## Session overview [[Governance is both a social process and a collection of norms and arrangements]] ### Learning outcomes By the end of this session you should be able to: - Define the concepts of governance and global governance; - Contrast key features of policymaking and policy implementation at the global and national level; - Identify key features of global health governance and reflect on how they affect global health policy; - Critically consider how actors, practices and norms in global health governance have shaped the global response to the COVID-19 pandemic. ## 2.1 Introduction ## 2.2 The meaning of governance ### 2.2.1 Domestic governance Democratic governments are intended to be representative of the votes of the people, in contrast to authoritarian or totalitarian rule, although inequalities, discrimination, practices of marginalisation and oppression often take place even in democratic systems. Even though domestic governments, or state sovereignty over its territory and its people, things are changing because of the increasing pressure being put on states to formally acknowledge and act on their *responsibility to protect* its citizens and environment - embodied in international human rights, humanitarian law, and the principles of criminal responsibility for serious violations of international law (i.e. aggression, genocide, war crimes, crimes against humanity). ### 2.2.2 Global governance Global governance is governance beyond the sovereign state, also known as international governance and international organisation. It's important to differentiate global and international. Inter-national implies bilateral and multilateral relations, inter-governmental organisations at the regional and international level, as well as state cooperation through informal groupings such as the G8 or G20. The term global, implies cooperation beyond the state and can include a combination of state and non-state actors, but also only non-state actors (both for-profit and not-for-profit). In sum, contemporary global governance is a product of historical developments and events, of conflict, contestation, domination, tension and cooperation among states and other actors. It is a process but can also be conceptualized as a set of rules, norms, institutions, practices, and different fields, including global health. In the next sections, we will shift the focus to global health governance, defining its features and dynamics. ### Activity 2.1 What does the term ‘governance’ mean to you? If you speak another language, what word would you use for this term? What connotations are embedded in these terms? What examples of governance can you think of – in the field of health and beyond? [[Insights]] In my language, 'governance' translated into *pemerintahan*, which derived from the word *perintah* (direction). It makes sense for me as the sovereign state was (and is) elected by the people, and has the authority to make binding rules on its territory and people, and provide the direction for the people on how to live in the community. ## 2.3 Global health governance Up to late 1990s health was not perceived as having particular significance in global politics and in the studies of international relations (compared to other issues such as security, international trade, development, and environmental politics). Since then, due to HIV/AIDS, Ebola, pandemic influenza, and most recently, COVID-19, further interest in global health governance is undoubted. ### 2.3.1 Terminology and scope The international law expert [[David Fidler]] defines global health governance as ‘the use of formal and informal institutions, rules and processes by states, intergovernmental organisation, and nonstate actors to deal with challenges to health that require cross-border collective action to address effectively’ This definition is quite broad, however, and leaves many questions unanswered – e.g. which institutions are involved, whether all challenges to health are treated with similar attention, what is the nature of the collective action that we can expect to see, or indeed who decides on what challenges need to be addressed and what actions need to be taken. The above para relates to previous note, also by Fidler: [[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"]] Lee and Kamradt-Scott (2014) conducted a scoping review of the global health governance literature, the findings of which align fairly closely with the analysis by Kickbusch and Szabo (2014). Both works identify three distinct ways of thinking about intergovernmental cooperation on public health issues. 1. The first focuses on ‘[[globalisation and health governance]]’, considering the ‘institutional actors, arrangements and policy-making processes that govern health issues in an increasingly globalised world’ and ‘the health-related institutions that govern collective responses to such issues’ (Lee and Kamradt-Scott 2014: 5). This conceptualisation puts the work of the WHO and its cooperation with other actors at the core of analysis. Similarly, [[Kickbusch]] and Szabo refer to ‘[[global health governance]]’ (2014:2) as a political space that involves inter-governmental cooperation directed at addressing public health issues. 