## Abstract Global health refers to ‘those health issues which transcend national boundaries and governments and call for actions on the global forces and global flows that determine the health of people’. (Kickbusch 2006) Governance in this trans-national and cross-cutting arena can be analyzed along three political spaces: ==global health governance, global governance for health, and governance for global health==. It is argued that the management of the interface between these three political spaces of governance in the global public health domain is becoming increasingly important in order to move the global health agenda forward. [[global health governance]] refers mainly to those institutions and processes of governance which are related to an explicit health mandate, such as the World Health Organization; [[global governance for health]] refers mainly to those institutions and processes of global governance which have a direct and indirect health impact, such as the [[United Nations]], [[World Trade Organization (WTO)]] or the Human Rights Council; [[governance for global health]] refers to the institutions and mechanisms established at the national and regional level to contribute to global health governance and/or to governance for global health such as national global health strategies or regional strategies for global health. It can also refer to club strategies, such as agreements by a group of countries such as the [[BRICS]]. In all three political spaces, the involvement of a multitude of state and non-state actors has become the norm  that is why issues of legitimacy, accountability and transparency have moved to the fore. The transnational nature of global health will require the engagement of all actors to produce [[global public goods for health (GPGH)]] and to ensure a rules-based and reliably financed global public health domain. ## Introduction [[Open Question]] Governance in the global public health domain must grapple with six key challenges that present overlapping opportunities for policy innovation and institutional development: 1. How can competing interests and fragmentation be overcome? 2. How can a greater commitment by countries for providing global public goods for health (GPGH) be ensured? 3. What role should corporations and their foundations play in global health, and how can the private sector become more accountable? 4. How can reliable funding be ensured for global health initiatives and organizations? 5. How can political support be gained for addressing the political, social, and commercial determinants of global health? 6. How can the voice of civil society be ensured in global health governance? ## Defining global health and global governance ![[CleanShot 2023-12-21 at 17.11.34.png]] [The ‘golden era of global health’ led to an explosion of players in the global health arena and, in particular, resource strong non-state actors have grown significantly in influence.]([[global health governance will increasingly be determined by economic institutions with the principle concern not of health but of market liberalisation]]) [At the end of the 66th World Health Assembly (WHA66) in May 2013, WHO Director General Dr. Chan stated that the pressure from trans-national private companies on Member States was never stronger, particularly in relation to the non-communicable disease (NCD) agenda, comparing it to earlier times on matters such as essential medicines.]([[There's a disjuncture between the capacity of national governments to operate within a global economy given the increasing economic power of MNCs]]) ## Global health governance Refers to those institutions and processes of governance that have an explicit health mandate, such as the [[World Health Organization (WHO)]], hybrid organizations such as the [[GAVI]], and the [[Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM)]]. Many of these organizations are located in Geneva - which is sometimes referred to as the 'capital of global health'. The architecture of this dimension has been much analyzed, with some viewing WHO in the center of the arena (based on its constitutional mandate) and others seeing a more polycentric structure emerging in which the WHO is just one of many players in global health governance. The hybrid organizations have introduced constituency based models of governance, whereas state based international organizations such as the WHO are [becoming subject to scrutiny]([[Insulation should be designed in an ideal degree where it will not attract blame and promote effectiveness and transparency, making the IGOs both accountable and protected]]), especially regarding conflicts of interest. Consequently, as part of the WHO reform, the WHO will propose a new framework for working with non-state actors, both from the [[NGO]] and civil society arena and from the private business sector. The [[WHO continues to serve as the main global health governance venue for legitimate decision-making processes, and it also serves an essential and unique coordinating role]]. The example is [[Framework Convention on Tobacco Control]] in 2023, revision of [[International Health Regulation (IHR)]] in 2005, and the other adoption of other frameworks and codes on global health issues such as virus sharing and mobilityo f health workers, WHO has regained relevance. Indeed, there are regular calls for increased legislative activity: most recently a Global Framework Convention on Research and Development was proposed. Other legislative suggestions include treaties and codes in relation to alcohol, marketing to children, falsified medicines, and anti microbial resistance. There are also suggestions for an allencompassing Framework Convention on Global Health. [[Interesting Phrase]] Providing an interface for what Wiseman has termed ‘[[polylateral diplomacy]]’ within the formal WHA processes is one of the governance challenges faced by WHO. Suggestions, such as the proposal for a ‘[[Committee C]]’ to address policy coherence and accountability, have been put forward for mechanisms to support normative and strategic coordination among different actors in global health. As the global public health domain has expanded, not only has the formal WHA agenda become overloaded, member states and other actors now increasingly use the [WHA as a forum to discuss issues that are not on the agenda]([[WHA as a platform, WHO as a negotiation hub]]). At the WHA66, dozens of such events were organized throughout Geneva by member states as well as other health organizations and the private sector, often with overflowing attendance, reflecting the priorities and positioning of member states and attendant NGOs, private-sector actors, and other attendees. They included issues such as antimicrobial resistance (AMR), women’s and children’s health, response to H7N9, universal health coverage, global health diplomacy, eHealth and health internet domain names, and neglected tropical diseases. These meetings do not only reflect the need to discuss issues in a format that is different from the WHA process, where formal statements by delegates restrict what can be said, but they also provide ministers of health a platform on which they can position themselves more proactively and politically than in the formal WHA sessions. These side events reflect the convening power of WHO as a network and negotiation hub that can support and strengthen the other two political spaces of global governance. By providing