# 1. Session Overview By the end of this session the student should be able to: - Explain what global public goods are - Show how and where the concept is relevant to health and healthcare - Outline key aspects related to the finance and provision of global public goods for health - Understand how the concept relates to other aspects of global health policy - Evaluate the use and limitations of the concept for global health policy # 2. Introduction There is a growing awareness of cross-border issues in health and trade that requires new policy responses and financing mechanisms. This expanding importance of health as an international issue has brought to prominence the concept of [[global public goods for health (GPGH)]]. The GPG concept considers the production of 'goods' that are in the interest of the world as a whole, such as controlling global climate change and preventing infectious disease pandemics, but also that demonstrate 'public good' attributes: once they are provided no-one can readily be excluded from their consumption, and one person's consumption doesn't prevent anyone else from consuming them. ==These attributes mean that there is often a lack of incentive to produce these goods==. Thus, the central issue of concern within the concept of GPGs becomes one of ensuring collective action at the international level. This clearly relates closely to global health policy, and it is therefore important for those interested in global health policy to have an appreciation of what the GPG concept is and can offer. ## 2.1 Key terms in this session **Public Goods and Private Goods**: Most goods are private goods. Their consumption can be withheld until a payment is made, and once consumed they cannot be consumed again. Public goods have the opposite characteristics: once the good is provided, it cannot be restricted and is available to all (non-excludable) and consumption by one individual does not limit consumption of that same good by others (non-rival in consumption). [[global public goods for health (GPGH)]]: Goods (including things produced or achieved) that are in the interest of the world as a whole (such as controlling global climate change, or preventing infectious disease pandemics), but which demonstrate ‘public good’ attributes: once they are provided, no-one can readily be excluded from their consumption, and one person’s consumption doesn’t prevent anyone else from consuming them. **Collective Action**: A collective response to achieve an outcome that is beneficial to a large group but for which there may not be economic incentive for individuals to produce. # 3. Public Goods Most goods are private in nature: their consumption can be withheld until a payment is made in exchange, and once consumed they cannot be consumed again. For example, the consumption of a cake can be withheld from the consumer until the consumer pays the baker a price, and once the consumer has eaten that cake it cannot be eaten again. A private good is therefore considered excludable and rival in consumption. If purely private goods are seen as lying at one end of the spectrum of goods, at the other lie pure public goods, which are defined as having the opposite characteristics. That is, the benefits, once the good is provided, cannot be restricted and are therefore available to all (i.e. non-excludable), and consumption by one individual does not limit consumption of that same good by others (i.e. nonrival in consumption). ==The core problem is that free markets under-supply public goods because, first, non-excludability means that a price cannot be enforced, leading to what is termed ‘free-riding’ – an individual can benefit from the actions of others without reciprocation.== Second, non-rivalry means that efficient consumption is where individual marginal cost is just greater than zero but this will be below market price, leading to less than optimal supply. Virtually all public goods are such services or other intangibles, with few, if any, 'commodities' (in the narrow sense of physical objects) meeting these criteria; the exception to this being physical infrastructure, such as sewage systems, which once completed are largely non-rival in consumption, and difficult to exclude people from using. However, both excludability and rivalry are relative, not absolute, concepts. In terms of excludability, access to public goods in particular may be, for example, geographically specific: for instance, TV broadcasts reach only an area defined by the location of transmitters, the strength of signals and topographical constraints. It may be subject to access goods, subject to administrative control (for instance a TV licence creating artificial exclusion), or subject to change over time (such as the latest generation of satellite TV signal encryption creating exclusion. Similarly, rivalry in consumption may be relative to capacity, particularly in the case of physical infrastructure. For example, if a sewage system has spare capacity its use is non-rival, but as the capacity constraint is approached use becomes rivalrous. Between these extremes of pure private and pure public goods lie two particularly important categories of goods. First, ‘common pool goods’, which are non-excludable but rivalrous in consumption, such as forests, where the environmental benefits of forests are not excludable, but if they are used for logging, these benefits are forgone. Second, ‘club goods’, which are, conversely, excludable but non-rivalrous, with the benefits spread among a sub-group of the population, whose membership may be controlled by the providers of the good or others. Examples include cable and satellite television broadcasts, which have the characteristic of non-rivalry for those who subscribe to them, with non-subscribers being excluded. Thus, ==the classification of a good as public or private may be somewhat misleading. Rather, it is more appropriate to discuss the degree to which goods may be subject to excludability and/or the degree to which their consumption is rival.