WHO, NCDs and GHG – Governing global health in the 21st century

The entire milieu of global health has been abuzz for nearly two decades; abuzz with funding, ideas, focus, networks, actors, initiatives, successes, failures and opportunities. More than any other issue area, public health has attained a level of globality not seen or witnessed in other areas like climate, trade, and agriculture. The sheer cacophony of actors and institutions make the realm a dynamic albeit disparate one littered with myriad gaps and deficits. Interests and ideas on how to tackle pressing mainstream health challenges abound; indeed, even what those challenges are under heavy scrutiny and contestation.  Debates about the sheer nature and constitution of global health are in vogue. Should it revolve around a conception that is pivoted within ‘politics’ or one that is imbued with a governance tenor; or in other words, global health governance or global health politics? The choice or the presence of one or the other might be a false sequitur; governance cannot be understood without a robust grounding in politics despite ongoing attempts to do so and politics of health often manifests through governance choices. How should global health be conceptualised? Do mainstream epistemic approaches privilege and foreordain and exchange between east and west, north and south? Or is it as often perceived and exercised a one way flow of ideas, capital and action from the core to the periphery? This question is important given that the eventual framing has a tremendous impact on the knowledge generated and actions prescribed. And what about the principal epidemiological challenges that need to be addressed, largely and disconcertingly bifurcated alongside the communicable (Malaria, HIV/AIDS, TB) and non-communicable (Cancer, Heart disease, Diabetes) divide? And the institutions that exist to address these challenges – Can the WHO withstand the dynamic non-state actor assault over the recent past as we tread ahead? Should they reform and give more voice to actors and groups from the private and civil realms? How should governments and donors fashion their relationship with the WHO given its rather perceptive and conspicuous defects and its inability to surmount them? Can emerging powers devise a new accord with the central international health authority independent of its relationship with established powers? How should development assistance for health (DAH) be structured for a landscape that is characterized by ‘unstructured plurality’ and ‘regime complexity’? Needless to say, questions surrounding the efficacy of global health dominate and the need to institute reforms such that it can deliver is perhaps more urgent than ever given how complex governance of health at all levels have become and the range of health concerns that need to tackled. A series of recent articles on the state of global health and its challenges and opportunities touch upon all these critical issues enabling us to take stock of the international health climate, make judgments on the nature of extant debates, appraise the efficacy of existing governance arrangements to deftly address pressing challenges, and make sense of what we need to do going ahead.

Julio Frenk and Suerie Moon pen a recent article on the nature of ‘global health governance’ expending much-needed time to distill just how we should conceptualize global health for an era fraught with plurality, diversity and complexity. As they claim, despite billions of dollars being spent, consensus on the definition of the term is rather elusive. And here they argue that global health should be reconceptualized as ‘health of the global population,’ since it would enable us to shed conceptual boundaries that demarcate the discipline as derivative from the west given its intellectual lineages. Doing so, they argue, would enable health to be considered more broadly, not just within the incumbent challenges but also in conjunction with other issues like trade, agriculture, environment, which has a tremendous bearing and effect on healthy outcomes across the world. What they hope to dispel and arguably inter is the rather paternalistic attitude common within disciplinary and practitioner circles which (implicitly) posits that the developing countries are the dominant and pervasive sources of global health issues which the developed world hopes to check through its largesse. Frenk and Moon instead call for a levelling where all actors, north and south, exist and operate within the same plateau, working to and alongside each other to address issues. Thus, the field must move beyond legacies that consign more than half the world’s population as threats and the other half as saviours. Global health should rest on pillars of interdependence and not dependence alone. Also, they hope to inspire a sense of solidarity that can be channelled through to existing programs and ideas, giving voice and ostensibly authority for all global citizens to engage and contribute to the achievement of a ‘global society.’ Some of their rhetoric is rather fluffy and moralising but the desire is sincere.

But this piece is a surprise given that their article from 2012 does not give us a sense that their prevailing conceptualization would shift so quickly, at least the core understanding of what the discipline is. Last year, Frenk and Moon in the NEJM provide a thorough overview of the existing global health governance landscape, the plural nature of its being, its principal challenges, chief functions before gathering thoughts on policy implications. Here, they focus on the governance aspect or why the importance of a responsive and responsible institutional architecture is critical given the fluid amorphous and disparate nature of global health activities across the world; as they enumerate, there currently are about 175 different initiatives, donors, funds and agencies that dot the global health landscape. Settling on viewing the paradigm as ‘global governance for health’ instead of GHG, they call for an emphasis that focuses attention on health through other areas that affect it – trade, environment, energy, etc. By doing so, they argue that ‘good’ global governance for health can only arise when three components: effectiveness, equity and efficiency, credibility and legitimacy. But achieving these goals are difficult due to structural factors that impede effective management of issues that pivot around these three challenges. Due to concerns of sovereignty, accountability and multi-sectoral character of global health challenges, they claim that generating and effecting adequate governance for global health will a complex and difficult endeavour.

