaria (âthe Global Fundâ) 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., WHOâs â3 by 5â 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 worldâs poor, maternal and infant survival, reduced health disparities, and reduced spread of health hazards across national boundaries. First, in section II, we review the âgrand challengesâ for global health that need to be addressed by GHG. The issues highlighted are not meant to be an exhaustive list of todayâs 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 todayâs 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
0 THE U.S. COMMITMENT TO GLOBAL HEALTH 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 âneglected diseasesâ) continue to be left at the wayside despite their significant burden on societyâespecially in resource- poor countries (Gostin 2008a). Overall, there is a sense that underlying health needs are being âobscuredâ 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 âgrand challengesâ (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.â WHOâLeadership 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 WHOâs 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.â HarnessâtheâCreativity,âEnergy,âandâResourcesâforâGlobalâHealth 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-
0 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 âmonitor, evaluate, and rank corporations on their degree of âhealth responsibility,â much the way that companies are ranked on their âgreennessââ (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 pharmaceuticalâs 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.â CollaborationâandâCoordinationâofâMultipleâPlayers 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 â[developing coun - try] governments looking to tackle health problems . . . face a bewildering array of global agencies from which to elicit supportâ and, in consequence, typically results in overburdening the health ministries with âwriting proposals and reports for donors whose interests, activities, and processes sometimes overlap, but often differâ (Bloom 2007, IDC 2008). Related to fragmentation among the current proliferation of actors is the growing competition between international NGOs and local service providers
0 THE U.S. COMMITMENT TO GLOBAL HEALTH (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 levelsâinternational, national, and local (Rosenberg et al. forthcoming). Several recent efforts at coordination and harmonization among actors have been launched, such as the âHealth 8â 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.â BasicâSurvivalâNeeds 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 âbasic survival needsâ (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 worldâs 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 countriesâ âownershipâ of their own development effort is a key aspect of aid effectiveness (IDC 2008). 2 The âHealth 8â 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 âto improve the coverage and use of health servicesâwhether through public or private channels, or through non-governmental organisationsâin order to deliver improved out - comesâ 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).
0 APPENDIX E example, are health-related: child mortality, maternal health, and reducing the burden of infectious diseases (UN Depât of Intâl 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.â FundingâandâPriorities The fifth grand challenge relates to the skewed priorities in international funding. Currently, a significant amount of funding is directed towards âspecific diseases or narrowly perceived national security interestsâ 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 timeâe.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
0 THE U.S. COMMITMENT TO GLOBAL HEALTH 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.â Accountability,âTransparency,âMonitoring,âandâEnforcement 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 âthey often lack detailed and realistic targets for health outcomes or for the intermediate actions they take to promote healthâ (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 âmonitoring and evaluationâ 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.
APPENDIX E To conclude, these six âgrand challengesâ 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 âlittle or no formal mandate in healthâ 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.
THE U.S. COMMITMENT TO GLOBAL HEALTH A.â TheâLackâofâLeadershipâbyâtheâWorldâHealthâOrganization 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 âdirecting and coordinating authority on public healthâ (Art. 2) and endowed it with extensive normative powers to proactively promote the attainment of âthe highest possible level of health.â 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 WHOâs treaty-making powers are noteworthy. The agency can adopt binding conventions or agreements which, unlike normal treaties, affirmatively require States to âtake actionââsubmitting the convention for ratification and notifying the Director General of the action taken and Stateâs 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 topicsâe.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 âopt out.â 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. WHOâs 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 thinâtwo of the three existing international health instruments predate the
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 feverâthe 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 IHRâs primary focus is on âpublic health emergencies of international concern,â defined as âa public health risk to other States through the international spread of diseaseâ (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 healthânamely, to dramatically improve the plight of the worldâs 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 âthe devastating health, social, environmental and economic consequences of tobacco consumption and exposure to tobacco smokeâ (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).
THE U.S. COMMITMENT TO GLOBAL HEALTH The adoption of normative mechanisms under the WHO has been highly skewed towards recommendations over treaties and regulations. Consequently, the agency has strongly favored technical advice over creating norms and gain- ing conformance of the international community. Recommendations can take various forms, but two primary types include resolutions and codes of conduct. Resolutions are recommendations of the WHA that help âdraw international attention to important issues faster than multilateral treaty approachesâ and allow Member States great flexibility with its implementation. Codes of conduct are recommendations that often âcall upon governments to pass national legislation and urge industry to adhere voluntarily to [its] provisions.â Both approaches are considered to be âpersuasive with no binding legal powerâ or, in other words, soft law (Lakin 1997). A problem with these approaches, however, is the difficulty of influencing Member States to act in ways that promote national and global health and holding them accountable. The explanations for this inability to lead are economic, legal, and political. The agency does not have the economic power to effectively create incentives and achieve tasks. Its funding is usually inadequate to fulfill it broad mission. This is true in absolute terms, as it is reliant on external funding from States, foundations, or other donors such as the GAVI alliance. Additionally, the funding it does receive is often specifically targeted. As a result, the WHO often must follow the priorities of funders rather than exercising its own judgment about needs and priorities. The WHO also does not have the legal power due to its inadequate moni- toring and enforcement of reporting and other state requirements. According to Article 62 of WHOâs constitution, â[e]ach Member shall report annually on the action taken with respect to recommendations made to it by the Organization and with respect to conventions, agreements and regulations.â The constitution also states, under Article 63, that countries should report âimportant laws, regulations, official reports and statistics pertaining to health which have been published in the State concerned.â Taylor (1992), for example, observes that the WHO report - ing procedure has not been âstrictly applied.â As a result, Member States either âroutinely [fail] to report required information to WHOâ or present âself-servingâ information (Fidler 1998, Taylor 1992). The politics of WHO are also formidable. Not only do Member States and external funders direct funding, but also the agency feels the need to gain broad agreement of Member States to support its mission, priorities, and goals. This may take the form of formal approval of the WHA. Or, it may be that particularly powerful states can influence, or even block, activities that the agency would otherwise wish to pursue.3 3 There has not always been consensus between member states and the WHO Secretariat on the normative mechanisms selected at the WHO. The International Code of Marketing of Breast-milk substitutes (Burci and Vignes 2004, Resolution WHA 34.22 (1981)) was one such case. This code
APPENDIX E Finally, the economic, legal, and political realities of WHO make it hard to function in the modern environment. It is clear that states play only a limited role in harming, or helping, global health efforts. In the modern environment, WHO needs to lead not only with respect to what states may, or may not, do, but also a wide variety of stakeholders. The WHO must harness the creativity, energy, and resources of multiple actors, such as foundations, NGOs, businesses, public- private partnerships, and civil society more broadly. The WHO Constitution never envisaged this kind of all-embracing role, but effectively leadership requires the organization to effectively engage, influence, and coordinate the activities of a wide range of important actors in global health. Much criticism has been directed at WHO for its reluctance to apply stronger international health governance mechanisms, despite the bold mission and sweep - ing powers granted in its Constitution (Fidler 1998, Taylor 1992, 2004, Lakin 1997). Scholars observe that the organization âappears to envision its legislative role as neither active nor even reactive, but merely observationalâ (Taylor 1992). This has resulted in beliefs that WHOâs weak policy controls are âslavishly in thrall to its Member States,â whereby âappropriate respect for national sover- eigntyâ has been âovertaken by [WHOâs] blind obeisance to narrow national wishesâ (Fidler 1998). These critics argue that the meaning of âsovereign stateâ has changed in the context of todayâs global health environment, and WHO must âreorient its attitude towards Member State[s]â (Fidler 1998). Such an effort would require WHO to revamp its current reputation for observational data col - lection and technical medical standardization to one of âdynamicâ international governance, as originally intended by its Constitution (Lakin 1997, Taylor 1992, Burci and Vignes 2004). While scholars have attributed WHOâs reluctance to apply its legal powers to the organizationâs âtraditional conservatism,â WHOâs organizational behavior has actually been changing since the term of Director-General Gro Brundtland (which ran between 1998-2003) (Taylor 2004). Examples, such as the WHOâs changing attitude towards its engagement with other institutions (e.g., WTO), approach to health issues (e.g., human rights), and use of legal powers (e.g., the 2005 IHR revision), indicate a significant move from being a strictly technical organiza - tion. Yet, given the frequent turnover in WHO leadership that has occurred since 2003 (with the sudden death of Lee Jong-wook, the interim direction by Anders arose from concerns over the processed food industryâs controversial marketing practices for breast- milk substitutes. These concerns led to a 1979 joint meeting on infant and young child feeding by WHO and UNICEF, and the subsequent draft code that was submitted to the WHO Executive Board for consideration in 1981. A key topic of discussion at this meeting was whether to adopt the code as a regulation or a recommendation. Interestingly, the WHO Legal Counsel at the time argued that breast- milk substitutions should be considered ânutritional medicineâ which meant that this topic could be regulated under Article 21. The Executive Board, however, ultimately decided upon the application of a recommendation in order to âavoid rejection of a binding code by a number of developed countries trying to safeguard their commercial interestsâ (Burci and Vignes 2004).