2. The second conceptualisation - ‘[[global governance for health]]’ - refers to the work of organisations outside of the health sector, whose work has implications for health – such as the World Bank (WB), the International Monetary Fund (IMF), and the World Trade Organisation (WTO). Kickbusch and Szabo include a broader variety of organisations in this category – e.g. the International Labour Organisation (ILO), the Food and Agriculture Organisation (FAO) (2014: 5). Regardless, the authors of both articles recognise the governance of public health issues is influenced by decisions in many other sectors, including decisions related to safety standards for workers, the intellectual property of pharmaceutical products, food security, the environment, and many others. ==One of the defining features of this political space is that the effects on health are rarely an intended consequence of policy-making in other fields of global governance, which is why there have been growing calls to recognise Health in All Policies==. WHO defined [[Health in All Policies]] as follows: Health in All Policies is an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts in order to improve population health and health equity. It improves accountability of policymakers for health impacts at all levels of policy-making. It includes an emphasis on the consequences of public policies on health systems, determinants of health and well-being. (WHO 2013:1) 3. The third conceptualisation - ‘[[governance for global health]]’ – refers to governance arrangements and efforts needed to further global health goals (e.g. access to medicines, universal health coverage) as well as the pursuit of broader policy goals and norms such as the promotion of human rights and social justice (2014: 6-7). For Kickbusch and Szabo, such efforts are usually represented in the form of foreign policy or strategies that work at the intersection of global, regional, and national priorities. ### 2.3.2 Actors #### 2.3.2.1 States Historically, the wellbeing, security and prosperity of citizens have been considered a key responsibility of sovereign states. States continue to be considered the building blocks of the contemporary international politico-legal system. [[Sovereignty guarantees equal legal status to all states, but their power is deeply unequal]]. Collectively, states are the only actors that can agree on international legal rules, principles and regulations to govern their conduct and interactions with other states and intergovernmental organizations (IGOs). These rules are broadly expressed through the body of public international law. And while international law is intended as a set of binding rules, due to the principle of sovereignty, states can select the degree to which they participate in international governance and abide by international legal principles. Inter-state cooperation to address transborder health threats continues to be one of the main channels of global health governance, with sovereign authority both enabling and constraining cooperation efforts. However, some have contested the primacy of state authority in international politics: > [[where states were once the masters of markets, now it is the markets which, on many crucial issues, are the masters over the governments of states]] (…) . the declining authority of states is reflected in a growing diffusion of authority to other institutions and associations, and to local and regional bodies, and in a growing asymmetry between the larger states with structural power and weaker ones without it. (Strange 1996: 69) Even if one disagrees that state authority has declined or been lost to corporate power, it is evident that non-state actors feature prominently in the field of global health governance, too. In other words, [[states now operate in a much more crowded policy arena where non-state organisations have been gaining significant influence]]. - Direct funding or deliver health programmes eg, PPP such as Global Fund, philanthropic foundations - Empower marginalized populations to deliver health programmes and services in support of states or in fragile or conflict-affected settings, eg, [[Medecines sans Frontiers]], Save the Children, Oxfam, the ACT UP coalition to end the AIDS crisis. #### 2.3.2.2 Inter-governmental organizations Multilateral arrangements have been in increasingly important mode of governance, in the form of inter-governmental regional and international organizations. An [[inter-governmental organization (IGO)]] is composed of three or more sovereign states, established by a treaty or other agreement acting as a charter, and has a permanent secretariat. The mainstream explanation of why states create inter-governmental organisations is to reduce the transaction costs of their cooperation, to achieve foreign policy aims, to promote cooperation and security, to achieve goals that they cannot attain on their own, as well as to deal with and regulate intensifying cross-border relations (Keohane and Nye 1977). [[Interesting Phrase]] IGO proliferation has led to competition for leadership on issues, as well as to ‘[[forum-shopping]]’, whereby stakeholders selectively engage with organisations that are most likely to assist them in achieving their goals or promoting their preferences. [[Insights]] Expanding mandates of [[inter-governmental organization (IGO)]] have also led to conflict or overlap between them, confrontation with states, and coordination issues. A prominent example in the field of global health is the leading role that the World Bank has assumed within it (Tichenor et al 2021). Barnett and Finnemore (2004) argue that, over time, IGOs develop independent bureaucratic legal authority, which allows them to broaden their mandates and expertise and gain decision-making autonomy away from the authority granted to them by their member states. This is an alternative view to mainstream conceptualisations of [[IGOs as mere puppets of state interests]]. #### 2.3.2.3 Private (non-state) for-profit and not-for-profit actors Private for-profit actors: commercial or corporate Not-for-profit actors: civil society organizations, non-governmental organistions, philanthropic foundations, epistemic communities, communities of faith, trade unions, and so on. [[Key concerns raised in relation to the work of corporate actors and philanthropic foundations include their disproportionate economic resources, the fact that their work and priorities reflect private interests, views and values, which is in turn associated with questions about accountability and transparency, effectiveness, as well as questions around impact assessment and evaluation]]. > As Williams and Rushton point out, the ‘private turn’ in global governance has ‘opened a policy space within which GHPs and foundations have emerged as legitimate governance actors (…) further entrenching the role of markets, business models and corporate influence in global health’ (2011:21). Critically appraising the work of private actors raises important questions – e.g. about the role and