== ![[Public Goods.png]] ## 3.1 [[global public goods (GPG)]] GPGH are commonly seen to be public goods with benefits that are universal in terms of countries (covering more than one group of countries), people (accruing to several, preferably all, population groups) and generations (extending to both current and future generations, or at least meeting the needs of current generations without foreclosing development options for future generations). However, as shorthand, we tend to see global public goods as goods which exhibit a significant degree of publicness (that is, a significant degree of non-excludability and non-rivalry) across national boundaries (as this is typically the collective action issue facing policy makers, and often encompasses population or generational boundaries). [[Question]] Why public goods, and of course, global public goods, are of policy interest is because free markets will either not, or will under supply them? Because non-excludability implies 'free-riding' and non-rivalry means less than optimal supply. [[Most fundamental problem of global public goods is when non-beneficial nonrival goods are not excludable|The most fundamental problem arises, however, when beneficial non-rival goods are not excludable]] . Here, everyone in society will benefit from provision of the good, but nonexcludability means that individuals or nations may free-ride, leading to under, or none, supply of the good and thus a societal loss of welfare. In essence, it is becoming ever clearer that our increasingly inter-dependent and inter-connected world means that domestic action alone is not sufficient to secure better health, but that collective action at the global level is essential to address the increasing cross border issues of pollution, security and health. If the core policy issue is to ensure collective action at the national level to finance and produce a good that is non-excludable, then at the global level the core policy problem is to facilitate the production of, and access to, goods which are largely non-excludable and nonrival in consumption, and yield significant external benefits, across multiple nations. Addressing this problem is at the core of the concept of Global Public Goods. #to-write Indonesia and contributions to avoid free-riding in global issues [[Question]] Why does global public goods have anything to do with global health policy? First, health is not public good, either individually or nationally. Health status is a private good in the sense that he/she is the primary beneficiary of it. An individual’s health remains primarily of benefit to that individual, although there may be some positive or negative externalities resulting from it, such as exposure to communicable disease. Further, in terms of the goods and services which are necessary to provide and sustain health, such as food, shelter and use of curative health services, ==health ‘care’ is mostly rival and excludable between individuals and nations.== Nonetheless, there is an important externality aspect of health, both at the local level and across national borders, which may be amenable to conceptualising as having global public goods properties. ## 3.2 Communicable Diseases Preventing one person from getting a communicable disease (or treating it successfully) clearly benefits the individual concerned, but it also provides a significant positive externality to others by reducing their risk of infection. Similarly, the reduction of communicable disease within one country reduces the probability of cross-border transmission to other countries. [[Communicable disease control is non-rival in its effect, but requires excludable and non-excludable inputs for its production]] However, while communicable disease control is non-rival in its effect, its production requires excludable inputs, such as vaccination, clean water or condoms, as well as non-excludable inputs, such as knowledge of preventive interventions and best practice in treatment. In this sense, it may generally be considered a ‘club good’ (non-rival but excludable), although its non-rival effect does imply that even if it is feasible to exclude people it may not be desirable, as the marginal effects on the health of others may outweigh the marginal savings from exclusion. For example, the Global Polio Eradication Initiative, launched by the World Health Assembly in 1988 to eliminate paralysis due to poliovirus is a classic global public good for health: all people everywhere will share equally in the benefits of a polio-free world, possibly in perpetuity and hence across generations. Everyone in the world will be protected from polio and one person’s protection will not reduce another’s (i.e. it is non-rival). There will be no limit to the safety from polio that eradication will offer in terms of geographic reach or the number of people protected (i.e. it is nonexcludable). This goal of polio eradication is provided and pursued through the collective action of over 10 million people working or volunteering worldwide. However, since not all communicable diseases are global, clearly only the prevention or containment of some communicable diseases may be considered as global public goods. For example, malaria control benefits only endemic areas, so can only be a ‘[[regional public good’]]. Thus, only a sub-set of communicable diseases can the prevention/containment of such diseases be considered a GPG. For this sub-set of diseases whose control can be considered a GPG, it is also important to distinguish between control within a country or region, to limit the global ‘stock’ of disease which may be disseminated (e.g. polio eradication), and control of cross-border transmission (e.g. through International Health Regulations). These two approaches have very different implications, particularly for the distribution of benefits. ## 3.3 [[global public goods for health (GPGH)]] [[global public goods (GPG)]] and [[global public goods for health (GPGH)]] is