THE U.S. COMMITMENT TO GLOBAL HEALTH Nordstrom, and the relatively recent installment of Margaret Chan), it remains unclear whether Brundtlandâs legacy of organizational change will be carried on to achieve a âgenuine adaptation or evolution of WHOâs conservative cultureâ (Taylor 2004). Furthermore, WHOâs ability to change is constricted by its limited budget - ary resources and a growing need to compete with other international agencies for the financial support of Member States and the private sector. The ongo - ing practice by Member States of primarily funding outside the WHO General Budget, which receives only 28 percent of non-earmarked funds while 72 percent goes into specified programs,4 has transformed WHO into a very âdonor-drivenâ organization and restricted its ability to direct and coordinate the agenda (WHO 2007c, Burci and Vignes 2004). (For further details on the WHO budget, please refer to the Appendix at the end of this paper.) A consequence is that WHOâs operations have become increasingly fragmented, compartmentalized programs so that donors can claim credit and assert control. It is believed that this has also led to the associated problem of âunhealthy competition among departments within the WHOâ (Peopleâs Health Movement et al. 2008). In the end, WHOâs financial struggle significantly hinders its ability to promote institutional leader- ship against the pressures of state sovereignty and to advance the application of its legal powers (Taylor 2004). In summary, global health is such a complex and important goal that it demands effectively leadership. A good leader has the tools, and political will, to establish, in collaboration with others, a clear mission and priorities, govern diverse activities, monitor progress, and ensure the achievement of major goals. Due to a variety of economic, legal, political, and functional reasons, the WHO has not been able to exercise the leadership needed in the modern global health context. B.â TheâProliferationâofâActorsâinâGlobalâHealth Without effective global health leadership, the response to vital challenges has been ad hoc and highly fragmented. A proliferation of actors has appeared on the global health scene armed with differing agendas and a selective set of initia - tives. In the response to HIV/AIDS and other high profile health crises, an upsurge in actors, funds and initiatives has occurred, but with little coordination. The proliferation of actors, of course, can be beneficial, as it brings poten - tially great wealth and creativity into the global health arena. Global health, like global climate change, used to attract little attention from states, foundations, 4A recent study by Stuckler et al. revealed that WHOâs general budget âwas much more closely aligned with the actual global burden of disease than were the extra-budgetary funds.â WHOâs gen - eral budget (2006-2007) allocates 61 percent to infectious diseases, 38 percent to noncommunicable diseases and about 1 percent to injuries. On the other hand, WHOâs extra-budgetary funds (for 2006- 2007) allocate 91 percent to infectious diseases, 8 percent to noncommunicable diseases, and about 1 percent to injuries (Stuckler et al. 2008).
APPENDIX E NGOs, and businesses, but that is changing rapidly. The goal, of course, is not to have these actors disengage, but rather to fully engage them in ways that are well coordinated and highly effective. It is an enormous missed opportunity when all of these stakeholders enter the global health arena in scattered, sometimes conflicting, ways. What is most important is to harness the energy, resources, and creativity of all these actors to work together to significantly improve global health. To examine the challenges that the growth in actors presents for governance, this section considers the involvement of the four most powerful players in global health today. They are the World Bank, PEPFAR, the Global Fund, and the Gates Foundation. These organizations also represent the different categories of actors (i.e., IGOs, bilaterals, nonstate actors, and PPPs) that have come to dominate the global health field. Through their resource-based power, these actors have been able to exercise considerable influence on the direction of global health policy. However, because these institutions all answer to different stakeholders, the approach taken by each has not been consistent and is tied to institutional survival instincts. This raises serious concerns about the accountability and appropriate - ness of these actors in global health, and how the GHG system must deal with the issue. Intergovernmental Organizations Influencing Health: The World Bank Many non-health-focused IGOs, such as UNICEF and UNDP, have crossed into the realm of global health (Dodgson et al. 2002). Yet, none have traversed the global health boundary quite as far as the World Bank. Since the 1990s, the World Bank has become known for its large financial investments in health initiatives in developing countries. Upon recognizing the connection between public health and its mission of âreducing poverty and improving living standardsâ in devel - oping countries (Abbasi 1999), the World Bank moved beyond its core financier operations and launched the implementation of âa whole array of health initia - tives . . . bringing new money and fresh ideas to tackle diseaseâ (Yamey 2002). The combination of the World Bankâs financial power and aggressive health initiatives led many observers to believe that the World Bank would displace the WHO as the âpremier global health agencyâ (Yamey 2002). During the 1990s, such prospects were possible for the World Bank because WHO had become stagnant in its international role. Reports of âcronyism, a lack of direction and cohesion, a reluctance to shift its focus away from prevention of infectious dis - eases, and a reluctance to tarnish its image with governmentsâ were crippling problems that plagued WHO under the leadership of then Director-General Hiro - shi Nakajima (Abbasi 1999). As a result, WHO was sidelined to the supporting role of providing âmedical expertise and technical supportâ while the World Bank worked on health initiatives with the ministries of health, finance, and planning in developing countries (Abassi 1999).
