The U.S. Commitment to Global Health Recommendations for the Public and Private Sectors (2009) / Chapter Skim
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Appendix E: Commissioned Paper: Global Health Governance Report--Lawrence O. Gostin and Emily A. Mok
Appendix E: Commissioned Paper: Global Health Governance Report--Lawrence O. Gostin and Emily A. Mok
Pages 203-246
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* Visiting Researcher, O'Neill Institute of National and Global Health Law, Georgetown University, and D.Phil candidate, Centre for Socio-Legal Studies, University of Oxford.
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. 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)
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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 transform today's global health situation.
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. In this section, we high light six of the key grand challenges in relation to global health governance.
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have served as a primary means for engaging 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.
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. 2 The "Health 8" refers to the group of eight major international health-related agencies (i.e., WHO, World Bank, GAVI, UNICEF, UNFPA, UNAIDS, the Global Fund to fight AIDS, Tuberculosis and Malaria, and the Bill and Melinda Gates Foundation)
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Currently, a significant amount of funding is directed towards "specific diseases or narrowly perceived national security interests" that have been placed high on the global health agenda by a small number of wealthy donors (such as OECD countries, the Gates Foundation and the Global Fund) (Garrett 2007b, Gostin and Taylor 2008)
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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.
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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.
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. Despite these impressive powers, modern international health law is remark ably thin -- two of the three existing international health instruments predate the
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World Health Regulation No. 2, the International Health Regulations (IHR)
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Consequently, the agency has strongly favored technical advice over creating norms and gaining conformance of the international community. Recommendations can take various forms, but two primary types include resolutions and codes of conduct.
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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)
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B. The Proliferation of Actors in Global Health 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.
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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.
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. Furthermore, its 2007 health sector strategy reinforces the recent attempts by UN agencies at a collaborative division of labor with global partners.
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. Finally, PEPFAR has been criticized for not making greater contributions to the Global Fund.
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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)
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development. It is feared that the Global Fund's approach, on top of existing health initiatives, would "contribute to a further fragmentation of health policies at the national level" (Bartsch 2007)
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Because the Global Fund endorses a "bottom-up" 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.
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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.
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. From the health side, WHO has also recently produced two international health agreements with a potential impact on trade.
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. For example, unsafe drinking water, along with poor hygiene and sanitation, is one of the foremost global health and environmental concerns resulting in 1.7 million deaths per year (Health and Environment Linkages Initiative a)
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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)
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. National Security: Direct National Interests The opportunities and challenges of a foreign policy based on international health are complex and important.
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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.
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International health assistance is often earmarked for specific purposes, with only about 20 percent going to support the local government's health system (WHO 2007b, Foster 2005)
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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 "enlightened" interest, or they might see international development assistance for health as part of their humanitarian obligations.
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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.
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Such global health software pro grams include laws (e.g., IHR 2005 and FCTC) and hybrid organizations/mechanisms (e.g., Global Fund)
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, 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.
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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)
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These three proposals represent some of the fresh ideas on how the international community can address current problems in global health governance. David Fidler proposes a reconceptualization of GHG, away from current architecturally based thinking, and identifies the need to come to terms with global health's natural state of "open-source anarchy." 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.
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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.
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funding and support toward multilateral programs (including the Global Fund to Fight AIDS, Tuberculosis and Malaria and the UN Millennium Development Goals)
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2007. "The Global Fund to Fight AIDS, Tuberculosis and Malaria." in Global Health Governance and the Fight Against HIV and AIDS, edited by Wolfgang Hein, Sonja Bartsch, and Lars Kohlmorgen.
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2008. "A Trickle of a Flood: Commitments and Disbursement for HIV/AIDS from the Global Fund, PEPFAR, and the World Bank's Multi-Country AIDS Program (MAP)
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2007. "Foreign Policy, Trade and Health: at the Cutting Edge of Global Health Diplomacy." Bulletin of the World Health Organization 85, no.
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2008. "Global Health and US Foreign Policy Considerations." http://www.iom.edu/ CMS/3783/51303/52288/53023.aspx (accessed June 15, 2008)
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International Health Partnership.
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2005. "Globalisation, Health and Foreign Policy: Emerg ing Linkages and Interests." http://www.globalizationandhealth.com/content/1/1/12 (accessed June 15, 2008)
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2002. "Global Governance, International Health Law and WHO." Bulletin of the World Health Organization 80, no.
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2005. "Revision of the International Health Regulations 2005." Fifty-Eighth World Health Assembly.
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." http://www.wto.org/english/tratop_e/sps_e/spsund_e.htm (accessed June 15, 2008)
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