different, because while health is a private good, there are a number of goods which may be considered global public goods for health. The scope of potential such global public goods is wide. It can be broadly divided between those which address in-country health problems with cross-country externalities - primarily communicable disease control, but perhaps also non-communicable disease control to the extent that it has economic effects -, and those which address the cross-border transmission of factors influencing health risks, such as food safety, tobacco marketing and international trade in narcotics, which are covered elsewhere within this course. Within each of these categories, global public goods may then be classified in to three broad areas. ### First, knowledge and technologies Information itself, such as on health risks and treatment regimes, is in principle both non-excludable and non-rival in consumption, at all levels from local to global. However, in practice, it may not be. For instance, the control of communicable disease relies on countries to produce and to act on information, which requires an effective health infrastructure. Similarly, much of the technology for curative and preventive interventions is embodied in private goods such as pharmaceuticals and vaccines, turning a global public good into a club good. ### Second, policy and regulatory regimes The collective nature of policies, whether in health or other sectors, makes them public goods. Regulatory regimes, such as for food or drug safety are ‘club goods’, as groups can be included or excluded by a regulation, but once a regulation exists it can apply to one or many ### Third, health systems act as access goods For example, eliminating polio depends on the existence of a functioning health system to deliver vaccines and to identify and treat cases. Health systems may thus be treated as if they were global public goods. A final piece of background is the relationship between global public goods and the debate between the ‘[[vertical program|vertical]]’ and ‘horizontal’ specification of programmes. Vertical programmes may be considered to be disease-specific programmes, the ‘traditional’ means by which governments, [[NGO]]’s, international bodies and donors work in many countries, partly as a means of limiting the problems of working through under-resourced health systems. While such programmes have saved many lives, they have also been seen as inefficient; giving rise, for example, to problems of coordination, skewing priorities from national towards donor concerns, diverting scarce human and other resources away from general health services, and generating costly duplication between parallel programmes. These limitations arise primarily from the asymmetry in financing between these, relatively well-financed, vertical programmes and grossly under-resourced ‘horizontal’ health systems. A contribution of the global public good concept is thus that horizontal and vertical approaches will be seen as complementary, rather than competitive, with a set of common horizontal global public goods for health creating the conditions in which disease-specific global public goods can be provided more effectively. On the other hand, vertical programme co-ordinates the provision of inputs needed for each disease, or group of related diseases. This discussion leads us on to the core of the issue facing us which is to ensure collective action to secure the provision of global public goods, which essentially means considering how such goods are to be financed. In this respect there are several standard options concerning public goods. ### Establishment of property rights The typical example here is that of patenting, where an artificial degree of ‘legal excludability’ is created to ensure that the private market has an incentive to engage in provision of the good. Of course, governments can directly provide the provision of public goods, financed through the taxation system. This is historically a major role for government. For instance, in the provision of law and order, street lighting, armed forces and home security. So, nationally, public goods are dealt with by government intervention, through direct provision, taxes, subsidies or regulation. However, in the case of global public goods the absence of a ‘global government’ means that the collective action problem becomes more complex, with the increased number of players involved and the absence of effective, collectively-enforced sanctions against non-compliance. So, what happens? The main potential contributors to the financing of [[global public goods (GPG)]] are threefold. 1. International agencies. These are most useful for consensus-building and collective decision-making, as coordinators, promoters, and channels of government support and supporters of control mechanisms and regulatory frameworks. However, while international agencies may provide a politically convenient means of channelling government support, they are financed and [[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|controlled]] (in varying ways) by their member governments, limiting their relevance as an independent source of financing; 2. National governments, as potential beneficiaries, sources of funding, and providers of mechanisms for control. Developing countries have limited resources though. 