THE U.S. COMMITMENT TO GLOBAL HEALTH In spite of the World Bankâs efforts to spearhead more responsive health initiatives in developing countries over the past two decades, its institutional competence was challenged when it failed to reach promised goals and was accused of reporting false outcomes (Attaran et al. 2006). One major criticism of the World Bank has been its lack of technical expertise necessary to implement health programs (Abassi 1999). Critics have argued that the World Bank holds âno compelling advantageâ in working with the health ministries and urged the institution to ârevert strictly to its core competence as a financierâa bankâand deposit the pledged commitments . . . into a dedicated fund for the exclusive use of other, more technically competent and transparent agenciesâ (Attaran et al. 2006). In recent years, the World Bank has been âtrying to find its footing on shifting ground in global healthâ (Levine and Buse 2006). The increase in global actors providing health assistance focusing on specific diseases (i.e., HIV/AIDS, malaria and tuberculosis), along with the criticism it received, prompted the World Bank to reevaluate its health sector strategy with an updated approach in 2007 (World Bank 2007b). With a steady decline in commitments to health sector operations between 2001-2006 from U.S. $10B to U.S. $7B, the World Bank has been working to focus and enhance its capacity towards its comparative advantages and the less popular global health issues such as health system strengthening at the country level (Levine and Buse 2006, World Bank 2007b). Furthermore, its 2007 health sector strategy reinforces the recent attempts by UN agencies at a collaborative division of labor with global partners. The strategy calls upon the World Bank to leave functions such as the technical aspects of disease control (e.g., the determination of treatment options for diseases), human resource train - ing in health, and internal organization of service providers (e.g., the operation of medical services) to other organizationsâsuch as WHO, UNICEF, and UNFPA (World Bank 2007b, Ruger 2007). The World Bank has also become increasingly engaged in collaborative efforts with other global health actors. Earlier this year, at the XVIIth Interna - tional Conference on AIDS in Mexico City, a new collaboration between the World Bank and WHO to provide technical guidance for better global health investments was announced. The collaboration was instigated in response to the ongoing debate over disease-specific initiatives versus health systems approaches and will âexamine and combine the strengths of different approaches around the world in order to get better results from investments and improve health outcomes for allâ (World Bank 2008). Bilateral Programs: The Presidentâs Emergency Plan for AIDS Relief (PEPFAR) Bilateral programs serve as a means through which donors can exercise direct control over how its funds are allocated and applied. PEPFAR, the single
APPENDIX E largest funder of HIV/AIDS programs in the world, is a prime example of the bilateral phenomenon (Gostin 2008c, Oomman et al. 2008). Launched in 2003 under President Bush, PEPFAR began as a $15 billion commitment over five years towards HIV/AIDS prevention and treatment assistance in 120 countries as well as the funding of HIV/AIDS research and the Global Fund. Most of PEPFARâs funds, however, are geared towards 15 focus countries which are predominantly located in Africa. PEPFARâs five-year goals, also known as the â2-7-10 goals.â entail the treatment of 2 million people, the prevention of 7 mil - lion new infections, and the care of 10 million people (including orphans and vulnerable children). According to the U.S. government, PEPFAR is on track to meet these goals this year (United States Presidentâs Emergency Plan for AIDS Relief 2008). As PEPFAR nears the end of its five-year term, total spending is expected to exceed its original commitment by $3.8 billion (for a grand total of $18.8 billion). President Bush has also recently signed into law a reauthorization of PEPFAR for up to $48 billion over the next five years. Despite PEPFARâs progress, significant criticism has been directed at its approach to funding HIV/AIDS programs that are indicative of clashes between the U.S. agenda and recipient country priorities. One criticism was directed at PEPFARâs initial refusal to purchase generic versions of HIV treatments, despite WHO prequalification of those medicines (Nelson 2004). It was suspected that PEPFAR rejected the option of purchasing generics due to domestic pharmaceuti- cal interests (McNeil 2007). Another criticism of PEPFAR targeted its restrictive program requirements and funding preferences. Restrictive directives for the PEPFAR program include the requirement of spending a third of its prevention and education funds on abstinence-promotion, the prohibition of funding for syringes or needles for intravenous drug users, and the requirement of recipient countries to denounce prostitution (Garrett 2005, McNeil 2007). These limiting factors have prompted calls for a move away from âideologically driven policiesâ towards areas of proven medical success (McNeil 2007). Also, some individuals in developing countries feel that money should be put under greater local control rather than being channeled through U.S. faith-based NGOs in order to cut costs (Stolberg 2008). PEPFAR appears to be taking steps towards addressing this concern under its reauthorization plan through the adoption of a âpartnership compactâ model. According to PEPFAR, this approach would increase partnerships with countries by building up country resources for HIV/AIDS and health systems among other activities (U.S. Office of the Press Secretary 2007). Finally, PEPFAR has been criticized for not making greater contributions to the Global Fund. Instead, PEPFAR has chosen to limit its contributions to num - bers that fall under its designated amount of 33 percent and direct more towards bilateral efforts. The Global Fund, as described later, has been struggling with a lack of adequate funds in recent years and many have argued that the United States should at least meet its designated contribution level. The U.S. government
0 THE U.S. COMMITMENT TO GLOBAL HEALTH has responded that the 33 percent is âa maximum limit, not an annual obligationâ (United States Presidentâs Emergency Plan for AIDS Relief 2006). Nonstate/Private Actors: Bill and Melinda Gates Foundation Nonstate actors, such as corporations, foundations, and civil society, play an increasingly important role in global health. Through the use of different forms of influence and power, nonstate actors can affect the direction of global health. The Gates Foundation, which has been labeled the ânew â800 pound gorillaâ in global health,â is a key nonstate actor with significant influence on global health (Yamey 2002). With approximately $8 billion spent towards global health projects since 2000, and an even larger amount expected with the commitment from Warren Buffett, the Gates Foundation has firmly placed itself on the global health gov- ernance map by mobilizing resources for innovative financing mechanisms and product development (Side effects of doing good 2008). The Gates apparently avoided putting money into the UN system, preferring to channel their funds âinto smaller, independently governed initiatives that focus on âquick fix,â high profile health problemsâ (Yamey 2002). This is illustrated by the Foundationâs heavy investment in the development of vaccines as well as drugs and diagnostic tests (Okie 2006). The foundation is also a major supporter of GAVI and the Global Fund. Some are concerned by the Gates Foundationâs narrow focus on technical interventions and high-profile research rather than the broader context of pub - lic health systems (Birn 2006, Piller and Smith 2007). Critics claim that âthe foundationâs grant making may not always reflect the priorities of recipients in developing countries, and its choices may influence the decisions of other agen - ciesâ (Okie 2006). It has also been reported that its initiatives are pulling away resources from basic care at the local levels (Piller and Smith 2007). The founda - tion has made attempts at broadening its focus through initiatives related to clean water and sanitation as well as some health system-related issues (Okie 2006), but more needs to be done. Finally, if major philanthropies are going to be part of the GHG system, it will be important to find ways to influence their activities and hold them accountable. At present, there are very few mechanisms for hold - ing large foundations accountable to any international standard, and there are no universal rules for transparency in decision making. Global Public-Private Partnerships: The Global Fund to Fight AIDS, TB, and Malaria A number of global public-private partnerships (GPPPs) have appeared in the past decade, and it is estimated that about 75 to 100 GPPPs exist (WHO 2007b). While the current GPPPs cover a range of health issues, most are focused on communicable diseasesâwhereby about 60 percent of GPPPs target HIV/AIDS,
