Global health governance is a relatively new area for global governance. Its rise to prominence has been driven the growing economic and political globalization, but also by shared challenges – climate change, global crises and the spread of Western consumption habits and urbanized lifestyles. Global health governance refers to “the use of formal and informal institutions, rules, and processes by states, intergovernmental organizations, and non-state actors to deal with health challenges that require cross-border collective action” (Fidler 2010). Global health policies encompass a wide range of issues: the incapacity of the international community to effectively deal with epidemics and pandemics (e.g. A (H1N1) 2009); HIV/AIDS prevention; antimicrobial resistance; counterfeit drugs; the global prevalence of non-communicable diseases related to tobacco consumption and obesity; the migration of health workers from developing to developed countries; and the deterioration in the social determinants of health. The efforts to address these and other global health problems often end up revealing that existing institutions, rules, and processes are insufficient to meet these global health problems.
The intensified transfer of health risk factors across borders means that domestic action is no longer sufficient to deal with outbreaks of both infectious and non-communicable diseases. The global health system today is composed of a group of actors whose primary intent is to improve health, along with the rules and norms governing the interactions of both. In the context of deepening health interdependence, it becomes more urgent and yet more difficult for countries to agree on their respective rights and responsibilities. This difficulty hampers effective responses to common health threats.
The challenge of achieving “good” global health governance (e.g. effective, equitable and efficient in achieving outcomes) among the diverse groups of actors has drawn increased political attention. The only way to address these challenges in a meaningful and effective way is through greater international cooperation, which may require that health become a major sustained issue for global governance in a forum such as the G20.
The State of the World’s Health
The adoption of the Millennium Development Goals (MDGs) in the year 2000 by 193 United Nations member states put health at the top of the global development agenda. Three of these goals are directly concerned with health—MDG 4, reducing child mortality; MDG 5, reducing maternal mortality; and MDG 6, controlling HIV/AIDS and other infectious diseases — and the others relate to key social determinants of health.
Significant progress has been made towards MDG 6. The annual number of new HIV infections fell from 3.2 million in 2001 to 2.5 million in 2011, there has been a 24% decline in AIDS-related mortality since 2005, malaria incidence rates have fallen by 17% since 2000, and the 1990 death rate from tuberculosis is on track to be halved by 2015 (UNAIDS 2012). The progress in tackling the “big three” infectious disease has been coupled with a decline in deaths from other infectious diseases from 1990 to 2010 (Health Metrics and Evaluation 2010). Nevertheless, there will still be a major global burden of infectious diseases in the post 2015 era.
Similarly, UN estimates show that although progress has been made towards MDGs 4 and 5, the rates of decline in child and maternal mortality remain too slow to reach the 2015 MDG targets (UN 2012).
The MDGs did not address the “emerging agenda” of non-communicable diseases (NCDs), which are responsible for two thirds of all deaths globally (WHO). Recently, there has been a catastrophic rise in deaths from cardiovascular disease, cancers, diabetes, and chronic respiratory illnesses in low- and middle-income countries (WHO 2011). The increase in NDC incidence is related to populations living longer and to increased exposure to NCD risk factors, particularly smoking, alcohol, sedentary lifestyles, and the consumption of highly processed foods (WHO 2011). The emerging agenda also involves global preparedness for future shocks, such as a new pandemic, the global rise of antibiotic resistance, and the risks posed by nuclear, biological, and chemical weapons.
One of the most striking features about the state of global health is that it is characterized by drastic inequities. Health inequity can be broadly defined as the “unjust distribution of the socially controllable factors affecting population health and its distribution” (Daniels 2008). There are deep inequities between and within countries in the structural determinants of health, particularly education and income. Inequities are also amplified by the crises of globalization, including financial instability, global warming, environmental and ecological degradation, food insecurity, and mass migration (McMichael 2013). Today, there is a 36-year gap in life expectancy between countries. A child born in Malawi can expect to live for only 47 years while a child born in Japan could live for as long as 83 years (WHO 2012). And within countries, the differences in life chances are dramatic and are seen worldwide (WHO 2008).
Efforts at the World Health Organisation
The World Health Organisation (WHO) has taken up a central role in the emerging global health architecture. The organization has made considerable efforts to overcome some of the key hurdles to the achievement of equitable global health through its work on the social determinants of health and health-related economic issues.