3. [[MNCs]], as developers and suppliers of relevant technologies. However, they are primarily motivated by profit, and will generally make contributions only to the extent that they expect to benefit, unless they can be effectively coerced. All of this suggests that developed country governments are the major prospective source of financing for GPGs, either directly or through international institutions. In this respect, of critical concern is that global public goods might divert existing overseas development assistance (ODA). > Although this might improve efficiency, assuming that current aid monies are invested wisely if the global public good concept led to 'changing the share' rather than 'increasing the size' of the cake, it would fail in its core role to liberate additional funding for projects. The global public good concept highlights the need for the provision of certain goods because of their current under-supply, predicated on self-interest – that we would all be better off if collective action could be orchestrated to produce a particular good. Thus, if some countries are unable to finance their 'part' of this collective action, the benefits to others of their involvement, or the lack of cost of their involvement, make it irrational to exclude them, and in many cases make it rational to fund their activity. This implies that supporting other countries is not a question of humanitarian aid, but a selfinterested investment in domestic health: while recipient countries also benefit, the primary objective for the developed countries is to improve their own health. This suggests that national health (or other) budgets are a more appropriate source of funding, leaving existing aid monies unaffected, and increasing total funding to developing countries rather than merely reallocating it between uses. Resources to cross-subsidise global public goods should therefore not come from current aid resources, but primarily from developed countries' domestic budgets, as their support is, as indicated, a matter of self-interest. Where the benefits of a global public good to developed countries are financial, rather than in terms of health (for instance savings on polio immunisation after eradication), savings in principle provide a basis for estimating the appropriate contribution from domestic budgets, although this may be complex in practice, due to uncertainty and long time-lags. [[Insights]] I don't think this is acceptable for developed countries. [[Question]] Thus, if we are expecting largely developed country’s to fund global public goods, how might the balance of funds be determined, given the global ‘free rider’ problem? Four ways: voluntary contributions (but prone to free-rider problem), ear-marked national taxes coordinated between countries (rest on the discouragement of particular activities, such as tobacco consumption or pollution), taxes imposed and collected at the global level, such as the '[[Tobin tax]]', market-based mechanisms (such as trading of emission rights). There are potential losers and gainers for whatever ways or combined ways to finance the [[global public goods for health (GPGH)]], so how to negate the problems arise from countries/parties to disengage from providing GPG and no incentive to play any part in its provision? Coercion and/or compensation. International law is limited in imposing constraints on formal coercion to stakeholders Limitations of international law impose constraints on formal coercion: there are no mechanisms available for formal coercion of national governments, and formal coercion of non-state actors relies on governments introducing laws within their respective jurisdictions. The problem is compounded by the influence of companies, organisations and individuals on national political systems, as we have seen elsewhere in this module. Informal coercion includes, for example, offers to developing countries of (or threats to withdraw or withhold) economic or military aid, favourable market access, and support for membership of, or loans from, international institutions. ==However, it is often easier to secure formal agreement than actual compliance in these cases==. Compensation for costs incurred by low-income country governments (even with coercion) is likely to be essential for the provision of global public goods as resource constraints can undermine political will. NGOs also who are involved in global public good provision (such as for polio eradication) are also likely to need compensation for their services, both to ensure that they participate (the rather vague definition of NGOs undermines the potential for formal or informal coercion to achieve this), and to ensure that their activities are adequately resourced. Global Public Goods core feature is the recognition of the interdependency of national health and health system, and its focus on collective action Overall, the global public good concept has much to offer to the financing and provision of global health programmes. Critically, the core feature of the concept is a recognition of the interdependency of national health and health systems, and its focus on international collective action. From this basis, the global public good concept provides a distinctive framework for analysing the finance and provision of specific global public goods to improve health. ## 3.4 Communicable Disease Control From a [[global public goods (GPG)]] perspective, the non-rival nature of communicable disease control means that even if it is feasible to exclude people from some of these mechanisms, this may not be desirable. For example, imagine a society where some families do, and some do not, vaccinate their children. This decision is based on the expected costs and benefits to themselves and their children, and not to others. The marginal benefit of vaccination to those not vaccinating must therefore be less than the marginal cost in time and/or money. However, the gain to society is much larger than it is to the family, as a higher rate of vaccination affords greater protection to others by decreasing exposure. Thus, although people could be excluded from vaccination, these external benefits may be sufficient to make their exclusion socially irrational. [[Epidemics are global public bads, but the international surveillance differs from national surveillance because there is no legal structure]] Epidemics are clearly a global public bads: contagious disease has the ability to spread rapidly from country to country. Yet the international situation obviously differs from the national one in that there is no legal structure - such as a public health law that obliges