Dodgson R, Lee K, Drager N. (2002) Governance for global health: A conceptual review.

GLOBAL HEALTH GOVERNANCE, A CONCEPTUAL REVIEW

The solution lies not in turning one’s back on globalization, but in

learning how to manage it. In other words, there is a crying need

for better global governance…

UN Deputy Secretary-General Louise Frechette (1998)

…global governance cannot replace the need for good governance

in national societies; in fact, in the absence of quality local

governance, global and regional arrangements are bound to fail or

will have only limited effectiveness. In a way, governance has to

be built from the ground up and then linked back to the local

conditions.

R. Vayrynen, Globalization and Global Governance (1999)

1.1 INTRODUCTION

In today’s world of changing health risks and opportunities, the capacity to

influence health determinants, status and outcomes cannot be assured

through national actions alone because of the intensification of crossborder

and transborder flows of people, goods and services, and ideas. The need for

more effective collective action by governments, business and civil society to

better manage these risks and opportunities is leading us to reassess the rules

and institutions that govern health policy and practice at the subnational,

national, regional and global levels. This is particularly so as a range of health

determinants are increasingly affected by factors outside of the health sector –

trade and investment flows, collective violence and conflict, illicit and criminal

activity, environmental change and communication technologies. There is an

acute need to broaden the public health agenda to take account of these

globalizing forces, and to ensure that the protection and promotion of human

health is placed higher on other policy agendas (McMichael and Beaglehole

2000). There is a widespread belief that the current system of international

health governance (IHG) does not sufficiently meet these needs and, indeed,

has a number of limitations and gaps. In light of these perceived

shortcomings, the concept of global health governance (GHG) has become a

subject of interest and debate in the field of international health.

This paper seeks to contribute to this emerging discussion by reviewing the

conceptual meaning and defining features of GHG.

This paper begins with a

brief discussion of why GHG has become such a subject of discussion and

debate. The particular impacts that globalization may be having on

individuals and societies, and the fundamental challenges that this poses for

promoting and protecting health, are explained. This is followed by a review of

the history of IHG and, in particular, the traditional role of the World Health

Organization (WHO). The purpose of this brief section is to draw out the

distinction between international and global health governance, and the

degree to which there is presently, and should be, a shift to the latter.

This is

achieved by defining, in turn, the terms global health and governance from

which the essential elements of GHG can be identified. This leads to an

A more detailed analysis of the institutional forms and mechanisms of international and global health

governance is provided in Fidler D. (2002), “Global Health Governance: Overview of the role of

international law in protecting and promoting global public health,” Discussion Paper No.3.

A more detailed analysis of the historical dimensions of global health governance is provided in

Loughlin K. and Berridge V. (2002), Historical Dimensions of Global Health Governance, Discussion

Paper No.2.
6

identification of key challenges faced by the health community in bringing

about such a system in future. The paper concludes with suggestions on how

the key types of actors and their respective roles in GHG might be defined

further.

1.2 HEALTH GOVERNANCE: THE CHALLENGE OF GLOBALIZATION

In broad terms, governance can be defined as the actions and means adopted

by a society to promote collective action and deliver collective solutions in

pursuit of common goals. This a broad term that is encompassing of the

many ways in which human beings, as individuals and groups, organize

themselves to achieve agreed goals. Such organization requires agreement on

a range of matters including membership within the co-operative relationship,

obligations and responsibilities of members, the making of decisions, means of

communication, resource mobilisation and distribution, dispute settlement,

and formal or informal rules and procedures concerning all of these. Defined

in this way, governance pertains to highly varied sorts of collective behaviour

ranging from local community groups to transnational corporations, from

labour unions to the UN Security Council. Governance thus relates to both

the public and private sphere of human activity, and sometimes a combination

of the two.

Importantly, governance is distinct from government. As Rosenau (1990)

writes,

Governance is not synonymous with government. Both refer to

purposive behaviour, to goal oriented activities, to systems of rule;

but government suggests activities that are backed by formal

authority…whereas governance refers to activities backed by

shared goals that may or may not derive from legal and formally

prescribed responsibilities and that do not necessarily rely on

police powers to overcome defiance and attain compliance.

Government, in other words, is a particular and highly formalised form of

governance. Where governance is institutionalised within an agreed set of

rules and procedures, regular or irregular meeting of relevant parties, or a

permanent organizational structure with appropriate decision making and

implementing bodies, we can describe these as the means or mechanisms of

governance (Finkelstein 1995), of which government is one form. In other

cases, however, governance may rely on informal mechanisms (e.g. custom,

common law, cultural norms and values) that are not formalised into explicit

rules.

Health governance concerns the actions and means adopted by a society to

organize itself in the promotion and protection of the health of its population.