In 2005, WHO established the Commission on Social Determinants of Health (CSDH), on the premise that action on the social determinants of health is the fairest and most effective way to improve health for all people and reduce inequality. Social determinants of health (SDH), broadly stated, are “the conditions in which people live and work that affect their opportunities to lead healthy lives” (Labronte & Shrecker 2007). Ethical questions of fairness, distributive justice and moral responsibility are inherent to the SDH approach. By adopting this approach, the WHO emphasizes that global health governance should be concerned not only with states and sovereignty, but also with generating sufficient resources and their equitable distribution.
The WHO collaborates with the World Trade Organization (WTO) and other international organization involved in trade to develop policies on international trade and health that are reciprocally coherent and that maximize the health benefits and minimize the risks, especially for the poor and vulnerable populations.
Central to WHO’s effort towards achieving health and trade policy coherence is its work related to WTO’s copyright pharmaceutical arrangements (TRIPS) that require all members of the WTO to grant twenty-year product patents, which effectively make new medicines unaffordable for some. The WHO has committed to assist countries in implementing the 2005 TRIPS amendment, which provides additional flexibilities so as to facilitate access to medicines under TRIPS (WTO 2005).
Despite WHO’s efforts, the organization has been criticized for its inadequacy in addressing the major health challenges and crises of a rapidly globalizing post-Cold War, post-9/11 world. Most notably, WHO has received widespread criticism both from within the organization itself and from the larger international community for its failure to control the rapid spread of HIV/AIDS.
Global Health at the G8
In response to the WHO’s perceived inadequacies, the Group of Eight (G8) major market democracies, created in 1975, gradually developed health as a regular emphasis. At first the G8 worked to support the WHO and broader United Nations (UN) system in raising the money they needed but were unable to attract on their own.
In 2000 in Okinawa, this process culminated in the creation of the Global Fund to Fight AIDS, Malaria and Tuberculosis. Since then global health has become a crucial topic for discussion at the G8.
The creation of the Global Fund shows that the G8 summits can have a significant impact on global health governance. In sharp contrast to the limited capacity and poor performance of the old multilateral organizations, the G8 countries possessed the overall and specialized capabilities required to combat the new diseases, and share these among G8 members in a way that enables and requires all to contribute in a materially meaningful way.
Despite the G8’s relative success with the Global Fund, it has failed to address the huge gaps in healthcare funding that exist in developing countries, although it possesses the capacity to do so. While the G8 has managed to pledge large sums of financial resources for health, the G8 has failed to fulfill most of its promises such as those made in Gleneagles in 2005 to increase development assistance by $50 billion from $80 billion in 2004 to nearly $130 billion by 2010 (Garrett & Alavian 2010). The failure of some nations to fulfill their annual promises has undermined the credibility of the G8, which made reaching internal consensus an even more difficult process.
Many have also been critical of the G8’s model which rests on the changing priorities of an elite club of rich nations that excludes both non-state organizations and the majority of those nations that face the most serious health and disease threats (Duten 2010).
The G20: an Opportunity for Global Health
The 2008 financial crisis led to a colossal shift in global wealth. This shift in power over global wealth has marked the beginning of a major change in governance from a G8 to G20 dominated world. In contrast with the G8, global health governance has never been directly addressed at the G20.
Nonetheless, introducing global health governance as a priority topic for the G20 could provide an invaluable opportunity to effectively address global health governance challenges.
First, “twenty representatives of states from around the world is likely to produce a healthy balance of perspectives on any given health issue” (Cooper 2013). More inclusive than the G8, the G20 could more easily coordinate and fund raise for global health efforts precisely because it can effectively pool state resources. It can also keep global health firmly on the high-level political agenda.
In addition, the G20 can play a transformative role in global health policy-making. The forum can facilitate the shift from classic models of charity that have characterized G8 financial aid to collective action, sustainable development, and greater accountability and transparency (Chandy, Gertz, & Dervis 2010).
Given the lack of interest shown by the G20 so far, how optimistic can we be about the G20’s future impact on global health? Although the G20 has a tremendous potential to aid the achievement of effective global health governance, this can only happen provided that the existing hurdles to effective cooperation of G20 countries are overcome.
First, major players of the G20, including China, India and South Africa still rely on foreign assistance for their domestic HIV and other disease-specific programs. These rapidly-growing economies are undoubtedly heading towards complete donor independence and may one day embrace the responsibility of global donors. Nevertheless, at the time of this transition, many of the G20 nations play the poverty card when it suits them, even as they demand greater power. Therefore, the challenge is to aid the full transition of all G20 nations towards self-sufficiency.