APPENDIX E TB, and malaria (Caines 2005). The most prominent GPPP that exists today is the Global Fund, which was established in 2002 as a new type of financing mechanism for the prevention and treatment of HIV/AIDS, TB, and malaria. As the leading funder of malaria and TB programs and the second largest funder of HIV/AIDS programs, the Global Fund is a unique joint endeavor between gov- ernments, civil society, and the private sector that has established itself as one of the most prominent GPPPs today (Bartsch 2007, Bernstein and Sessions 2008). The model of the Global Fund is also unique in the sense that it possesses no in-country or technical assistance expertise because it strictly operates as a financ- ing mechanism without involvement in implementation activities (Bernstein and Sessions 2008). This creates an interesting dynamic between the Global Fund and the broader network of other global health actors that provide technical assistance to developing countries, as discussed later. The Global Fundâs new prominent role has created several tensions for the governance of global health. Firstly, as a GPPP, the Global Fund is expected to engage all of its partners. Yet, there have been concerns over the lack of engage - ment of CSOs and private industry in the Global Fund. For example, it has been noted that Southern governments have been reluctant to grant CSOs greater involvement at the global and national levels due to a fear of âlosing influence and policy optionsâ if authority is shared with CSOs (Bartsch 2007). Also, as a PPP, the Global Fund should attempt to leverage the benefits offered by its dif- ferent partnersâincluding private industry. The Global Fundâs requirement of financial donations and its obstinate refusal to allow the pharmaceutical industryâs proposal of gifts in kind (e.g., medicines), or other collaborative mechanisms, has been an area of debate (Bartsch 2007). Secondly, the Global Fundâs lack of harmonization with other global health initiatives has been a significant concern. The Global Fundâs support of narrow vertical (i.e., disease-focused) initiatives varies from other global health efforts that support broad, horizontal (i.e., health systems) development. It is feared that the Global Fundâs approach, on top of existing health initiatives, would âcontribute to a further fragmentation of health policies at the national levelâ (Bartsch 2007). Interestingly, the Global Fund has taken note of how basic health systems factors, such as infrastructure and capacity building, are critical to the achievement of its objectives. This led to a later decision to accept proposals for âhealth systems strengthening,â but only âwhere it is directly related to AIDS, tuberculosis or malariaâ and not health systems strengthening more broadly (Global Fund b). Thirdly, the Global Fundâs Country Coordinating Mechanism (CCM) has introduced a number of problems at the national and global level in terms of its lack of coordination with extant systems of governance. Under Global Fund procedures, CCMs function in the capacity of developing and submitting grant proposals as well as overseeing implementation (Global Fund a). The establish - ment of CCMs, however, has been âin additionâ to extant national coordinating
THE U.S. COMMITMENT TO GLOBAL HEALTH institutions (e.g., National AIDS Council and UN Theme Groups) (Bartsch 2007). This has resulted in problems of duplication and confusion for developing coun - tries as well as greater political competition for power and influence between the different coordinating authorities (Bartsch 2007). The CCMs have also been a source of conflict at the global level between the Global Fund and other actors. Because the Global Fund endorses a âbottom-upâ approach to health initiatives, it does not have an in-country presence nor does it house technical expertise to assist CCMs with their proposals. CCMs, as a result, rely on technical assis - tance from bilateral and multilateral organizations. This dependency adds to the workload of other organizations, such as WHO and UNAIDS, which support the CCMs without compensation. This issue was later resolved through a revision in grant proposals to allow for technical assistance compensation. Finally, the sustainability of the Global Fund approach has been an issue of contention. The Global Fund faces an increasing shortage of funds due to the challenges of donor fatigue, difficult economic times, and competition with other organizations for funding (Bartsch 2007). For example, the Global Fund has been âside-steppedâ by the United States (a key donor of the Global Fund) through the creation of PEPFAR. With the increasing shortage of funds from donors, some wonder whether the Global Fundâs approach to supporting disease programs can continue as it would have to âmobilize enough resources to run treatment pro - grams [for] as long as they are neededâ (Bartsch 2007). As illustrated by this set of key organizations, the current proliferation of actors in the global health domain highlights a number of problems with the current approach to governance. First, all of these actors are encroaching upon the authority of WHO. This highlights concerns about the accountability of these actors, as they all report to different stakeholders and do not necessarily hold representative âhealthâ interests. Second, there is misalignment between country priorities and actor agendas. Most of these actors take a disease-focused approach, rather than allocating resources to the broader issues of basic survival needs and healthcare systems. Third, some of these actors are competing among each other. For example, there is tension between the PEPFAR and the Global Fund in terms of funding. There is also tension between the World Bank and the Global Fund in terms of country-level coordination. This highlights the need for greater collaboration and coordination among the various actors. Fourth, many of these actors are not harnessing the energy, creativity and resources offered by nonstate actors. The Global Fund has tried to avoid a conflict of interest by refusing name brand treatments from pharmaceuticals, but this could be a lost opportunity to harness the resources of all actors to help those in need. Also, PEPFARâs lack of engagement with local service providers (e.g., businesses and NGOs) is a lost opportunity to foster greater country ownership. Fifth, there is no independent policing entity for these actors. While there is an emerging practice of establishing monitoring and evaluation systems for many of these actors, these actors generally participate on a voluntary basis and there is no way to enforce the achievement of goals.
APPENDIX E C.â â lobalâHealthâsâOverlapâandâPotentialâTensionsâandâSynergiesâwithâOtherâ G Sectors The growing overlap between the health sector and other fields presents a number of tensions and synergies that need to be addressed by GHG. The tensions posed by overlapping sectors have the potential to impede global health objectives and need to be addressed by GHG appropriately. On the other hand, the potential synergies that result from overlapping sectors need to be utilized to serve the betterment of global health. In this section, we review the overlap between health and the sectors of trade, environment, and foreign policy. We consider how the sectors overlap and whether there are opportunities for governance synergy, in terms of common goals between sectors, that can be leveraged or whether there are tensions, such as conflicting sectoral objectives, that must be managed. Health and Trade Increased trade liberalization, one of the driving forces behind globalization, brings a number of new opportunities and challenges to the health sector. Trade liberalization may well improve economic prosperity generally and therefore improve health outcomes. Increased trade in health-related goods, services, and people (i.e., patients and professionals) offer numerous opportunities to econo - mies around the world (Blouin et al. 2006). For example, the trade system offers the opportunity to lower prices for health-related goods with the reduction of trade tariffs or alter health systems with the transfer of health services. On the other hand, trade brings the challenges of spreading disease across borders with traded goods, advertising unhealthy lifestyles, and potentially limit - ing access to medicines under restrictive trade rules. Although free-trade advo - cates believe that trade liberalization will lift up the prospects of the poor as well as the rich, there is still legitimate concern and controversy that free trade benefits mostly the global rich, leaving the poor in no better, and perhaps worse, shape economically. The global rich, of course, can benefit from trade liberalization and particularly international protection of intellectual property through TRIPS (see below). However, poorer countriesâwhich lack the scientists, entrepreneurs, and industrial capacityâmay not benefit as much from the world trade system. The health sector itself also has a significant impact on the trade sector. The economic impacts on travel, tourism, and commerce of SARS, BSE, and avian influenza illustrate the powerful effects of disease on markets (Drager and Sun - derland 2007, Helble et al. forthcoming). All in all, the interlinkages between the trade and health sectors are complex and opportunities to address these ties are possible on both sides. The two sectors also bring entirely different philosophies, institutions, and laws. The intersection of these two spheres leads to deeply important questions, such as when a tension or conflict arises which philosophy, institution, or legal system should prevail, and why?