impact of organisations from high-income countries on populations and governments in less resourced settings; whether the benefits of contributions by private donors outweigh the private gains for associated corporate interests; whether analysts ought to be concerned with the lack of public accountability (domestically and abroad) by private actors. Marion (2021) argues that the significant involvement of philanthropic foundations in the COVID-19 response illustrates a complex relationship between public and private governance for health, and the role of private foundations in funding international relations (and public health) research may hinder the ability of these disciplines to critically and objectively evaluate the role of these organisations in governance. ### [[Think it through]] Activity 2.2 Choose a health issue, which is addressed in global health governance (this could be a communicable or non-communicable disease, for example). Make a list of different types of actors and organisations working on this issue within and across national borders. Select five of these entities, label them – public/private, state/non-state - and share the list in a forum post. Write a short paragraph of reflection on the influence you think these actors are having on the governance of the issue that you have selected. Comment on the lists and paragraphs of other students. Tuberculosis. 1. Stop TB Parnertship 2. TB Caucus 3. Global Fund 4. WHO 5. BRICS ## 2.4 Key features of global health governance Proliferation and diversity of actors. ### 2.4.1 Proliferation of actors [[Proliferation of public and private actors working on health issues is considered one of the main causes of fragmentation in global health governance]]. While the WHO is nominally the leading organisation in global health governance, it is funded by contributions from states and in significant part by the [[Bill & Melinda Gates Foundation]]. The largest funders of health programmes are the [[World Bank (WB)]] and the [[International Monetary Fund (IMF)]], throwing wide open the question of who is leading or indeed coordinating health governance. Related: [[Key concerns raised in relation to the work of corporate actors and philanthropic foundations include their disproportionate economic resources, the fact that their work and priorities reflect private interests, views and values, which is in turn associated with questions about accountability and transparency, effectiveness, as well as questions around impact assessment and evaluation]] ### 2.4.2 Nature of global health issues Common priorities and interests are often difficulty to identify, so concerted state action becomes even more problematic. International health and global health tended to prioritise a narrow range of emerging and re-emerging infectious diseases, often perceived as a threat to the Global North, and emanating from the Global South. These attitudes are very similar to the logic underpinning tropical medicine and ignore broader and shared challenges - such as growing threat posed by non-communicable diseases, environmental degradation and pollution, weak health systems, as well as the far-reaching effects of the social, economic and political determinants of health. ### 2.4.3 Role of international legal principles The principles are visibly expressed in the form of international laws and through public declarations by governments and inter-governmental organisations. Most notable health-specific international legal instruments: IHR (2005) and FCTC (2003). Other principles that affect health policy and practice, include the [[International Covenant on Economic, Social, and Cultural Rights (IESCR)]], [[TRIPS Agreement]], and [[General Agreement on Trade in Services (GATS)]]. Values not codified in international law, but expressed publicly through declarations and international commitments include the Alma Ata Declaration, Oslo Ministerial Declaration on global health as a foreign policy issue (2007); Helsinki Statement on [[Health in All Policies]] (2013); [[Sustainable Development Goals (SDGs)]]. [[Open Question]] While some analysts call for public health to utilise the power of law, so legal instruments can mandate states to protect health and define international responsibilities (Gostin 2012; Gostin et al 2019), others argue that more important than creating new law is embedding and making public health more prominent in the current global governance system (Fidler 2002: 47). There are also calls for further reflection on the value of international law in promoting state action as well as for appreciation of some of the shortcomings of international law – including the limitation of what international law can achieve (Fidler 2002: 46-7; Gostin and Sridhar 2014: 1737-8), its hegemonic character, its indeterminism and lack of guarantee that legal instruments will be used as intended and would indeed promote state action (Stoeva 2020). ### 2.4.4 Power inequalities and coloniality [[Power inequalities are evident in comparisons between the annual turnover of major MNCs and the GDP of many small and medium-sized states]], or in comparisons between the wealth and power of a handful of states and the rest of the world, or when comparing budgets of different UN agencies (which can reflect the preferences of the more powerful member states), and so on. Power inequalities shape intergovernmental organisations and other institutions to cater for and indeed, to further institutionalize, the interests of dominant states and other actors (Milsom et al 2020). They affect decision-making and the resulting policies; and they skew political agendas and priorities by obscuring some problems while emphasising others. ### Activity 2.3 > How ‘global’ is global health governance? Reflecting on the divergent viewpoints presented in the session and drawing on any personal experiences or examples that you are familiar with, briefly set out your position on the above question together with 2-3 key arguments (in bullet point form) to explain it. Post your responses to the relevant discussion forum on Moodle and comment on the arguments and positions of at least one other student As eloquently explained in the session notes, I acquired firsthand experience on how skewed the global health governance towards the interests of Global North during the G20 Indonesia. 