Second, global health leaders must find solutions to trade and intellectual property issues that augment mistrust between the emerging and traditional wealth worlds.
In the post-2015 era, the global health community will still be tackling an “unfinished agenda” of avertable infectious, reproductive, maternal, newborn and child deaths in high mortality settings. The MDG review also highlighted a dangerous lack of coordination and the absence of a coherent systemic approach to health and development issues. Given the need to strike a balance between tackling urgent health threats and reinforcing health systems in general, it is important to ask how global health should be steered in order to most effectively address the wide range of health-related problems in the international arena.
Considering WHO’s poor performance in the face of the rapidly expanding global vulnerability from the new diseases, it is unlikely that the organization will be able to deal with the rising challenge of NCDs. The G8 also suffers from weaknesses associated with its low representation, the failure to fulfill its promises and to secure financial flows to health in developing countries.
Against the background of the failings of the WHO and the G8, embedding global health as a priority for the G20 by creating demand for global health issues on its agenda is a unique opportunity that would allow for redefinition and elevation of the sense of urgency with which we deal with global health. The G20 could offer both a more legitimate forum for debate and the possibility of gaining access to sustainable financial resources.
Chandy, Laurence, Gertz, Geoffrey , and Dervis, Kemal, ‘Institutional Development: How the G-20 May Help the World’s Poor.’ Brookings Institution, March 15, 2010, At: http://www.brookings.edu/opinions/2010/0315_g20_poverty_dervis.aspx.
Cooper, A. F. Cooper, ‘The G8/G20 and Global Health Governance: Extended Fragmentation,’ in Ilona Kickbusch, Graham Lister, Michaela Todd, Nick Drager (ed.), Global Health Diplomacy: Concepts, Issues, Actors, Fora and Cases (London: Springer, 2013), p. 247.
Daniels, Norman, Just health: Meeting health needs fairly (Cambridge, UK: Cambridge University Press, 2008), p. 101.
Duten, Alexia (2010), ‘Global Helath – G20 to the Rescue’ (2010, ISN, Zurich), p. 2.
Fidler, David P., The Challenges of Global Health Governance, Working Paper, (New York: Council of Foreign Relations, 2010), p.3
Garrett, Laurie and Alavian, El’Haum, ‘Global Health Governance in a G-20World,’ Global Health Governance, 4(1) (2010), p.3.
Health Metrics and Evaluation, Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010), At: http://www.healthmetricsandevaluation.org/gbd/publications/policy-report…
Labronté, R. and Shrecker, T. Schrecker, ‘Globalization and Social Determinants of Health: Introduction and Methodological Background’, Globalization and Health, 3 (5) (2007), p.2.
McMichael, AJ, ‘Globalization, climate change, and human health’, New England Journal of Medicine, 368 (2013), pp. 1335-1343
UN Maternal Mortality Estimation Inter-agency Group, ‘Trends in Maternal Mortality 1990 to 2010: WHO, UNICEF, UNFPA, and the World Bank Estimates’, (Geneva: WHO, 2012).
UNAIDS, ‘Global report: UNAIDS report on the global AIDS epidemic 2012’, (Geneva: UNAIDS, 2012).http://www.unaids.org/en/media/unaids/contentassets/documents/epidemiolo….
United Nations Inter-agency Group for Child Mortality Estimation. ‘Levels and Trends in Child Mortality Report 2012’, (New York: UNICEF, 2012).
United Nations, ‘Millennium Development Goals Report 2012’, (New York: United Nations, 2012)
World Health Organisation (2008), ‘Closing the Gap in a Generation: Health equity through action on the social determinants of health’, At:http://www.who.int/social_determinants/final_report/csdh_finalreport_200…
World Health Organisation, ‘Global status report on noncommunicable diseases 2010’, (Geneva, Switzerland: WHO, 2011), At www.who.int/nmh/publications/ncd_report_full_en.pdf
World Health Organisation, The Top 10 Causes of Death, http://www.who.int/mediacentre/factsheets/fs310/en/index2.html
World Health Organisation, World Conference on Social Determinants of Health (2012), At: http://www.who.int/sdhconference/background/news/facts/en/
World Trade Organisation (2005), ‘How to accept the Protocol Amending the TRIPS Agreement’, At: http://www.wto.org/english/tratop_e/trips_e/accept_e.htm