THE U.S. COMMITMENT TO GLOBAL HEALTH Currently, the governance of these interlinkages depends on the existing system of international rules5 and institutions for trade and health. The World Trade Organization (WTO), the multilateral organization for trade, has produced a number of international trade rules that are relevant to health; these rules include: General Agreement on Tariffs and Trade (GATT), the General Agree- ment on Trade in Services (GATS), the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS), The Agreements on Technical Barriers to Trade (TBT), and the Application of Sanitary and Phytosanitary Measures (SPS). Together, these agreements form a rule-based system within which WTO mem - bers must operate. Some agreements, such as TRIPS and GATS, provide certain rule âflexibilitiesâ or exceptions that can be exercised in recognition of public health needs (for example, please see Art. XIV GATS and the Doha Declaration on Public Health and TRIPS). Other agreements, such as SPS, allow countries to restrict trade for the purposes of protecting public health (e.g., set food safety and animal and plant standards) while preventing âarbitrary or unjustifiable discrimi - nationâ through such practices (WTO 1998). A discussion of how each of these rules impact health is beyond the scope of this report, but a number of scholars have conducted detailed analyses on this subject (WHO/WTO 2002, Bettcher et al. 2000, Labonte and Sanger 2006a, 2006b, Bloche and Jungman 2003). From the health side, WHO has also recently produced two international health agreements with a potential impact on trade. One such agreement, the revision to the IHR (2005), addresses the issue of unduly restrictive trade and travel measures in public health responses to international disease outbreaks by calling upon the WHO and Member States to âto avoid unnecessary interference with international traffic and tradeâ (Abdullah 2007). Another agreement, the Framework Convention on Tobacco Control (FCTC), states in its preamble that there is a priority to the right to protect public health and it is believed that this could mean a priority over the trade matters relating to tobacco. At the international level, there is no formal arrangement between the WTO and WHO on matters of health and trade; however, the institutions will participate in each otherâs meetings (such as WTO Ministerial meeting and World Health Assembly) in an âobserverâ capacity. In this capacity, the WHO and WTO are allowed to attend pertinent discussions and provide expert advice at the meetings. While there is no formal arrangement, the two organizations have increasingly engaged in an array of ad hoc collaborative projectsâsuch as joint research, training, policy consultations, and country missions (Helble et al. forthcoming). Much of this appears to be driven by the health sector as the WHO was directed by its Member States, under a 2006 WHA resolution on International Trade and Health, to collaborate with other organizations on trade and health policy matters 5 While international trade agreements feature prominently in the overlap between the trade and health sectors, there is also an emerging body of regional and bilateral free trade agreements (FTAs) with critical health implications (Labonte and Sanger 2006b, Helble et al. forthcoming).
APPENDIX E (WHO 2006). Most recently, WHO hosted a set of Intergovernmental Working Group (IGWG) meetings on Public Health, Innovation and Intellectual Property to develop a global strategy and plan of action addressing the problem of research and development and funding for diseases that disproportionately affect develop - ing countries. The global strategy and plan of action passed as a resolution (WHA 61.21) at this yearâs World Health Assembly (WHO 2008a). Yet there continue to be deep concerns that the major voice belongs to WTO rather than WHO for many reasons, including the perceived economic importance of trade, the bind - ing norms of the world trade system, and the WTO institutions that wield far greater power (and rule enforcement) than is available in the health sector. As more countries join the WTO and trade liberalization grows, the governance of the health and trade sectors will only become more critical. Health and the Environment There are undoubtedly fundamental synergies between the environment and health, and between global climate change and global health in particular. Climate change is a significant and emerging threat to the publicâs health, and especially the most vulnerable populations (Heinzerling 2008). The report of the Intergovernmental Panel on Climate Change (2007) demonstrates that climate variability and change cause death and disease through natural disasters, such as heat waves, floods and droughts, which cause deaths through catastrophic events (e.g, extreme weather events such as cyclones or tsunamis), and longer term problems of food security (malnutrition) and clean drinking water (diarrheal diseases). Climate change also exacerbates common vector-borne diseases such as malaria and dengue. The intersection of health and the environment is well understood in pub- lic health and goes well beyond climate change (WHO 2007a). Human health is directly affected by environmental deterioration, which includes insufficient potable water, indoor smoke, road traffic, urban air pollution, unintentional poi - sonings, and lead exposure (Smith et al. 1999, Health and Environment Linkages Initiative a). For example, unsafe drinking water, along with poor hygiene and sanitation, is one of the foremost global health and environmental concerns result- ing in 1.7 million deaths per year (Health and Environment Linkages Initiative a). Such environmental risks, as a major factor in the spread of both infectious and chronic diseases, are responsible for 25-33 percent of the global disease burden (Smith et al. 1999). Additionally, these environmental factors have a dispropor- tionate impact on different groups, placing most of the burden on children under the age of five and those living in low- and middle-income countries (Smith et al. 1999). Another issue that intersects the fields of environment and public health is the Millennium Development Goals (MDGs). This set of objectives addresses issues of global concern, including poverty, health, and the environment, thus
THE U.S. COMMITMENT TO GLOBAL HEALTH facilitating an interdisciplinary approach. MDG 7 prioritizes environmental sus - tainability (Health and Environment Linkages Initiative a). However, addressing the environmental aspects of this goal also work to tackle several others, includ - ing eradicating extreme poverty and hunger, reducing child mortality, promoting gender equality, empowering women, and improving maternal health (Health and Environment Linkages Initiative a). Consequently, the MDGs lend themselves to promoting environmental sustainability as a means of addressing a broad range of other global issues, especially health. The main institutions governing the health and environmental sectors are WHO and the United Nations Environment Programme (UNEP), respectively. WHO has recognized the importance of environmental influences on human health, as it focused World Health Day 2008 on protecting public health from the detrimental effects of climate change (WHO 2008b). UNEP, the United Nationsâ designated entity for addressing environmental issues (United Nations Envi - ronment Programme b), was established after the 1972 UN Conference on the Human Environment. UNEPâs mission is âto provide leadership and encourage partnership in caring for the environment by inspiring, informing, and enabling nations and peoples to improve their quality of life without compromising that of future generationsâ (United Nations Environment Programme b). To address the interlinkages of health and the environmental, these two organizations have col - laborated on several joint initiatives. For example, WHO and UNEP established the Health and Environment Linkages Initiative (HELI) to promote and facilitate environmental initiatives directed at protecting human health in developing coun - tries (Health and Environment Linkages Initiative b). In addition to informal institutional arrangements, there are numerous over- lapping international norms and treaties that govern the interaction between the environmental and health sectors. One of the most important agreements affecting international environment and health, the Vienna Convention for the Protection of the Ozone Layer, established a framework for international cooperation in reduc - ing damage to the ozone layer and eventually resulted in the establishment of the Montreal Protocol, which has effectively mitigated ozone damage. In addition, the United Nations Framework Convention on Climate Change, which has been signed by 192 countries, promotes intergovernmental efforts to combat the effects of climate change (United Nations Environment Programme a). Furthermore, countries signing the Kyoto Protocol to the UN Framework Convention on Cli - mate Change agreed to lower their greenhouse gas emissions, further recognizing the detrimental effects of these pollutants and their effect on climate change. The international community, moreover, is actively engaged in the process of creating an international legal regime for the future. International governance arrangements have not been fully effective in effec- tuating fundamental environmental reform, but it is nonetheless clear it has had a major role. And it is equally clear that there is broad and growing consensus about the importance of a communal response among states. The same cannot be