1. The apparent and visible power of [[MNCs]] in controlling mRNA technology knowledge: the COVID-19 pandemic revealed that the cutting edge technology was "owned" by Big Pharma and probably, getting the stamp of approval by the state where they were located. Despite continuous efforts and pushbacks from various groups to the governments to facilitate tech transfer, it looks like the final say was in the companies executive boards' hands. 2. Power inequalities in vaccine procurement and distribution: high-income countries to buy vaccine through backdoor scheme, bypassed the ACT-A procurement mechanism that were put in place to ensure fair distribution to countries who didn't have the resources to bid higher prices. In short, the pandemic revealed that the the LMICs were at the mercy of those with money and power. ## [[Think it through]] 2.5 Integrating activity: responding to the COVID-19 pandemic - a case study of global health governance The COVID-19 pandemic has brought global health governance challenges into sharper focus. Many of these challenges are political and arise out of political structures, organisations, and patterns of organised political activity. They often involve other areas of global governance, which justifies engagement across disciplinary and issue-specific boundaries in search of effective solutions to problems of global collective action.  Please read your essential reading article: Johnson, T. ‘Ordinary Patterns in an Extraordinary Crisis: How International Relations Makes Sense of the COVID-19 Pandemic’. _International Organisation_. 74 Supplement. December 2020: pp. E148-E168. Consider the following questions in light of the issues presented in this session and the above article. Respond with your thoughts in a couple of short paragraphs and post these on the relevant discussion forum on Moodle. Please comment on the response of at least one other student. 1. Consider some of the characteristics of global health governance. How do they play out in the international efforts to respond to and end the COVID-19? 2. Consider Johnson’s article - how useful is insight from international relations in guiding public health policy and efforts to end the pandemic? 3. What other factors can you think of that are affecting the global response to COVID-19? What evidence is there to support your thinking? Before I try to answer how global health governance respond to COVID-19, I remember reading [Vaxxers by Prof. Sarah Gilbert](https://www.goodreads.com/book/show/58347316-vaxxers) and I discovered that WHO's published list of pandemic potential pathogen guided the researchers around the world on the quest to *prevent* outbreaks becoming full-blown pandemic by developing the necessary countermeasures. The current global health architecture is ill-prepared and fragmented to respond to pandemic. In [G20 Indonesia's Health Ministers' Chair's Summary (2022)](http://www.g20.utoronto.ca/2022/Chairs-Summary-G20-Health-Ministers-Meeting-27-28-October-2022.pdf), the Ministers highlighted the commitment to ensure better pandemic PPR by strengthening the global health architecture, impliclitly confirming the fragmented system. The swift response by the international "non-state actors", i.e., WHO and partners, establishing the Access to COVID-19 Tools (ACT) Accelerator in April 2020 to ensure equitable access to COVID-19 countermeasures, WHO COVID-19 dashboard recorded as of July 4th 2022, high-income countries (HICs) have vaccinated 79.98% of the population with at least one dose, while low-income countries (LICs) have only vaccinated 20.18% of the population with at least one dose. Johnson's observation that this is an "ordinary pattern" fits with how the crises played out. Government leaders focused only on the immediate needs of their own countries: [rich countries got to the front line of the vaccine line](https://www.nytimes.com/interactive/2021/03/31/world/global-vaccine-supply-inequity.html), and even bought more than they need. Not only that, even when they donated, [the vaccine batch arrived with a short shelf life](https://www.reuters.com/world/asia-pacific/indonesia-seeks-longer-shelf-life-donations-19-mln-covid-shots-expired-2022-03-30/), proven to be an additional challenge for the donation receiver to distribute the vaccine in such a short time. Other factors that contributed to the wide inequity is because the [global health governance is increasingly determined by the principle concern of market liberalisation]([[global health governance will increasingly be determined by economic institutions with the principle concern not of health but of market liberalisation]]). When global vaccine stock is short while the demand was high, vaccine producers will sell to the highest bidder. The restrictions on [[Intellectual Property Rights (IPR)]] by single authority regime of [[World Trade Organization (WTO)]] also proven to hinder knowledge democracy and cost lives. Even though there is a clause on the terms & condition of compulsory licensing for national government, in COVID-19 reality, that did not happen. [India and South Africa submitted draft to waive TRIPS agreement specifically for the COVID-19 vaccines](https://www.keionline.org/34061). Despite having the support of more than 100 lower-income countries and UN chief, Antonio Guterres, but the discussion faced a deadlock and the proposal did not get through. But of course, it's easier to put the blame on IGOs. [[Governance is both a social process and a collection of norms and arrangements]] ## 2.6 Summary ## 2.7 References ### 2.7.1 [[Essential readings]] From [[Ross MacKenzie]]: I would recommend reading Rosenau’s 1992 [[Governance, order and change in world politics]] first as it establishes a good foundation for subsequent readings. [[@spicerItFarToo2020]] [[@johnsonOrdinaryPatternsExtraordinary2020]] [[@kickbuschNewGovernanceSpace2014]] ### 2.7.2 [[Recommended reading]] ### 2.7.3 Bibliography