# Question 1 Critically discuss the role of **two** types of non-state global health actors in global health policy-making. Compare their functions and power/influence, and illustrate your arguments with examples. 1. Introduction to [[Non-state actors]], what are they role and function/power and influence 2. Non-state Public actors 3. Non-state Private actors: [[civil society organizations]] and NGOs 4. Corporations or [[Transnational corporations]] 5. [[Non-state actors]] are broadly categorised into two: public actors, and private actors. As illustrated in the lectures, non-state public actors involved international organisation, which are within UN system such as World Health Organization, UNAIDS, or outside UN system, such as [[World Bank (WB)]], [[Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM)]], FIND, Gavi, while private actors comprised as not-for-profit NGOs and civil society organisations such as MSF, Oxfam, and for-proft institutions such as multinational/transnational pharmaceutical companies, and private foundation such as Bill and Melinda Gates Foundation. Their roles and function differs and diverge as the world is increasingly globalised and new global health actors keep spawning. In this answer, I'm going to compare their roles, functions, in what areas they complement or conflict with each other, with a view of what power they deploy to gain influence. First, non-state public actors within UN. In the absence of supreme supranational body that governs health, each body or NGO vying for more influence in the global state. If we traced back to the origin of nowadays state, after World War II the victors dictated or directed the state of global policymaking, showcasing the first face of power through domination. The UN itself shifted their position in 1990s in relation to growing private actors' influence, from 'freeing' market to 'modifying' market, marking the deep neoliberal policies happening worldwide. As a result, [[states now operate in a much more crowded policy arena where non-state organisations have been gaining significant influence]], limiting their policy space. [[Non-state actors]], such as WHO in the field of global health, play a pivotal role to ensure the state of health, or welfare state are kept in check and align with the international law or global health law. WHO, since its inception, has six core functions that span across articulating evidence-based policy, managing information, and agenda-setting for research & development, and other functions. Such as unique position WHO is compared with other NSAs in terms of its single leadership in global health policy, as illustrated with the [[International Health Regulation (IHR)]] that placed as WHO the command center for public health emergencies. However, in other areas, WHO's function as the "single leader" is challenged by other emerging actors, such as the proliferation of new donors, namely World Bank and BMGF, coupled with chronic underfunding of WHO, maimed WHO's capabilities to align and harmonise their objectives with other actors in global health, as WHO has little to no influence over the health spending of these organisations. Second, non-state public actors outside UN system, such as World Bank and [[Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM)]] has the economic power of channeling funds and quickly became prominent global health players. World Bank is increasingly morphed to intervene in the technical expertise in health, as one of the barriers countries experienced wanting to gain WB funding was the lack of expertise WB sought to fund. On the other hand, [[Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM)]] is one the global health organisations that has clear health mandate to give financial support for specific diseases (AIDS, Tuberculosis, and Malaria). Third, not-for-profit private actors. This category consist of civil society and NGOs, but one might argue that the definition between those are blurred, with civil society is defined more as association with common interest, while NGOs are more "organised." To further complicates the matter, some authors argued about the exclusion of for-profit motivation of CSO or NGOs, but in this answer I exclude the for-profit motives. CSO and NGO have different political tactics and resources to deploy in global health policy-making, which are: 1. Information politics. For example, a few months ago International Baby Food Action Network exposed a formula milk producer that added sugar to some Low- and Middle-Income countries just because they can exploit the regulatory gap compared with European countries. The network carefully conducted the research by themselves and deploy information politics to pressure the company that harms public health. 2. Symbolic politics. Through this tactic, CSO or NGO deploy symbols to gain awareness of media and attention of other promiment global health organisations such as WHO. For example, the red ribbon symbol for HIV/AIDS was created by an artist and got amplified until it was recognised by WHO and is still widely used until today. 