Ravi Duggal ([email protected]) is an independent health researcher and is associated with the International Budget Partnership and the People’s Health Movement.
Good governance has in recent times emerged as the new mantra to address the failures of public systems. Especially so, in the arena of public health where there is a clear divide between the front line providers of healthcare who face the public and the bureaucracy that makes the decisions. There is growing literature both at the country level1and globally2 on the criticality of governance in delivering efficient and good quality services. Jeremy Youde’s book is an addition to this literature focusing on global governance in health.
Governance implies the exercise of political and administrative authority and within countries this is derived from the sovereignty of the nation state. At the global level such sovereignty is absent and this poses a major challenge to address inter-country or global issues. In the health arena there are numerous global challenges and the difficulties in meeting them hinge on governance failure.
In a recent article in the New England Journal of Medicine, Frenk and Moon have identified three global health challenges that are difficult to realise because of governance failure – the unfinished agenda of infections, undernutrition and reproductive health problems; rising global burden of non-communicable diseases and associated risk factors like smoking and obesity; and the challenges arising out of globalisation itself such as health effects of climate change and trade policies.3 Youde’s book deals precisely with these issues and how global mechanisms for dealing with this have been coping.
Global Health Governance by Youde begins with an overview of the historical evolution of international health governance efforts and then moves to discuss how some of the key actors like the World Health Organisation (WHO), World Bank, Global Fund, Gates Foundation, Treatment Action Campaign, among others have played their roles to reign in various global health challenges, and finally, discusses some key issues like infectious disease surveillance, health security and access to pharmaceutical as examples of the struggle to address global health governance challenges.
While the book does justice to documenting the evolution of global health governance and some of the key events which shaped its form, functioning and influence, it fails to adequately capture the political-economy context under which such governance efforts developed or rather failed to sustain. Historically WHO (emerging from its precursor the Health Organisation of the League of Nations) was mandated by nation states to engage with global health governance issues with a clearly defined constitution to direct it, but the character of the global political economy prevented it from achieving its goals. The profit-first nature of global capitalism, exemplified by the global pharmaceutical industry, and the cold war did not permit WHO to exercise its authority in right earnest. Due to these political-economy factors the evolution of global health governance assumed a direction in which a fragmented and selective approach developed leading to the spawning of a number of other players like the Global Fund and UNAIDS – the United Nations Programme on HIV/AIDS – on one hand, and private players like the Bill & Melinda Gates Foundation and the Clinton Foundation on the other.
Youde recognises the problems of these developments, but does not attribute the failure of WHO to these developments. Rather, Youde mentions that the failure of WHO was responsible for emergence of these mechanisms. This may appear to be true when we view it from the evolutionary perspective, but if we recognise the political economy context, then the story is very different. Let me summarise Youde’s trajectory of arguments.
Youde begins with identifying four key attributes of effective global health governance – it must focus on factors that cross and ignore geographical boundaries, it must employ multisectoral and multidisciplinary approaches to craft effective interventions, it should give voice to a wide range of actors and it needs to rely on transparent and accountable systems. No disagreement with this. But for governance to be effective two other factors are critical. First an adequate budget to deal with its mandate, and second a political backing to make it work. Later in the book Youde does identify these factors while discussing why WHO failed, but if Youde had recognised these upfront, then the trajectory of arguments could have developed differently.
The evolutionary history of global health governance is very well-documented by Youde from the international sanitary conferences of 19th century to the role of the Rockefeller Foundation post-first world war and right through to today. But there is one factual issue that needs to be addressed. There seems to be an assumption that the cross-border spread of disease was an east to west phenomena. While many diseases emerged in Asia and Africa, the west also contributed through syphilis, typhus, tuberculosis, etc, which spread to the east through trade.
The earliest response to contain epidemics was quarantine and this was done on country borders and entry points, but traders did not like it as it affected movement of goods, and consequently, their profits. Soon international conventions emerged like the International Sanitary Bureau in Americas, International Office of Public Hygiene in Europe and ultimately culminating into the Health Organisation of the League of Nations and post-second world war, WHO.