a site for national delegations to raise challenges of domestic concern, WHO serves as an arena to define and prioritize global health issues. Once these issues have been brought to the forefront of the agendas of organizations within the realm of global health governance, they can be incorporated into the institutions and processes of global governance for health, such as the [[United Nations]], [[World Trade Organization (WTO)]], and [[World Bank (WB)]]. [[Government vs governance]], [[Politics vs policy]] | NCD was first raised by WHO through resolutions and action plans, then it moved to the United Nations and was finally debated there in 2011 by heads of governments after being recognized at UNGASS as a global priority, it was referred back to the health ministers at WHO to set priorities and indicators; finally  after reaching agreement at the WHA 2013  NCDs were debated at ECOSOC 2013. Here, a resolution was adopted to establish a WHO-led Interagency Task Force on the Prevention and Control of NonCommunicable Diseases. During this process, a multitude of actors were engaged to drive the agenda forward at different negotiation hubs. This is an interesting contrast to the 1990s, when countries did not think WHO capable of handling the interagency dimensions of the HIV/AIDS pandemic and created UNAIDS to address the issue. ## Global governance for health Refers mainly to those institutions of global governance that do not necessarily have explicit health mandates, but that have a direct and indirect health impact, such as the [[World Trade Organization (WTO)]] and [[Sustainable Development Goals (SDGs)]]. > Many of these institutions and processes are related to the social determinants of health, and to the global flows of goods, services, and ideas related to health. Increasingly like the United Nations General Assembly they set health agendas. Several authors, such as Frenk and Moon, have discussed the range of policymaking arenas that influence the global health system, including international trade, security, migration, and the environment. As emphasized in the Rio + 20 report, [[health is]] not only affected by cross-cutting global governance arenas such as food and water security and institutional development, but it may support or undermine these other governance challenges if not effectively addressed. These challenges increasingly relate to patterns of [production and consumption]([[Trade liberalisation boosts adoption of behaviours such as smoking and unhealthy diets]]). ## Governance for global health Refers to the institutions and mechanisms established at national and regional levels that contribute to global health governance and/or to governance for global health. > As a growing industry, the health sector represents over USD 6.5 trillion of global flows, and this figure is projected to surpass 10 trillion by 2020. These interests, public and private, exert enormous pressures on governance mechanisms at the domestic level. The health sector and the domestic institutions and process that contribute to global health  ranging from outbreak surveillance mechanisms to insurance systems, and more broadly to financial stability and food security is a critical issue in domestic politics around the world. Given the crosscutting nature of global health, national and regional governance for global health must have strategies firmly in place for navigating the intersection between domestic and global interests and politics. Optimal governance solutions will depend on aligning national priorities and global responsibilities, such that domestic institutions can support governance for global health with strategies for policy coherence and inter-sectoral cooperation. This relates to concepts such as ‘[[Healthy Public Policy]]’, which emphasizes the need to consider health as a shared value across all sectors. For example, domestic governance questions, such as the aging of societies, social inequities, and financial stability, are all determinants of and influenced by health. Given that health has important effects on goals of other sectors, ‘Healthy Public Policy’ ==aims to harmonize policies across sectors, to complement public health initiatives and ensure coordination between ministries and diplomats. Increasingly, this also includes foreign policy.== [[Insights]] In 2007, Switzerland established the Swiss Health Foreign Policy, developed by the Departments of the Interior and the Department of Foreign Affairs to integrate national and global health policies. The UK’s ‘[[health is]] Global’ strategy, launched first in 2008, aims to manage the relations between different government departments, supporting cooperation and policy coherence domestically, regionally, and globally. In the United States, the Council on Foreign Relations, the Departments of Defense and of State, and the Center for Strategic International Studies (CSIS) have all taken up the question of global health policy, analyzing domestic opportunities to strengthen global health diplomacy and support polylateral coordination of health programs. ^28e84b Kickbusch has emphasized that, ‘[[global health begins at home]]’, with the attitude that health goals should be shared across domestic sectors and government agencies, and that all diplomats should work to achieve health goals, irrespective of their governance context. Health Ministers must now be concerned with the priorities and activities of the security, trade, finance, agriculture, development, and employment industries if they are to effectively address health issues domestically and in global negotiations. ==As the role of Ministries of Health changes in the sphere of global health governance, so too does the role of foreign ministries operating in the dimension of global governance for health==. Domestic policies taking a ‘Healthy Public Policy’ approach seek to integrate health goals across all levels of governance, convincing negotiators outside the health sector to speak on health in other arenas. This approach also necessitates taking the goals developed at the level of global governance for health, such as the MDGs or the post-2015 SDG process, and implementing them on a national level across policy areas. ## Conclusions We need to gain a better understanding of the interface between the three dimensions of governance in the global public health domain. All three are highly relevant and managing them well can support the progress of public health in a global environment. [[All three are driven by contestations of power, interests, and values, which in turn translate into political and commercial determinants of health]]. [[Health is back on the political agenda and the health debate at this point in time is fundamentally about the definition of the common good and the role of the state, the market, and the community in a period of globalization, commercialization and individualization]]. GPGH can only be produced if all three political spaces for governance combine to serve this purpose. ## References #to-read Frenk J, Moon S. Governance challenges in global health. New Engl J Med 2013; 368: 93642. #to-read Kickbusch I. Good global health begins at home: policy coherence at national level. Global Health Diplomacy Brief. The Graduate Institute of International and Development Studies; 2012. Available from: http://repository.graduateinstitute.ch/record/16587/files/policy-coherence-brief-v7 20022013-2.pdf [cited 15 October 2013].