3. Accountability politics. [[Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM)]] has their own internal mechanism for ensuring accountable usage of their financial support. A country has been exposed once and the GF used the accountability tactics to safeguard its donors' trust to GF to deliver the support was strategic. On the other hand, CSO also utilise this tactic as "watchdog" and spot any hypocrisy by politicians or other actors to hold them accountable for their past promise or saying. 4. [[Leverage politics]] are used to leverage powerful actors' voice to amplify the CSO's cause. For example in many fora, patient or survivor of a certain disease was brought to voice their concern and experience to the decision-makers. The four tactics above are weaved into the function of CSOs in global health policymaking, namely political functions, operational functions, and self-empowerment functions. Fourth, for-profit private actors. It is not suprising that the entity seeks profit, or even if they establish not-for-profit entity, it was to serve the purpose of its profit-seeking parent entity or to secure their power. For example, Philip Morris established Foundation for a Smokefree World as a decoy to aid their narratives that they are part of the solution. We are seeing this similar tactis used by [[unhealthy commodity industries]] (UCI), such as Obesity Awareness and Solutions Trust, Gambling Therapy, etc. On trade issues, we learned from Australia's plain packaging cigarettes that were met with backlash and legal fights from the big tobacco using [[Technical Barriers to Trade (TBT)]]. Even after winning the case, the corporations successfully produced [[chilling effect]] to other countries who cannot afford to rest their case. Four paragraphs above give a glimpse of how global health governance policy-making has become what Fidler said as open-source anarchy, where the process now dominated by fragmentations of power, influence, and informal mechanisms between state and non-state actors. With increasingly limited policy space of state, and increasingly wide policy space and role [[Non-state actors]], the function of public actors are important to protect public health and welfare state of people, even from within public sector but non-UN such as WB which emphasize privatization policies. The tactics and resources by CSOs and NGOs, more often than not, undermined by private actors' profit-seeking behavior above all else, so the role of NSA is increasingly important. Even UN entities seek to carefully engage with NSA, reflected by WHO's [[Framework of Engagement with Non-State Actors (FENSA)]] and after the COVID-19 pandemic, WHO is softer to private associations, such as IFPMA, recognising their important role to play in public health emergencies. Overall, the converge of tactis by for-profit private sectors deployed by primarily their institutional power and economic power, must be met with other power capitals as categorised by [[Bourdieu]]: namely social capital, cultural capital, and symbolic capital. Empowering WHO to increase their institutional capacities, empowering CSOs to be a more powerful watchdogs, give them platform, will expose the harm intentions by entities that seek to profit from health sector and global health policy-making, and despite having a limited policy space, NSAs can construct a more healthy global policy-making. # Question 2 Critically discuss if and how human rights and equity concerns were incorporated in national and global responses to the Covid-19 pandemic. In your answer consider relevant theories of human rights and illustrate your arguments with examples. The history of human rights and rights for health started back from 1945 UN Charter which affirmed human rights as a core pillar of the UN system, then in 1946 Constitution proclaimed that health as a fundamental health right. Next, the 1948 Universal Declaration on Human Rights became the fundamental proclamation of advancement rights for health, but it took around two decades from the declaration to crystalize into legal obligations under the 1966 International Covenant on Civil and Political Rights and International Covenant on Economic, Social and Cultural Rights, enshrining the highest attainable standard of physical and mental health. The above declaration and series of events laid the cornerstone of WHO's mission to politically advocate for health as human rights, as stated in the Preamble of WHO's Constitution. International Response to Covid-19 pandemic was led by WHO, though historically state challenged and withhold their sovereignty even though in the face of global public health emergencies. The early response was questionable, but ordinary, as stated by Johnson, 2020. Even though COVID-19 produced a innovative technological breakthrough, which was mRNA vaccine, the early response was widely criticised, particularly where President Trump, the president of the USA at that time, blamed WHO's slow bureaucracy and soft stance towards China, threatened to withdraw from WHO's membership. It was an ordinary pattern, to blame international organisations, resulting in a fragmented and I would argue, fractured, response to the pandemic. The state prioritzed short-term interest rather than long-term response