Key Players of Global Health
In the next section Youde discusses the key players like WHO, World Bank, Global Fund and a few non-state actors who are presently part of the global health governance mechanism. Again each organisation that Youde discusses is done quite thoroughly and here Youde does factor in the influence of the political economy context, especially in the discussion of the WHO. Youde tells us that over time WHO does evolve into a strong organisation and the Alma Ata Declaration forms a key watershed of its strength as a global organisation addressing global health challenges as well as supporting public health issues within countries, especially the developing world. It reaches its peak under the leadership of Halfdan Mahler with Health for All as the epitome of its success – what Youde calls the activist orientation phase of WHO which promoted health equity.
This phase of WHO demonstrated that global health governance is feasible – there was a political leadership under Mahler and its finances were quite robust. Youde acknowledges this but does not go far enough to say that this in itself posed a threat to global capitalism which in the health sector operates primarily through the pharmaceutical industry. After Mahler, the next director general of WHO, Hiroshi Nakajima, was indeed, a pharmaceutical man (who had earlier worked for Roche in Japan), who changed the trajectory of WHO setting it on a path of destruction. This changed political economy destroyed WHO and opened up the arena for new players in the global health governance arena led by the World Bank.
WHO under Nakajima
The fact that the World Bank entered the scenario, not only undermined WHO, which under the two terms of Nakajima’s leadership (incidentally Nakajima died recently on 26 January 2013 and the world over obituaries focused on how under his leadership WHO became fragmented and deteriorated as an organisation) was considerably weakened through under-financing of the core budget – a clear shift of resources of WHO from the dominance of its regular budget that member countries contribute to a dominance of programme – and project-based budgets that donors contribute and then dictate the agenda.
Youde has captured this quite well. This budget shift also began the process of fragmentation of WHO’s strategy into dealing with global health challenges as vertical programmes. The latter was already happening with public health programmes across most developing countries and this clearly moved the agenda from Health for All, a universal access approach, to a selective and fragmented approach to deal vertically with specific diseases and health issues like polio, malaria, immunisation, tobacco control, and later HIV/AIDS and reproductive and child health (RCH). This shift has been largely under the leadership of the World Bank,4 Global Fund and various private players like Gates, Ford and Clinton Foundations, among others, as also various bilaterals like the United States Agency for International Development (USAID) and Department for International Development (DFID).
Fragmenting Global Health
Youde has again documented very well the roles of the World Bank, UNAIDS, the Global Fund and the Clinton and Gates Foundations in supporting this new trajectory in global health governance where the control shifted from nation state controlled-WHO to these other so-called “non-political” players. It is precisely the change in politics of health that changed the lead players in global health governance and Youde acknowledges this by quoting Nuruzzaman5 – the World Bank’s strategy as a change from understanding health as a fundamental right to a conception of health as a private market-based good. This, in turn, changed the political economy of global health governance. User fees, public-private partnerships, privatisation, outsourcing, health insurance, etc, are some of the strategic changes that the structural adjustment policies of the World Bank brought to global health governance. WHO, unfortunately now follows this along with most other key players in global health, and primarily because WHO’s budget is predominated by donor contributions who call the shots.
Youde explains that UNAIDS actually emerged out of a conflict situation within the WHO, whose Global Program on AIDS (GPA) was headed by Jonathan Mann, who was a great fundraiser and helped raise the profile of HIV/AIDS globally that attracted huge funding and this created strong jealousies and disagreements with the leadership of WHO under Nakajima forcing Mann to quit, and subsequently, the GPA was transformed into an independent agency of the United Nations (UN) christened as UNAIDS under the leadership of Mann’s assistant Peter Piot. Since UNAIDS focused on providing technical and informational support, another agency to play the funding support role called the Global Fund to Fight AIDS, tuberculosis and malaria was created. This maintained the continuum of fragmenting global health governance and reducing the importance and strength of the WHO.
Youde describes all this very illustratively. One question comes to mind when reading Youde’s discussion of these institutions: What was the underlying reason of setting up these institutions and moving it out of WHO’s control? Was it the new patents regime and the need to facilitate pharmaceutical industry’s profit-making by keeping the control of governance of global health outside the nation state-controlled WHO? And a related question – despite having strong oversight mechanisms in the Global Fund, why has there never been an audit of pharmaceutical purchases by the Global Fund?