countries to report outbreaks or to take measures to protect other countries from epidemics. It is, however, a collective action problem at the global level, which has two facets requiring international action to secure its provision. First, if there were an international agreement to notify all dangerous outbreaks with a potential to spread internationally, it is easy to see that countries could 'free ride'. They would be alerted to all external outbreaks, and thus be able to take countermeasures. However, a failure to notify internal problems would not leave their own populations worse off at least not in developed countries that have the resources to control an epidemic internally - and it would not have negative consequences for their own export or tourist industry. Second, countries face a '[[prisoner's dilemma]]'. The strongest disincentive to international notification has little to do with public health, but rather with economics: countries know that if they report outbreaks, their economy will suffer. There is also a '[[temporal asymmetry]]', since other countries will be much quicker to impose trade sanctions against an affected country than to lift them when the problem is over. Ideally, before the international notification system comes into place, each country should be aware of the measures other countries intend to take to protect themselves from importation of disease. Just as for national infection control, there are two primary parts to the process: ==the alert function and the control measures==. The global public good concept has relevance to both of these elements. ### 3.4.1 The alert function Information should be non-excludable and non-rivalrous, but it hinges on transparency. Otherwise, it would become club goods among countries with sensitive international intelligence systems If an outbreak happen, country need to immediately notify other countries. In this sense, the alert function is a non-rivalrous and non-excludable [[global public goods (GPG)]]. In this example it is the information itself that should be a global public good for health, but it is easy to see that unless the process is totally transparent, some countries could be excluded from information, and it would thus become a 'club good' among countries with sensitive international intelligence systems. Also, just as in the example of the '[[cordon sanitaire]]', 'global' may not include the affected country. In most instances, this country has little to gain from an alert, and more often than not it will suffer - at least in the short run. Tourists will stop coming, its citizens will be subjected to check-ups or quarantine when travelling abroad, and its exports may be stopped. Assessment of the costs and benefits of global collective action become critical here, as do possible compensation measures. The surveillance and control of communicable disease displays the characteristics of a “[[weakest link]]” type of transnational public good. Whether the supply of this good succeeds or fails depends on the country that does the least. When working in a network, the least-reliable information influences the level of intelligence for all participants. When stemming the dispersion of a disease, the least active effort determines outcomes. ==Everyone must pitch in, at an adequate level, for the good to be produced==. Some countries may be incapable of pitching in. These are usually developing countries, or most likely, failed states. Such states lack the capacity to provide necessary services, and as such, may put the rest of the world at risk. This situation reflects a global collective action problem requiring cooperation not just in health security but in development. Such states must be brought up to a basic level of capacity so that they can contribute to the supply of the global public good. | | Rival | Excludable | Global/regional/national | | --------------------------------------------------- | ------------------------------ | ------------------------------ | ----------------------------------------------- | | Alert:<br>Surveillance<br>Rapid information-sharing | <br>No<br>No | <br>Potentially<br>Potentially | <br>All levels<br>All levels | | Control:<br>Clean water<br>Vaccination<br>Isolation | <br>No (usually)<br>Yes<br>Yes | <br>No (usually)<br>Yes<br>Yes | <br>National/regional<br>All levels<br>National | Classic way to stop the spread of disease is to erect border controls for people as well as for goods. The link between public health and trade is stressed by a sentence in the portal paragraph that gives as its purpose to "ensure the maximum security against the international spread of disease with a minimum interference with world traffic". The global public good concept would seek to reunite these spheres of influence (trade and health). Critical for communicable disease control from a global public goods perspective is that the greatest cost of building a functioning global surveillance system lies with strengthening national capacity in a large number of countries. It may not be easy to secure funds of the size required from national budgets in developed countries: the need to improve surveillance and control in developing countries on the other side of the globe will probably come low on the priority list. Also, the notion of the world as one single arena for epidemics is still not intuitive. Instead, the reflex to return to the closing of borders lies deep within us, however inefficient this may be. Therefore, this consequence of globalisation needs to be stressed repeatedly to policy makers. Another aspect from the country perspective concerns the relations between public health and trade. An adoption of a more efficient IHR will lead to a stronger position for public health in matters of trade and trade sanctions. This may not be an easy shift of balance in several countries. ### 3.4.2 The control measuers # 4. Genomics Genes carry information about physical and functional inheritance vertically between generations. Genomics