The rules defining such organization, and its functioning, can again be formal

(e.g. Public Health Act, International Health Regulations) or informal (e.g.

Hippocratic oath) to prescribe and proscribe behaviour. The governance

mechanism, in turn, can be situated at the local/subnational (e.g. district

health authority), national (e.g. Ministry of Health), regional (e.g. Pan American

Health Organization), international (e.g. World Health Organization) and, as

argued in Section 1.5, the global level. Furthermore, health governance can be

public (e.g. national health service), private (e.g. International Federation of

Pharmaceutical Manufacturers Association), or a combination of the two (e.g.

Malaria for Medicines Venture).

Historically, the locus of health governance has been at the national and

subnational level as governments of individual countries have assumed

primary responsibility for the health of their domestic populations. Their

authority and responsibility, in turn, has been delegated/distributed to

regional/district/local levels. Where the determinants of health have spilled

over national borders to become international (transborder) health issues (e.g.

infectious diseases) two or more governments have sought to cooperate

together on agreed collective actions. This is discussed in Section 1.3.

Growing discussions of the need to strengthen health governance at national,

regional, international and, more recently, the global level has, in part, been

driven by a concern that a range of globalizing forces (e.g. technological

change, increased capital flows, intensifying population mobility) are creating

impacts on health that existing forms of governance cannot effectively address.

This has led to debates about, for example, the appropriate balance among

different levels of governance, what roles public and private actors should

play, and what institutional rules and structures are needed to protect and

promote human health.

This paper sees globalization as an historical process characterised by

changes in the nature of human interaction across a range of social spheres

including the economic, political, technological, cultural and environmental.

These changes are globalizing in the sense that boundaries hitherto separating

us from each other are being transformed. These boundaries – spatial,

temporal and cognitive - can be described as the dimensions of globalization.

Briefly, the spatial dimension concerns changes to how we perceive and

experience physical space or geographical territory. The temporal dimension

concerns changes to how we perceive and experience time. The cognitive

dimension concerns changes to how we think about ourselves and the world

around us (Lee 2000b).

Many argue that globalization is reducing the capacity of states to provide for

the health of their domestic populations and, by extension, intergovernmental

health cooperation is also limited. The impact of globalization upon the

capacity of states and other actors to co-operate internationally to protect

human health is fourfold. First, globalization has introduced or intensified

transborder health risks defined as risks to human health that transcend

national borders in their origin or impact (Lee 2000a). Such risks may include

emerging and reemerging infectious diseases, various noncommunicable

diseases (e.g. lung cancer, obesity, hypertension) and environmental

degradation (e.g. global climate change). The growth in the geographical scope

and speed in which transborder health risks present themselves directly

challenge the existing system of IHG that is defined by national borders. The

mechanisms of IHG, in other words, may be constrained by its statecentric

nature to tackle global health effectively (Zacher 1999b).

Second, as described above, globalization is characterised by a growth in the

number, and degree of influence, of nonstate actors in health governance.

Many argue that the relative authority and capacity of national governments to

protect and promote the health of domestic populations has declined in the

face of globalizing forces beyond national borders that affect the basic

determinants of health as well as erode national resources for addressing their

consequences (Deacon et al. 1997). Nonstate actors, including civil society

groups, global social movements, private companies, consultancy firms, think

tanks, religious movements and organized crime, in turn, have gained

relatively greater power and influence both formally and informally.

The

The emerging and potential role of civil society and private sector in global health governance are

discussed in Discussion Paper Nos. 4 and 5.

emerging picture is becoming more complex, with the distinct roles of state

and nonstate actors in governance activities such as agenda setting, resource

mobilisation and allocation, and dispute settlement becoming less clear. New

combinations of both state and nonstate actors are rapidly forming, in a

myriad of forms such as partnerships, alliances, coalitions, networks and joint

ventures. This apparent “hybridisation” of governance mechanisms around

certain health issues is a reflection of the search for more effective ways of

cooperation to promote health in the face of new institutions. At the same

time, however, it throws up new challenges for creating appropriate and

recognised institutional mechanisms for, inter alia, ensuring appropriate

representation, participation, accountability and transparency.

Third, current forms of globalization appear to be problematic for sustaining,

and even worsening existing socioeconomic, political and environmental

problems. UNDP (1999), for example, reports that neoliberal forms of

globalization have been accompanied by widening inequalities between rich

and poor within and across countries. In a special issue of Development

authors cite experiences of worsening poverty, marginalisation and health

inequity as a consequence of globalization. In some respects, these problems

can be seen as “externalities” or “global public bads” (Kaul et al. 1999) that are

arising as a result of globalizing processes that are insufficiently managed by

effective health governance. As Fidler (1998a) writes, these deeply rooted

problems “feed off” the negative consequences of the globalization of health,

creating a reciprocal relationship between health and the determinants of

health. Although many of these problems are most acute in the developing

world, they are of concern to all countries given their transborder nature (i.e.

unconfined to national borders).