APPENDIX E said about global health where there is still deep suspicion in some circles about the value of international law and governance. Health and Foreign Policy The status of health in foreign policy has dramatically changed in recent years. In the past, health was seen to be of âlittle importance in the hierarchy of foreign policy objectivesâ (Fidler 2007a). Recent pandemics and health security threats such as HIV/AIDS, SARS, bird flu, and national security efforts geared towards bioterrorism preparedness have vastly increased the level of attention nations pay to health in their foreign policy decisions. Today, the status of health on foreign policy agendas has been dramatically elevated and the interna - tional community is prone to link health and foreign policy in relation to three key areas: (1) national security (i.e., the need to protect from external threats); (2) trade, economic prosperity, and political stability; and (3) globalization and development (Owen and Roberts 2005). National Security: Direct National Interests The opportunities and challenges of a foreign policy based on international health are complex and important. Certainly, international health assistance can be seen as critical to a countryâs national interests, including its security. Govern - ments have no choice but to pay close attention to health hazards beyond their borders. DNA fingerprinting has provided conclusive evidence of the migration of pathogens from less to more developed countries (McNabb et al. 2002). More than thirty infectious diseases have emerged over the last two to three decades, ranging from hemorrhagic fevers, Legionnaires disease, and Hanta virus to West Nile virus and monkeypox. Vastly increased international trade in fruits, veg - etables, meats, and eggs has resulted in major outbreaks of foodborne infections. Wealthy countries, moreover, are less able to ameliorate these harms because many resurgent diseases have developed resistance to front-line medications. Trade, Economic Prosperity, and Political Stability: Enlightened Self-Interest Beyond narrow self-interest, there may be broader, âenlightenedâ interests in international health assistance (Fox and Kassalow 2001). Epidemic disease damp- ens tourism, trade, and commerce, as the 2003 SARS outbreaks demonstrated. Animal diseases such as foot and mouth disease, bovine spongiform encepha - lopathy, and avian influenza similarly had severe economic repercussions, such as mass cullings of animals and trade bans. Massive economic disruption would ensue from a pandemic of human influenza, with a projected loss of 3-6 percent in global GDP (Congressional Budget Office 2005). Countries with extremely poor health become unreliable trading partners
THE U.S. COMMITMENT TO GLOBAL HEALTH without the capacity to develop and export products and natural resources, pay for essential vaccines and medicines, and repay debt. Countries with unhealthy populations require increased financial aid and humanitarian assistance. In short, a foreign policy that seeks to ameliorate health threats in poor countries can ben - efit the public and private sectors in developed as well as developing countries. Extremely poor health in other parts of the world can also affect the security of the United States and its allies. Research shows a correlation between health and the effective functioning of government and civil society. In a 1998 report, the CIA noted that high infant mortality was a leading predictor of State failure, (Esty et al. 2008) and in 2000, the State Department suggested that AIDS was a national security threat (BBC News Online 2000). States with exceptionally unhealthy populations are often in crisis, fragmented, and governed poorly. In its most extreme form, poor health can contribute to political instability, civil unrest, mass migrations, and human rights abuses. In these States, there is greater opportunity to harbor terrorists or recruit disaffected people to join armed strug - gles. Politically unstable States require heightened diplomacy, create political entanglements, and sometimes provoke military responses. Globalization and Development: Health Diplomacy Many highly developed countries have begun to consider the role of interna - tional development assistance for health as part of their foreign policy. Develop - ment assistance has political significance, as the electorate believes that helping others in a crisis is an important part of a countryâs responsibility and leadership in the world. This can be seen in health emergencies such as the Asian tsunami, the China earthquake, or the Burma cyclone, where governments and citizens see the urgent need to help. Beyond emergency relief, international development assistance for health can have broader strategic importance. âGlobal health diplomacyâ is a concept under which a country uses development assistance as a way of promoting its values and image in the world and demonstrating its commitments to the com - mon good. WHO describes it more broadly as the âmulti-level and multi-actor negotiation processes that shape and manage the global policy environment for healthâ (Kickbusch et al. 2007, Drager and Fidler 2007). In the United States, for example, the new President should consider how âhealth diplomacyâ could improve Americaâs tarnished image in the world. Using Americaâs vast resources and expertise to noticeably improve the lives of poor people around the world, could have a profound positive effect on the way that others see the United States and its use of power. On November 9, 2008, for example, the Fogarty Interna- tional Center and the OâNeill Institute for National and Global Health Law jointly hosted a global meeting on âhealth diplomacyâ in celebration of the Centerâs fiftieth anniversary.
APPENDIX E Foreign Policy Also Has the Potential to Undermine Global Health Although foreign policy imperatives have undoubtedly raised the profile of global health, they also have the potential to undermine effective strategies, par- ticularly if narrowly conceived. One common problem is that foreign policy can skew priorities and practices. When a country views particular health issues to be of high priority, it is more likely to give unwarranted attention, resources, and technical assistance to that narrow area. In the scale of balance of the receiving country, disproportionate attention to a high-visibility health issue might skew its priorities and efforts at developing a general health system. One possible example is the priority that developed countries such as the United States have placed on HIV/AIDS, and in effect, its foreign policy priority in this regard is channeled through PEPFAR. While this initiative has clearly assisted developing countries to better cope with the disease, it has caused a drain of personnel and resources from other sectors of their health systems, which equally require immediate priority, to focus on HIV/AIDS. This situation is akin to what David Fidler calls the âtragedy of under-exploitationâ whereby critical health issues (e.g., chronic diseases and womenâs health) âreceive insufficient attention and suffer from fragmentation of public health and health-care systemsâ due to the proliferation of uncoordinated initiatives (Fidler 2007a). Another problem with foreign policy-driven assistance is the tendency to favor particular countries and actors as the recipients of health aid. For example, PEPFAR narrowly targets 15 countries (predominantly in Africa) as the main recipients of its funding but this leaves out a number of other heavily disease- burdened countries in other parts of the world. The general perception that health aid is best utilized in stable states has prevented donor countries from investing in the healthcare of fragile states, which account for one-sixth of the global popu - lation and which are most in need donor intervention to prevent and ameliorate humanitarian crises (WHO 2007b). Wanting quick and direct results for their efforts, the foreign policies of governments which impose sanctions on unpopular governments by failing to assist with development aid has a ripple effect on health and international security and affect the lives of millions who otherwise do not have say in the governance of their state. Also, some developed countries tend to channel funds through international (and sometimes local) NGOs instead of dealing directly with the official govern- ments of recipient countries (Garrett 2008). As a result, this practice has left a number of countries with weaker control of their health systems. International health assistance is often earmarked for specific purposes, with only about 20 per- cent going to support the local governmentâs health system (WHO 2007b, Foster 2005). Furthermore, aid tends to be targeted at a vertical intervention programs and this causes a misalignment with the health priorities identified by developing country governments. Another problem with the preference for NGO control is
0 THE U.S. COMMITMENT TO GLOBAL HEALTH that most NGOs do not possess the capacity to scale up interventions or ensure their long-term sustainability (Garrett 2008). The Critical Overlaps Between Health and Other Sectors This section reviewed the critical overlaps between health and other sectors, such as trade, environment, and foreign policy. As indicated, the GHG system must come to terms with important intersectoral synergies and tensions. The overlap between the trade and health sector highlighted some of the current tensions that exist between the two sectors in terms of fundamentally differing philosophies, institutions, and laws. As there are no formal arrangements at the international level between the health and trade sectors, attempts to address trade- related health issues typically occur on an ad hoc basis. WHOâs recent passage of the global strategy and plan of action related to intellectual property has been viewed by some as a move by developing countries to better position WHO in governing trade-related health issues (Kohlmorgen 2007). This illustrates the potential role that GHG could play in dealing with intersectoral tensions. In terms of the overlap between the environment and health, there are a number of opportunities for greater synergy between the two sectors. Essentially, a cleaner and safer environment is good for health. The potential GHG synergies in terms of developing similar priorities, harnessing creative solutions and incen - tives, and drawing together actors from both fields offer incredible opportunity to solve the global health and environment challenges collectively. And there are also lessons that global health could learn from governance initiatives on climate change, which are explored further in the following section. The overlap between health and foreign policy is another important area that holds the potential for both tensions and synergies. Developed countries might provide assistance to developing countries for reasons of self-interest or broader âenlightenedâ interest, or they might see international development assistance for health as part of their humanitarian obligations. We caution, however, that a foreign policy that is too narrowly conceived can actually be detrimental to those they intended to assist. An area of potential synergy offered by the intersection of health and foreign policy is the concept of global health diplomacy which a country could strategically use to both promote itself and demonstrate global commitment. In the end, GHG must find a way to deal with the complex array of actors, sectors, laws, and interests at play. Currently, the global environment is highly decentralized and dealing with these various forces coherently can be difficult. In the next section, we turn to a few innovative approaches that could help GHG overcome the âgrand challengesâ in governance and deal effectively with the emerging intersectoral forces that global health faces.