is thus primarily concerned with the generation, dissemination and utilisation of knowledge about the genetic attributes of organisms. This requires massive amounts of genetic information to be collected and analysed. It has only evolved in the last few decades as a result of developments in analytical tools, such as DNA sequencers and genotyping techniques, which make it possible to easily characterise large numbers and types of genes in a single experiment. Advances in information technology have also contributed to the growth of genomics by providing the means to manage and process these large databases. Genomics will also be a significant contributor to the biotechnology sector, which has major income generating potential. This will not only benefit developed countries. Cuba, for example, has invested heavily since the 1980's in biotechnology, produces several successful products, including the world's only meningitis B vaccine and holding at least 400 patents in the biotech field. However, to reap direct economic benefit from genomics, countries will have to be active participants in the development and manufacture of genomics products. Those countries that will benefit the most from genomics are those that have appropriate health products to improve the health of their populations and who are active in developing and supplying those products. Yet there is the potential for a 'genomic divide' between rich and poor nations. There is a sizeable gap between spending on research and development (R&D) in developed and developing countries - capacity for researching local problems and/or transferring and absorbing scientific knowledge produced elsewhere is extremely limited in many developing countries. It has been estimated that globally the private and public sector spend around US$70 billion a year on health research, yet only 10% of those funds are devoted to the health problems of 90% of the world’s population. Although in principle genomics knowledge has considerable global public good characteristics, in reality knowledge does not always express the public goods characteristics that it is claimed to possess. Of importance there are two major factors which compromise the public good characteristics, and therefore application, of genomics knowledge. These are the [[Intellectual Property Rights (IPR)]] concerning knowledge, and the importance of access goods. ## Main restrictions on the use of genomics knowledge There are two main restrictions on the use of genomics knowledge. First, knowledge is tacit: uncodified, embedded in people rather than in texts. Those people embodied with knowledge are rival (can only be in one place at once) and excludable (can refuse to cooperate). This restricts dissemination. Second, the absence of local R&D capacity: skills, training, equipment, institutions and networks to absorb and make use of basic knowledge. There is a distinction here between 'free availability' (access unregulated) and 'free use' (accessing and using information without cost). Different types of 'access good' are often required to make ‘use’ of the ‘available’ knowledge. Genomic knowledge is not likely to travel easily, despite the fact that massive amounts of genomic data are available free of charge on the Internet. Non-codified genomic-related knowledge is necessary in order to reproduce these results. Further, in order to absorb and develop applications of genomics, extensive investments are necessary in skills, research instrumentation and networks. In that sense, genomics is not a public good to those (predominantly developing) countries that cannot afford to put sizeable resources into developing genomic research capacity. The publicness of the utilisation of genomics knowledge is therefore not exhibited to a significant degree across national boundaries, which limits its globalness. Developing countries will require several '[[access goods]]' in order to develop appropriate applications from genomics for their needs, and become active participants in genomic developments. If the '[[genomic divide]]' is to be averted, there is urgent need for strategies at the local, national, regional and global levels to encourage the production, dissemination and use of genomics knowledge more equally. These strategies will involve a mix of government, non-government, private and international bodies, and collaboration will therefore be fundamental, as stressed by several international organisations. Both WHO in its Genomics and World Health Report and UNESCO in its Declaration on the Human Genome and Human Rights place emphasis on several measures to strengthen genomics in developing countries through international co-operation. These include building capacity for genetic research and seeking means to ensure that developing countries benefit from genomic research. Several key strategies are thus required, concerning capacity strengthening, research, public engagement and consensus building and financing of genomics. Unfortunately, we do not have time to go in to these areas in detail in this module. # 5. Global Health [[Question]] What are the role, relevance, and impact of the [[global public goods (GPG)]] on global health policy? The rise of wealthy private individuals and foundations, the global political move to the right, the increasing level of interconnectedness in global trade and affairs, all changed the landscape and the way in which the ‘business’ of global health was being conducted. The global public good concept adds traction to some of these changes, emphasising self-interest and explicit understanding and dealing with how the costs and benefits of specific actions falls. The concept perhaps gained most profile, or perhaps notoriety, in the concern with security that has arisen in the last decade. The global public good concept underpins this concept of global health security. [[Question]] So what opportunities does the [[global public goods (GPG)]] offer to global health policy? 