which prioritized solidarity and equity with other countries. As we have witnessed, even though [[ACT-A]] was born to ensure fair share and coordinated mechanism of procurement of vaccine, many HICs went through the backdoor and exercised their institutional power and economic power to prioritize their stock of vaccines. As a result in 2022, WHO COVID-19 dashboard captured the wide gap between number or rates of people who have received the first dose of COVID-19 vaccine between HICs and LICs, ranging from 10-20% in LICs, with 70-80% in HICs. Lastly, the international community reacted differently to experts and public health measures taken by countries. Government leaders and national health advisors reacted differently to lockdowns, with a few countries ready to comply and take the measures, such as New Zealand, but Russia resisted. We also witnessed how countries defied WHO's recommendation to not stop exporting/importing essential medical supplies, causing disruption in health supply chain, deprived some parts of the world from medical countermeasures. The divide of these response, I suspect stems from the two ideological camp of human rights, coupled with limited WHO capacities on human rights law and fell short attempts in the past on global health law, coupled with success story on international cooperation without legally binding regulation, such as FCTC and eradication of smallpox. First, the two ideological camps are divided into western bloc and eastern bloc. The wester bloc prioritised the freedoms in the International Covenant on Civil and Political Rights (ICCPR), one of the two implementating treaties of the Universal Declaration of Human Rights (UDHR), which includes freedom of expression. On the other hand, the eastern bloc focused on entitlement, like education and health, based on the other implementating treaties of UDHR, which was International Covenant on Economic, Social, and Cultural Rights (ICESCR). The diverged road between these two blocs explained the divide between views that health is a right that every citizen is entitled to, or a negative rights where individuals have the rights to exercise their freedom and agency power for their health status, and not necessarily owes anything to anyone on their health, much less about people in other countries. Second, history of where WHO embrace human rights law. WHO tried multiple attempts to advocate and streamline human rights into global health law. For example, in 1970s WHO championed the Health for All, which take primary health care as the frontface of its mission to incorporate health as a human rights and is an integral part of the national development. At that time, the states adopted Alma Ata Declaration, which was a significant milestone even though it experienced its own shortcomings in the following years. Next, in 1980s, WHO again embrace human rights law in HIV/AIDS response, recognising human rights protections as part of the health promotion program. Yet the spirit, multiple attempts, and conscious efforts fall short because of the limited WHO staff support for human rights law. (Gostin, et al., 2024). In the following decades, eradication of smallpox without legally binding regulation, followed by WHO's success story to produce [[Framework Convention on Tobacco Control]]and by [[International Health Regulation (IHR)]] with only international cooperation, further entrenched WHO's reluctance to exercise its normative function in global health law. In the same paper by Gostin, et al., authors argued that the reform of WHO after seventy-five years is needed. One of the proposed reform is mainstreaming equity and rights. The authors argued, "WHO governance must center human rights obligations in global health law, advancing equity under global health policy and harmonizing human rights law and global health law to realize the right to the highest attainable standard of health." (Gostin, et. al, 2024). However, COVID-19 served as a wake up call for WHO and the international community to bolster WHO's position in global health architecture and mainstream equity and rights. The recently reached consensus IHR perfectly illustrated how WHO has successfully embed key principles of human rights into global health law. With added items such as equity and solidarity, WHO's bolstered capacity to share early information on outbreaks, and provision of access to health products and financial mobilization, a mechanism to ensure accountability of states, and WHO's central role in pandemic emergency, would pave the way for WHO to usher Pandemic Agreement, which is drafted with human rights as the core principle, to reach consensus by Member States. # Question 3 Critically discuss the effects of global health partnerships on national health systems - including health service delivery, human resource management, governance and financing. Illustrate your argument with examples from the study materials and/or your wider reading or experiences. --- Previously, global health partnerships were marked by "donor" and "recipient" countries relationship but now, global health partnerships (GHP) are characterised by the proliferation of public and private actors