>The configuration of economic actors has shifted dramatically in recent decades as a consequence of the shift from an international to global economy. The 21st century thus faces a fundamentally different economic landscape, with governance far less about formal nation-state negotiation, and far more about informal mechanisms of state and non-state negotiation. Although economic power has always played a role in defining international health governance, this changing global economic context has increased the role of economic power in the development of global health governance. To ensure the continued protection and enhancement of global health, it is imperative for the health profession to recognize and more actively engage with this changing economic context, in order to seize opportunities and minimize risks to global health. If it does not, the danger is that global health governance will increasingly be determined by economic organizations with the principle concern not of health but of market liberalisation, ultimately constraining the capacity of nation-states to undertake measures to protect and enhance the health of their populations. ## Introduction Barnett and Duvall classify power as comprising four dimensions: 1. Compulsory power: direct control over another and, at the extreme, force them to do something. An obvious example is military power. 2. Institutional power: indirect control of one actor over another through the design of (international institutions that work in their favour at the expense of others. Example: political power. 3. Structural power. Example: ideological power (viz. socialist systems as alternatives to capitalism) 4. Productive power: exert control over another through the possession, use and distribution of resources and assets. Example: economic power. [[Most forms of power, particularly economic, is no longer concentrated within a nation state, but rather in the global governance of 21st century]] The core feature of this seemingly semantic change (from international governance to global governance) has been the disjuncture that is generated between economic power and other forms of power. It is no longer the case that all forms of power are mostly concentrated within a nation state. Although military power, and to a large extent political and ideological power remain state based, economic power is increasingly less so. And as economic power becomes increasingly decoupled from the nationstate, so too has political and ideological power; economic power is therefore critical in the development of 21st century global governance. The 21st century faces a fundamentally different economic landscape from previous centuries. The implication of these shifts in economic power is the declining capacity of national governments to regulate within a global economy given the increasing trans-nationalisation of economic power. With respect to health, the implication is that [[global health governance will increasingly be determined by economic institutions with the principle concern not of health but of market liberalisation]], ultimately constraining the capacity of nation-states to undertake measures to protect and enhance the health of their populations. [[Global health governance now is more about informal mechanisms between state and non-state negotiations. The governance space is now accessible by states and non-state actors, a condition Fidler called "open-source anarchy"]] As global health governance becomes far less about formal nation-state negotiation, and far more about informal mechanisms of state and non-state negotiation, economic power has grown in influence. Fidler characterises this change as moving to a system of “open-source anarchy,” where governance space is accessible by states and non-state actors, presenting a challenge to the “old school anarchy” of governance controlled strictly by nation-states, rendering nation-state governance initiatives vulnerable. 14 In this sense, Fidler distinguishes between governance as “software” and as “hardware,” where software refers to the norms and structures behind the protection and promotion of global health, and hardware refers to the physical infrastructure used to enact the software, and thus current national and international institutions. As institutions tend to remain the purview of nation-states (themselves or through international institutions), “open-source anarchy” is a constant stress on governmental capabilities and is the avenue by which economic power has become more prominent. This paper therefore provides an overview of the contemporary landscape of global health governance, looking especially at the key institutions involved in global (health) governance (the nation-state, regional trading bodies, inter-governmental bodies, private commercial sector, and private non-commercial sector) and the implications for global (health) governance from changes in the balance of economic power within and between them. ## National governments Yes, national governments commonly responsible for health due to their significant role in monitoring and protection, particularly from outbreaks, clean water and safe food, and in many countries, financing and provision of health services directly to groups of population. However, the involvement of private is getting greater and diminish the authority and capacity of national governments to influence health determinants and outcomes. For example, gun ownership and production. ## Regional trading bodies > Regional bodies developed as an attempt to protect a group of nations from the rising power of others, securing greater economic power through greater numbers acting together. But paradoxically, the regional bodies serve to both bolster national governance, simultaneously erode national governance through overriding national legislastion. For example, regional treaties may constrain the range of policy available to a national government to control alcohol availability, such as minimum legal purchasing age, government monopoly of retail sales, restrictions on hours or days of sale, outlet density restrictions, and alcohol taxes. In Finland, the national alcohol monopoly was weakened after joining the [[European Union (EU)]] and becoming the subject to the European Free Trade Agreement in 1994. There is also the irony of stricter environmental protection in the EU contributing to the build up of hazardous wastes in the Third World, where laws to protect workers and the environment are inadequate or not enforced. For instance, the export of hazardous wastes from the countries of the [[Organization for Economic Cooperation and Development (OECD)]] to less developed nations grew from some 4 million tons of hazardous wastes in 1989 to more than 1,000 million tons by 1993. Unfortunately, many of those countries importing this waste have neither the technical expertise nor adequate facilities for safely recycling or disposal, with many employees at these facilities developing a variety of health problems. ## Inter-governmental bodies The [[World Bank (WB)]] too has become a significant actor in global health governance in recent decades, although more directly than the [[International Monetary Fund (IMF)]] through the funding of health projects, especially related to HIV/AIDS. However, the WB has also been criticised in a similar way to the IMF through ==promoting market-orientated national health systems; recommending privatisation, user fees, private insurance==, etc. The [[World Trade Organization (WTO)]] has also been the subject of widespread concern from the health community. Although only a few countries have made commitments to liberalise their health sector specifically under the [[General Agreement on Trade in Services (GATS)]], other commitments have been made that may impact upon health and health care, such as within the finance and insurance sector. ==Health is also seen as the next major sector to be negotiated, with many developing countries seeing this as an area of [[comparative advantage]] and one which they may be able to trade for beneficial commitments in other sectors, such as agriculture. Given the isolation from this system of the heath profession in general, and the WHO specifically as outlined above, there is anxiety that trade and economic interests will therefore override health concerns==. ## Commercial Private Sector [[MNCs]] and its growing influence on health. Large commercial enterprise can use its economic power to manipulate and override the health governance of a nation-state. Example: In their study of British American Tobacco (BAT), the privatization of state-owned tobacco in Uzbekistan in 1994 enabled BAT to establish a production monopoly. During this process, Uzbekistan’s chief sanitary doctor issued Health Decree 30, which would have banned tobacco advertising, banned smoking in public places, and introduced health warnings. BAT’s response was to delay completion of its investment until this piece of health legislation, which would have protected the health of the Uzbek population, was overturned and replaced with a “voluntary advertising code.” BAT succeeded in successfully overturning bans on tobacco advertising and smoking in public places, and significantly reducing cigarette excise rates. The result has been that, since 1994, tobacco consumption has increased by some eight percent annually, primarily among young people, and BAT’s market share is now over 70 percent. [[TRIPS Agreement]] is the result of many years of intense lobbying by the industry within the various global fora of relevance, such as the [[World Trade Organization (WTO)]], as well as national governments, and provides a good example directly within health of how commercial concerns are influencing national health systems through their impact on global health governance. [[International trade is highly structured while global health governance provides little structure coherence]]. It means, the rigid highly structured were the result of intense lobbying by the commercial/private side. ## Non-commercial private sector Or NGOs. Many NGOs are now the product of, or influenced by, wealthy philanthropists. BMGF. Rockefeller. Ford Foundation. David and Lucile Packard. But hey, there is no free lunch. These foundations, even though they increase the funds available for investment in global health, also set the agenda for their own foundation and exert significant influence over global governance in health. The most significant one is GFATM. GF's "hands-off" approach to program formulation and implementation would mean that the GF would have no agenda of its own; aid-recipient countries would be able to set their own priorities. However, that would be naïve to assume that several billion dollars will not have an impact on the global health agenda. By the presence of GFATM, the money will flow to three areas of GF at the expense of NCD, and there are some suggestions that the arrival of GFATM has led many bilateral donors to limit their own efforts. > The importance of these organizations is not just that they influence *how* global health priorities are financed, but *what* is financed. A good illustration of this is provided in comments by Kickbusch39 on the [[Bill and Melinda Gates Foundation]], where she states that: “An ad hoc response system run on good will and philanthropic largesse like [the Bill and Melinda Gates Foundation] can only be an intermediary step. Already the law of unintended consequences is starting to have its effect. Newly established global disease investment funds, run from office suites in New York, Washington, Geneva and Brussels are set to fundraise, compete and conquer, each seeking contributions in the billions of dollars from the same sources for ‘their’ disease.” It is perhaps unfair to single out the Bill and Melinda Gates Foundation, but this is a classic case where the foundation – especially as it is so well resourced – supports global health development in areas of their choice (vaccine development and maternal and child health), but with massive ripple effects elsewhere. ## Conclusion SARS, and current concerns surrounding outbreaks of Avian Influenza or other infectious diseases, has increased the visibility of infectious disease, and hence the need for investment in surveillance and in tackling the emergence of outbreaks where they occur (i.e. investment in countries with poor health systems and health structures). In this sense, SARS provides a concrete example demonstrating how the public health community can harness the concerns of global economic governance institutions and utilise these to their advantage, as well as demonstrating the power of global health governance institutions, especially the [[World Health Organization (WHO)]], who, in that case, were clearly the fulcrum of global health governance. [[The public health community is in an ideal place to capitalise and reassert itself in climate and health discussions, through its scientific knowledge and history of action in global health governance]] Together with mounting evidence concerning the impact of environmental and social degradation, the health community is perhaps experiencing a time of opportunity on the world stage for influencing the agenda, not just in health care but also in wider areas that influence health. For instance, it is becoming ever clearer that the global economy is unsustainable without appropriate social, health, and environmental protections. The public health community is ideally placed to capitalise on this development and to reassert itself, through its scientific knowledge and history of action, in global health governance. It may do this through a number of avenues, although engaging more closely with the economic governance landscape is one that is perhaps left on the periphery of activity. However, it is also one of the most significant dimensions of power within governance, having increasing relevance to, and impact upon, health, and is a dimension to global health governance that the public health community needs to better understand to minimise the risks and maximise the opportunities that this offers for improving global health. If it does not, the danger is that global health governance will increasingly be determined by economic institutions with the principle concern not of health but of market liberalisation, ultimately constraining national health system sovereignty.