1. Explicit recognition of interdependence of national health systems and thus perhaps emphasizing the need for global health policy. It frames policy issues to make explicit two important elements in global health. First, the inputs needed to produce the good and benefits resulting from that good, and second, aspects of market failure and incentive structures and systems required for production/ finance of the good. 2. To address these, it also provides a framework to achieve certain objectives: advocate for additional resources, promote investment by developed countries in health systems of developing countries, promote strategic partnerships across developed and developing world and guide process of establishing, providing and financing global programmes with global public good characteristics. 3. However, there are several distinct limitations, principally around the use of the concept as purely political rhetoric. For instance, health itself is not a global public good, and to use it in this sense that anything to do with global health must be a global public good – just serves to overuse and misuse the term and thus devalue it, which is potentially counterproductive to protecting public health. 4. Second, the concept is concerned with efficiency and is ‘neutral’ about equity. In this sense the global public good ‘agenda’ may be set by the rich, perpetuating the existing imbalance of power. Poor nations may face costs in the production of global public goods, making them unable or unwilling to cooperate. The latter may have been evident for instance in Indonesia refusing to share virus samples to aid influenza vaccine development as the costs of the resultant vaccine did not seem to project the same spirit of the ‘public good’ as the sharing. 5. Of course, it is also the case that the concept may skew the global health agenda and crucially divert existing resources rather than attract new resources. To emphasis these points, just because a problem is global or formidable in scale, or just because the response is multilateral, does not necessarily mean that it has anything to do with the undersupply of a global public good. 6. Put another way, there are many issues on the global health agenda for which the concept is not applicable. Here for instance we see the top seven causes of mortality worldwide, only one of which one (TB control) might consider action as a global public good. [[Question]] If we use the global public good rationale to wholly define our policy agenda, how do we advocate for other issues which actually account for higher burdens of disease and death? In this respect you might find it interesting to read the recommended paper by Smith and MacKellar entitled “Global Public Goods and the Global Health Agenda: Problems, Priorities and Potential”, which takes stock of the concept and its use, and in particular looks at it against major global health policy initiatives to assess whether and how the global public good concept has contributed to defining objectives and strategies. # 6. International Law In the national context, governments have primary responsibility for the production and/or finance of public goods. In the international context, however, no central government exists to structure interstate relations, and as such states interact in a condition of '[[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"|anarchy]]'. International law, as "a body of rules governing the mutual interaction not only of states but of other agents in international politics," emerges from this anarchical structure of international relations. The function of international law in international relations is to facilitate interstate cooperation. International law is therefore an essential tool in the production of global public goods. This expansion reflects the extent to which states have, in the development of international society, created new tools (e.g., IGOs) and crafted new public-private partnerships with NGOs and [[MNCs]] as part of international cooperation. The production of GPGs through international law is therefore not strictly global in sense that states and non-states actors are involved (E.g. [[Framework Convention on Tobacco Control]] and [[International Health Regulation (IHR)]] revisions). [[Non-state actors]] involvement in the production of GPGs through international law does not, however, mean that non-state actors have equal status or authority with states. States remain the dominant subjects of international law for the purposes of GPG production. Rules of international law overwhelmingly address state rights and duties in the international system. This fact is important for understanding the production of GPGs. At the national or international level, public goods require governmental intervention because private actors have insufficient incentives or resources to produce the goods. The growth of [[NGO]] and [[MNCs]] involvement in international law does not, by itself, represent progress in the production of GPGs because whether states - the public actors - actually produce the public goods remains the central question. [[Question]]So, what does state use international law for? 1. To construct formal institutions empowered to work on global public health problems, e.g., [[World Health Organization (WHO)]], UNEP, ILO 2. To establish procedures through which states and [[Non-state actors]] come to grips with specific global public health problems, e.g., [[International Health Regulation (IHR)]] process through which WHO member states attempt to achieve maximum protection against international disease spread with minimum intreference with world traffic. 