working on health issues and underpins the relationship and responsibility between public and private actors in the process of policymaking. In fact, in one lecture, it is already classified as one of the key features of global health governance. GHP may be illustrated as two-edged sword. On one end, it paves new ways of partnerships where non-state actors and private sectors can also have a representation in health matters. On the other hand, the influence of too many actors, including profit-seeking entities, may infiltrate global health policymaking and governance. The state of [[global health partnerships]], after COVID-19 pandemic, marked a shift of stance regarding involvement of private sector in development. Academics and global health diplomats now consider insights from various disciplines and sectors as imperative to inform global health policymaking. The development sector is close with political choice, as it is a process that evolves over time and tied with economic growth—although insufficient. Global health partnerships, then, provide a forum where ideas and values collide and conversation happen. In 1970-1900s, the UN system has expressed interest in involving private sectors in development to legitimize their stance to fulfill its mandate—using private sectors' resource. The private sector itself is interested to dive into development, as it will grow their influence, both in international arena and national arena. Nowadays, increasing role of private sectors in development is already considered as the standard norm. As the enhanced accountability mechanism for both public private sector, coupled with transparency, the partnerships flourish to fulfill public health needs while safeguarding public interest over profit. There are examples of how global health partnerships happened in my country, Indonesia, on health system governance, health financing, health workers education, and health service delivery were enhanced by global health partnerships. First, health system governance. The presence of [[Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM)]] in Indonesia, with its mechanism to formally engaged with the country's effort and take a fair share of influence of how Indonesia should govern its tuberculosis programme, was dictated by the economic power of GFATM. The GF also introduced debt swap approach to incentivize Indonesia in diagnosing tuberculosis patients. The other example in health system governance is how the donors and pharmaceutical associations, such as PhARMA and IPMG, have tried relentlessly to shift Indonesia's access norm in pharmaceuticals. Indonesia is heavily invested in locally produce everything, stating its sovereignty in how they want to open/close their market. With trade as barriers to access to medicines in Indonesia, I've seen how WHO also evolved to cater to this barrier, with a recent workshop by WHO Essential Medicine team for National Regulatory Agency (BPOM) to train them how to overcome [[Technical Barriers to Trade (TBT)]]. Second, global health financing. The USAID funded several programs in Indonesia, which spans across communicable disease, digital health, and health financing. However, the legitimacy of this program has recently been aligned with national priorities, such as cost calculation for telemedicine service in rural areas where specialists are absent, etc., compared to previous focus of USAID where they heavily emphasize on communicable disease such as tuberculosis. There is discussion and worry from the government of Indonesia, as the partnership seems informally tied to the USA's market of monopoly of GenXpert reagen to diagnose drug resistant tuberculosis in Indonesia. Third, related to financing and delivery, is the DAH fragmentation. In Indonesia, DAH is fragmented due to uncoordinated donor priorities and alignmet. Indonesia has started to notice this is happening on the ground, especially how they see the risk themselves mismanaging donor funding and national budget to startup Digital Transformation Office (DTO) wihtin Ministry of Health, how the grant and assistance might duplicate and being ineffective, so Indonesia is planning to establish a Multridonor Trust Fund within Ministry of Health to gain more accountability to donors, ensure effectiveness of programs, and funding being disbursed to areas where the gaps are. Fourth, with partnerships now also emerged in the field of health resource management, such as education for community health workers (CHW), it caused internal brain drain as many health workers migrate from being a health workers inside the system to the donor-supported NGOs, further exacerbates Indonesia's health system that are already underresourced. Aside from my countries' experience, from the reading materials I was enlightened by the positive result of [[product development partnerships (PDPs)]], where partnerships able to fulfill public health needs for small size of the market for certain products. Companies who have the resources to produce the products but lacked the incentives, were able to be bridged by other partners, including the governments who need the products, and justify the investment case of the products.