The private actors discussed by Youde, Gates and Clinton Foundations, basically fell in line with the World Bank strategy and supported the need to raise substantially the involvement of non-state actors in global health governance. Both these institutions also helped raise further the HIV/AIDS profile globally with more resources being committed to it and also advocated for a more market-oriented approach, for instance, in the procurement of antiretroviral (ARV) medicines. In reality what they were doing is trying to address market failures in health so that the larger health system can be made more market-oriented.
The chapter on civil society organisations (CSOs) focuses on the role that CSOs have played in global health, primarily representing the interests of the common people, as Youde puts it – as voices for the voiceless. Youde illustrates this with the examples of OXFAM International and the Treatment Action Campaign from South Africa.
In the last section Youde goes back to the key issues around which he has built his discussion on global health governance – surveillance of infectious diseases, framing health security and access to pharmaceuticals, mainly ARVs. The first two issues revolve around global regulation of communicable diseases and the response of the international community and how the global health governance mechanisms discussed above have at best been able to engage in firefighting. In the case of access to pharmaceuticals, the access to ARV campaign is viewed as one that could possibly lay the basis for a larger campaign for access to free medicines – regarding medicines and public goods. The Twelfth Five-Year Plan in India, based on the experiences of Tamil Nadu and Rajasthan, is promising access to free medicines in all public health institutions. Will this become a stepping stone towards universal access to healthcare and take us back to the Health for All intiative?
Youde concludes by saying that global health governance has evolved from being a technical issue addressing mechanism until the 1970s to a more rights- and equity-based phase during the 1970s and 1980s, when WHO was in control and since then has entered its neo-liberal phase under the tutelage of the World Bank and various non-state actors, though in recent years, there is a clear effort with pressure from civil society to bring back the Health for All agenda under universal access to healthcare. But this would cost money, conservatively at least 5% of gross domestic product (GDP). Is there the political will of the G-8 or G-20 or other G’s to muster these resources by putting the burden on capitalism by imposing the Tobin tax or financial transaction tax, for instance, which can rein in huge resources in this era of finance capital, and of course, we do not want to forget the old Rio commitment of developed nations to contribute their 0.72% GDP for the global development agenda. The shaping of the post-2015 development agenda goals needs to emphasise this very strongly.
To conclude, Youde’s book is a very good documentation of how global health governance has evolved in the last 150 years or so but it is limited in its conclusions because Youde opted to use the lens of communicable diseases. Today, as Youde acknowledges in his conclusions, non-communicable diseases are much larger global health challenges, but governance issues for these would be very different from what he has discussed in the present book. To deal with these we will have to steep much deeper into issues governing global political economy.
1 Kumar (2005) 38-53 also see website http: //indiagovernance.gov. in Rao (2013).
2 See for example: Demmers et al (2004); see alsohttp://www.ohchr.org/EN/Issues/Development/GoodGovernance/Pages/Good-Gov… accessed 25 March 2013.
3 Julio Frenk and Suerie Moon, “Governance Challenges in Global Health”, NEJM, 368: 10, 7 March 2013, pp 936-42.
4 See the 1993 World Development Report – Investing in Health, OUP, New York, which became the Bible of this new approach to healthcare.
5 Quoted by Youde from Nuruzzaman, Mohammad (2007).
Demmers, Jolle, Alex E Fernández Jilberto and Barbara Hogenboom, ed. (2004): Good Governance in the Era of Global Neoliberalism: Conflict and Depolitisation in Latin America, Eastern Europe, Asia and Africa (London: Routledge).
Frenk, Julio and Suerie Moon (2013): “Governance Challenges in Global Health”, The NewEngland Journal of Medicine(NEJM), 368: 10, 7 March, pp 936-42.
Kumar, G Narendra (2005): “An Institutional Framework for Good Governance in India”, ASCI, Journal of Management,34(1&2), Administrative Staff College of India, Hyderabad, available at http://journal.asci.org.in/Vol 34 (2005)/04.% 20G N.%20Kumar.pdf accessed on 25 March 2013.
Nuruzzaman, Mohammad (2007): “The World Bank, Health Policy Reforms and the Poor”, Journal of Contemporary Asia, 37(1), pp 59-72.
Rao, N Bhaskara Rao (2013): Good Governance – Delivering Corruption-free Public Services, (New Delhi: Sage).
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