3. To craft substantive duties in connection with particular global public health challenges, eg, IHR obligate WHO member states to notify WHO of specific disease outbreaks and to restrict health-protecting trade measures to specified responses 4. To create mechanisms to enforce substantive legal duties against states that accept them, eg, [[World Trade Organization (WTO)]]'s [[Dispute Settlement Body (DSB)|dispute settlement mechanism]]. These four uses of international law in the production of GPGH differ in the breadth and depth of their impact on global public health problems. The institutional approach offers breadth of coverage, as illustrated by the myriad public health problems dealt with by the WHO, and breadth of membership, as evidenced by the WHO's near universal membership. While making such breadth possible, [[the WHO Constitution lacks depth in terms of the legal obligations of member states with respect to any given public health problem]]. The global public health community believes that GPGH are seriously undersupplied. Many commentators have noted how globalization may exacerbate public health problems nationally and internationally, from the global spread of infectious diseases to the worsening of occupational safety and health conditions worldwide. Clearly, at the very least, this perspective suggests that, although [[international law is necessary but insufficient for the production of GPGH|international law may be necessary, it is not sufficient for the production of GPGH]]. ## [[Question]]What are the limitations of international law? There are of course limitations that confront the use of international law in the world politics of public health: 1. The role of power in global public health. GPGs only come into being when powerful states want or need cooperation on a given issue. Power politics determines the agenda and the outcome of international cooperation. 2. The state-centric, consent-based nature of international law. While non-state actors play important roles, international law remains largely state-centric - the dominant actors are states and the bulk of the duties generated by international legal activity target states. 3. Priorities in the production of global public goods. These conflicts have arisen most famously in the context of international trade law. [[Open Question]] Many commentators have analyzed the question whether the GPG of trade liberalization, supported by the international trade law overseen by the [[World Trade Organization (WTO)]], trumps the GPG of better environmental protection pursued through international environmental law. Similar questions have arisen about whether trade liberalization takes priority over public health concerns and the improvement of international labour standards. 4. Financing international legal regimes. The production of GPGH requires resourcing. Financial woes plague the use of international law to produce GPGH. 5. Weaknesses of governments and national systems of law. The creation of international legal duties represents only the first legal step in producing GPGH. In virtually every case involving public health problems, states have to incorporate the international legal obligations into national law and policy. If the incorporation process breaks down, the entire international legal regime is jeopardized because states have not taken the necessary policy and legal measures domestically to attack the problem in question. # 7. Summary So, to conclude. The core feature of the GPG concept is recognition of the interdependency of national health and health systems, and its focus on international collective action. From this basis, the GPG concept provides a distinctive framework for analysing the finance and provision of specific (global public) goods to improve health. This provides a new rationale for investment by developed countries in resolving developing countries' health problems and strengthening their health systems, and could facilitate strategic partnerships between developed and developing countries in the production of goods which will enhance global health, and may in some cases contribute to poverty reduction. The GPG concept is an economic concept. It frames the issues and objectives of public policy to make explicit the inputs needed to produce the final good, quantify the benefits resulting from that good, and examine the collective action problem in achieving a socially optimal production of that good. Key in this examination is identification of the mix of public and private goods required, what domestic and international inputs are required, and what incentives are needed to produce and disseminate the final 'good'. Definition of health-promoting goods along a continuum from pure private to pure public goods, and from purely local to purely global, allows the application of economic theory and methods to the public policy issue of collective action in their production and finance. It may thus help in the development of collective global action in the collective global interest in the field of health. Overall, the GPG concept has the potential to make a real contribution to the promotion of health at the global level. # 8. References ## 8.1 [[Essential readings]] [[@kaulGlobalPublicGoods2001a]] Key Learning Points: The global public goods approach was highlighted and advocated strongly by the United Nations Development Programme, and as a result of this work the key authors of the UNDP work were asked to write about their reflections on the concept for health. This paper is the result, and is the first paper to really discuss health from a global public goods concept, and is thus an important paper in this area. [[@woordwardGlobalPublicGoods]] Key Learning Points: This chapter provides a concise introduction to the core concept of 'global public goods', set within a health-specific context. It covers the main definitions, concepts and issues arising, and sets this within a global health context. It forms the introduction to a full volume of work on global public goods and health which was commissioned by the World Health Organization, with a set of case studies. Some of these will be highlighted in the session, but it is not essential to read the whole book! ## 8.2 [[Recommended reading]] [[@smithGlobalPublicGoods2007]] [[@smithGenomicsKnowledgeEquity2004a]] [[@smithCommunicableDiseaseControl2004]]