APPENDIX E IV. Innovative Approaches to Global Health Governance Oran Young (1997) once asked, âWhat is to be done to close the dramatic gap between the demand for governance and the capacity to supply governance in international society?â In the context of global health, there are three potential options: (1) accept the currently fragmented, incoherent system that some have termed anarchy, (2) reform the WHO through restructuring, and (3) establish decentralized regimes (i.e., sets of roles, rules, and relationships) focused on specific issues. Decentralized regimes have been increasingly applied in global health, with the multitude of independent health initiatives that exist (e.g., the Global Fund or the health-related Millennium Development Goals), but the results of this approach still significantly lag expectations. The new âInternational Health Partnership and related initiativesâ (IHP+)6 is a commendable effort towards coordination and accountability as well as greater country ownership; however, does it go far enough? At this stage, there is not enough evidence to judge the success of IHP+ but the focused nature of its initiatives raises concerns about how it would coordinate with other non-IHP+ health initiatives (e.g., currently existing disease-specific initiatives) and nonpartner actors (e.g., United States), as well as adequately address developing world concerns. Hence, the decentralization of health actors and their initiatives will persist in global health but, perhaps, at a slightly more condensed level on certain health issues. The search for alterna - tive, innovative approaches to global health governance, in terms of structures and mechanisms, has produced several creative proposals that are considered in this section. The proposals outlined in this section are illustrative only, intended to show some of the more interesting current proposals for global health reform. But one thing is clear. There is an urgent need for imagination and bold ideas in global health. It is well understood in the field of climate change that the entire interna - tional community has a shared responsibility to propose and implement innova - tive reforms in global governance. The same could be said about global health. If the international community does not embrace bold governance reforms, it should expect little improvement in the health of the worldâs poorest populations. Even with all the new money and attention devoted to global health, without coherent policy and leadership, the chances of dramatic improvement are vastly reduced. AcceptâAnarchy:âReconceptualizingâGlobalâHealthâGovernanceâasâ ââSourceâCodeâ To make better sense of the global health environment today, David Fidler (2007b) proposes an alternative approach to GHG in terms of âsource codeâ rather than architecture. He explains that this source code contains âthe norma - 6 See also footnote 2.
THE U.S. COMMITMENT TO GLOBAL HEALTH tive policy reasons for why global health is important to protect and promote.â Furthermore, the source code can be applied by the entire range of global health actors, such as states, IGOs, and nonstate entities, who can produce âsoftware programsâ for certain global health problems. Such global health software pro - grams include laws (e.g., IHR 2005 and FCTC) and hybrid organizations/mecha- nisms (e.g., Global Fund). By using the metaphor to software source code, Fidler characterizes the cur- rent governance environment as being in a state of âopen-source anarchy.â This captures the fact that the political environment of global health has moved beyond the traditional conceptualization of anarchy, which is monopolized by states, to a new form of anarchy that is âopenâ to the engagement of nonstate actors. Fidler believes that this new conceptualization provides a useful way âto make sense of the proliferation of players, problems, and processesâ in global health diplomacy because âit jars the basic functions of diplomacy out of traditional State-centric patternsâ (Fidler, 2008). He acknowledges that the state of open-source anarchy with its various actors is âmessy and produces some negative externalities,â but it could help move global health governance further than architecturally based attempts (such as the âHealth for Allâ initiative). Fidler concludes that open-source anarchy âmay suit global healthâs quest for governance better than attempts to tame the freedom of action States and non-State actors embrace in such anarchy.â Fidler, however, does recognize a common problem for both the âsource codeâ and architectural approaches to global health governance. It is the lack of adequate public health infrastructures in states. In the context of open-source anarchy, Fidler calls this a âhardware problemâ because governance source code cannot produce the sought benefits without the proper hardware with which it must operate. Similarly, in the context of architecture, structured governance approaches will not work without the local and national foundational capabilities to interface with the global level. The lack of necessary infrastructure remains a major unaddressed hurdle to the advance of global health, and Fidler concedes that even the approach of open-source anarchy âproves difficult as a context in which to build sustainable capacity for public health within and between sover- eign states.â WHOâReform:âProposalâforâaâWHAâCommitteeâCâandâTripartiteâGovernanceâ Structure Over the years, many have decried WHOâs lack of leadership in global health and clamored for its reform (Godlee 1997, Yamey 2002, Ruger and Yach 2005). They justify this by pointing to the WHOâs constitutional mandate to act as a âdirecting and coordinating authorityâ on matters of health, as discussed earlier in the paper. WHO also holds the functions of âengaging in partnerships where
APPENDIX E joint action is needed,â âsetting norms and standards and to promote and moni - tor their implementation,â and âproviding technical support, catalyzing change, and developing sustainable institutional capacityâ (Drager and Sunderland 2007). Furthermore, as leader, WHO could âprovide the basis for generating public awareness, mobilizing resources, using resources rationally through coordinated action, setting priorities, and bestowing or withdrawing legitimacy from groups and causesâ (Dodgson et al. 2002). The current absence of a clear authority in global health has made these aspirations difficult, if not impossible. Two recent proposals suggest ways that the WHO could assume a greater leadership role in global health. The first is a proposal by Gaudenz Silberschmidt, Don Matheson, and Ilona Kickbusch (2008), which calls for the addition of a committee to the World Health Assembly that would help promote coordination and increase transparency and accountability in the activities of major global health stakeholders. These stakeholders include international agencies, philan - thropic organizations, multinational health initiatives, and civil society groups. The proposed WHA committee, titled âCommittee C,â is envisaged to (1) debate major health initiatives by other key players in the global-health arena, (2) allow these other organizations to present their plans and achievements to the WHA, and (3) address coordination and common concerns of different partners in global health. Under the current WHA structure, resolutions and decisions are handled by two committeesâCommittee A (on program matters) and Committee B (on budgetary and managerial issues). The proposed Committee C would be able to submit stakeholder commitments as annexes to relevant resolutions produced by the other committees. Critics argue, however, that the âambiguityâ of the Com - mittee C structure may lead to an undue power shift from developing countries to the donors and institutions of developed countries (Batniji 2008). Silberschmidt and Kickbusch (2008) respond that the structure actually does not âreduc[e] the influence of the poorest member states but, on the contrary, [enables] them to engage formally in strategy discussions with major actors, from which they are currently excluded.â The second proposal applies the concept of âtripartite governanceâ to intro - duce a partnership model in which WHO would play a normative steering role and the WHA would assume the central role of holding all actors accountable (as described by Silberschmidt et al. 2008). Under tripartite governance, three roles exist: (1) a normative steering role, (2) an oversight role, and (3) a service provi - sion role (Kempa et al. 2005). The WHO would hold the normative role, while the oversight role would be designated to a new body consisting of representa - tives from across the range of global health stakeholders. The service provision role would be held by partnerships and agencies with functional, demand-driven tasks. This governance structure seeks to create an arrangement where the three components for âgood governanceâ would be honed and strengthened through a clearly defined division of global health responsibilities (Kickbusch 2006).