Given these obstacles, can we achieve ‘healthy’ governance at the global level? No doubt, these issues are heavily contentious, especially when begin to grapple with the plurality of the landscape and the related weakening of extant authorities, the WHO, chiefly. Sridhar et al argue that to facilitate healthy governance, we really need to direct attention back towards the central authority on global health – World Health Organization, despite its beleaguered recent past that has been rather ignominious. Sridhar et al list some of its recent failures, including the rather tepid treatment towards elevating NCD’s as a cause worthy of global attention following the specially convened UNGA in 2011. The key problem is politics. WHO has lost most of its core political support with its significant donors, who are either investing more authority and funding to its budding rivals – GFATM and GAVI or by reallocating their existing monies to discretionary purposes, in turn, distorting the multilateral process at hand. Another problem is that the organization is not adeptly structure to tackle NCD’s going ahead given you need to be able to do two important things to make a dent – acquire government buy-in since the nature of these diseases require an approach that is far-sighted and secondly, multi-sectoral, bringing in actors from the private sector and other domestic government counterparts – like Finance and Trade, who are arguably more critical in curbing the spread of chronic diseases. However unlikely that prospect may be, another problem is funding, when the organization is struggling to raise resources to fund their basic existence, it might be too much to ask them to direct their focuses exclusively and lead the effort to mitigate health challenges that are not only truly global but also globally domestic, in that they require the efforts and leadership of other domestic actors within countries that have global concerns.

Let us consider the NCD’s issue further. One of the most contentious fault lines in global health politics is the ongoing tussle between expending more time, energy and resources on non-communicable diseases – cardio-vascular diseases, cancer and diabetes, chiefly. Lack of funding to combat these three challenges have been a lingering grievance for  global health hands who await for the scales to be tilted in their favor. Sridhar et al. analyze the implications of recent shifts in global governance on NCDs. The authors identify three trends as critical – rise of emerging powers, rise and fall of multi-bi financing, and institutional proliferation. At the backdrop of these developments, they argue that NCDs will find it hard to acquire funding given the institutional tilt towards communicable diseases being cemented through discretionary bilateral financing that are earmarked for specific (predominantly CDs) purposes that are also transforming multilateral health cooperation as explored here earlier. The rise of emerging powers will not have a commensurate impact on NCD’s since most of these countries have limited interactions with the global health system, opting to fashion their engagement through an economic or trade lens. And finally, institutional proliferation in global governance characterized by a litany of actors and networks and a mix of them is not bound to have a serious effect in bringing NCDs onto global agenda since most of the emergent health campaigns are one-dimensional or narrow in conception (ie. GAVI or GFATM) and second, NCDs are inherently multi-dimensional, especially their sources, which obviates effective consideration since coordination is a pre-requisite for any worthy dialogue to commence. Though the authors identify important global trends affecting collective action in important areas like health, they fall short of discussing some of the reasons underpinning lukewarm involvement of emerging powers in global health.

Thomas Bollyky frames the NCD issue as one that can and should be managed with more robust American leadership. Sidestepping the role of international networks, WHO, regional bodies and emerging powers in combating and reversing the NCD tide, Bollyky places more premium on Washington given its propensity to muster and implement similar global health campaigns, notably PEPFAR and others that tackle maternal mortality, which emerged and burgeoned under the G7. But here, Bollyky avers too much. Tackling this issue at the global level in near impossible given its multifaceted character and the diversity of vested interests that depend on changes not taking place. Washington cannot dictate regulatory changes to be instituted on this matter across the world; even NCD mainstreaming within America’s global health diplomacy is bound to fall short given that changes in this realm need to occur across different sectors within developing countries from trade to finance and environment. But one aspect where the US can lead is to prod and empower the WHO to lead on this issue, with support from its regional fiefs, given its unique institutional perquisites – agenda and norm setting and the promulgation of international health law. Despite the rather diffuse and disparate nature of the WHO’s structure, it does have the convening power to marshal a range of different actors, public and private, to the table and engage in the conversation and this is one that we urgently need before NCD’s and its attendant costs further destabilize economies of the developing world. But we must remember that good governance for human health will fundamentally rest on good public health governance at the national level and the changes instituted within independent of developments at the global level despite its capacity to facilitate that process.

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