THE U.S. COMMITMENT TO GLOBAL HEALTH UnitingâandâCoordinatingâDecentralizedâRegimes:âAâFrameworkâConventionâ onâGlobalâHealth With the many disparate efforts that are occurring in global health today, there has been interest in uniting them under a common legal framework. Decentral- ized regimes, which can be understood as âroles, rules, and relationships created to deal with issue specific problems,â exist in a variety of different formsâboth formal and informal (Young 1997). The variety of current efforts occurring in global health today can be conceptualized as an array of mini-regimes. Unfor- tunately, the big picture of global health lacks coherence and direction with the existence of the many mini-regimes that tend to cluster around popular issues and overlap. To address this problem, one of us (Gostin 2008a) has proposed an innova- tive international agreement called a Framework Convention on Global Health (FCGH). The framework convention-protocol approach refers to a process of incremental regime development. In the initial stage, States would negotiate and agree to the framework instrument, which would establish broad principles for global health governance: goals, obligations, institutional structures, empirical monitoring, funding mechanisms, and enforcement. In subsequent stages, specific protocols would be developed to achieve the objectives in the original framework (WHO 2003). These protocols, organized by key components of the global health strategy,7 would create more detailed legal norms, structures, and processes. The framework convention approach has considerable flexibility, allowing parties to decide the level of specificity that is politically feasible now, saving more com - plex or contentious issues to be built in later protocols. This approach promotes a âbottom-up strategyâ that strives to achieve sev - eral objectives, which include (1) building capacity for enduring and effective health systems, (2) setting priorities so that international assistance is directed at meeting basic survival needs, (3) setting minimal funding levels for international development assistance for health, (4) engaging stakeholdersâincluding state and nonstate actorsâso that they can bring to bear their resources and expertise, (5) coordinating activities among the proliferation of actors for harmonization, and (6) evaluating and monitoring progress so that goals are met and promises are kept. The proposed FCGH would represent an historical shift in global health, with a broadly imagined, global governance regime. It is envisioned that the initial framework would establish the key modalities, with a strategy for subsequent pro- tocols on each of the most important governance parameters. The broad principles for the FCGH would include mission objectives; engagement and coordination; state, party, and other stakeholder obligations; institutional structures; empirical 7 The Framework Convention on Tobacco Control (FCTC), for example, anticipates that issues such as advertisement, illicit trade, and treatment will be addressed individually in separate protocols (WHO 2003).
APPENDIX E monitoring; enforcement mechanisms; ongoing scientific analysis; and guidance for subsequent law-making process. The organization âIncentives for Global Healthâ (2008) has proposed a Health Impact Fund that is illustrative of the kind of protocol that could be achieved under a Framework Convention on Global Health. The Fund aims to stimulate research and development for life-saving pharmaceuticals. It offers pharmaceutical innovators a supplementary reward based on the health impact of their products, if they agree to sell those products at designated low prices. As the fund mainly depends on long-term financing by governments, the FCGH could serve as a mechanism to bind states to their commitments. The FCGH possesses a number of strengths that could overcome the intrac - table âgrand challengesâ mentioned earlier in this paper. Specifically, the FCGH can help facilitate global consensus, facilitate a shared humanitarian instinct, build factual and scientific consensus, transcend shifts in political will, and engage multiple actors and stakeholders. Yet, the FCGH also has some weak- nesses. It will not be a panacea, and there are multiple social, political, and eco - nomic barriers to the creation of such a framework convention. The framework convention-protocol approach cannot easily circumvent some current aspects of global health governance: the domination of the most economically and politi - cally powerful countries; the deep resistance to creating obligations to expend, or transfer, wealth; the lack of confidence in international legal regimes and trust in international organizations; and the vocal concerns about the integrity and competency of governments in many of the poorest countries. It also does not ensure consensus on contentious issues. Furthermore, the framework con- ventionâs extended, incremental process could encounter a loss in momentum or the derailment of subsequent protocols due to its long timeframe. But given the dismal nature of extant global health governance, an FCGH may be a risk worth taking. These three proposals represent some of the fresh ideas on how the inter- national community can address current problems in global health gover- nance. David Fidler proposes a reconceptualization of GHG, away from current architecturally based thinking, and identifies the need to come to terms with global healthâs natural state of âopen-source anarchy.â Meanwhile, proponents of WHO reform continue to recognize the necessity of WHO in global health and seek ways to make it a more effective leader in the global health domain. This has produced two structure-based proposals. The first proposal calls for the formation of a âCommittee Câ within the WHA, which would help account for the important role and contributions of nonstate actors in global health, and the second proposal attempts to reinforce WHOâs leadership role within a tripartite governance structure. Finally, Lawrence Gostin proposes a way to prioritize, unite and coordinate activities to address global health needs under an overarch - ing FCGH to create a shared vision and modus operandi for the future of global
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 healthâs 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 âbig pictureâ 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): â¢ Increasing the capacity of health systems to deliver HIV/AIDS treatment.
APPENDIX E Launching a âHealth Infrastructure 2020 Plan.â8 â¢ â¢ Changes in PEPFAR, including an additional $1 billion over five years towards the HIV/AIDS epidemic in Southeast Asia, India, and Eastern Europe. â¢ 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). â¢ 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 worldâs 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 âexceptionalismâ and demonstrate its âwillingness to engage positively with the rest of the worldâ 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 âfavor realism and reliabilityâ (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 âbrain drainâ 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 âgrand challengesâ discussed earlier in this paper require a broader and deeper level of commitment to a dramatic change in governance for the long 8 The âHealth Infrastructure 2020 Planâ has been described as âa 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 healthâ (Bristol 2008a). 9 Key examples of detrimental policies under the Bush administration include the âblock[age] of funds for needle or syringe exchange programmes . . . in countries with injection-driven epidemicsâ and an âobsession with abstinence-only approaches . . . [in countries] where the epidemic is driven by sexual contactâ (Rechel and McGee forthcoming).
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