Fourth, globalization has contributed to a decline in both the political and

practical capacity (see reading) of the national governments, acting alone or in

cooperation with other states, to deal with global health challenges. While

globalization is a set of changes occurring gradually over several centuries, its

acceleration and intensification from the late twentieth century has brought

attention to the fact that states alone cannot address many of the health

challenges arising. Infectious diseases are perhaps the most prominent

example of this diminishing capacity, but equally significant are the impacts

on noncommunicable diseases (e.g. tobacco-related cancers), food and

nutrition, lifestyles and environmental conditions (Lee 2000b). This

decapitating of the state has been reinforced by initiatives to further liberalise

the global trade of goods and services. The possible health consequences of

more open global markets have only begun to be discussed within trade

negotiations and remain unaddressed by proposed governance mechanisms

for the emerging global economy.

The fourth of the above points is perhaps the most significant because it raises

the possibility of the need for a change in the fundamental nature of health

governance. As mentioned above, IHG is structured on the belief that

governments have primary responsibility for the health of its people and able,

in co-operation with other states, to protect its population from health risks.

Globalization, however, means that the state may be increasingly undermined

in its capacity to fulfil this role alone, that IHG is necessary but insufficient,

and that additional or new forms of health governance may be needed. Some

scholars and practitioners believe that this new system of health governance

needs to be global in scope, so that it can deal effectively with problems

caused by the globalization of health (Farmer 1998; Kickbusch 1999).

Development, Special Issue on Responses to Globalization: Rethinking health and equity, December

1999, 42(4).

Globalization, in short, is an important driving force behind the emergence of

GHG.

1.3 THE ORIGINS OF INTERNATIONAL HEALTH GOVERNANCE

1.3.1 The growth of health governance in the nineteenth century

A fuller understanding of the distinction between international and global

health governance requires an historical perspective, of which a brief overview

is provided here.

Historically, we can trace health governance to the most

ancient human societies where agreed rules and practices about hygiene and

disease were adopted. Early forms of IHG, in the form of cooperation on

health matters between two or more countries, span many centuries with the

adoption of quarantine practices amidst flourishing trade relations and the

creation of regional health organizations. The process of building institutional

structures, rules and mechanisms to systematically protect and promote

human health across national borders, however, began more concertedly

during the nineteenth century. Following the conclusion of the Napoleonic

Wars, European states formed a number of international institutions to

promote peace, industrial development and address collective concerns

including the spread of infectious disease. This process of institutionalisation

of IHG, according to Fidler (1997), was a consequence of the intensified

globalization of health during this period.

Notably, these initiatives enjoyed

the support of political and economic elites across European societies who

believed that the crossborder spread of disease would hamper industrialisation

and the expansion of international trade (Murphy 1995; Fidler 1998a).

The first institution to be created during this period was the International

Sanitary Conference, with the first conference held in 1851. The achievements

of this meeting, and the ten conferences subsequently held over the next four

decades, were limited. In total, four conventions on quarantine and hygiene

practices were concluded, along with an agreement to establish an institution

for maintaining and reporting epidemiological data, and coordinating

responses to outbreaks of infectious diseases (Lee 1998). Importantly,

however, the conferences formalised a basic principle that has defined

subsequent efforts to build IHG, namely the recognition that acting in

cooperation through agreed rules and procedures enable governments to

better protect their domestic populations from health risks that cross national

borders. As such, the institutions adopted were envisioned as an extension of

participating governments' responsibilities in the health field to the

international (intergovernmental) level.

Along with this emerging sense of an international health community,

constructed of cooperating states, was a growing body of scientific knowledge

that was beginning to be shared in a more organized fashion (1998a).

Scientific meetings on health-related themes reflected substantial advances

during this period in understanding the causes of a number of diseases, such

as cholera and tuberculosis. In addition, international meetings were held on

social issues that impacted on public health, notably trafficking of liquor and

A more detailed analysis of the historical dimensions of global health governance is provided in

Loughlin K. and Berridge V. (2002), Historical Dimensions of Global Health Governance, Discussion

Paper No.2.

Early regional health organizations include the Conseil Superieur de Sante de Constantinople (c. 1830),

European Commission for the Danube (1856) and International Sanitary Bureau of the Americas (1902).

For a history of health cooperation in the nineteenth century see Howard-Jones N. (1975), The Scientific

Background of the International Sanitary Conferences, 1851-1938 (Geneva: WHO History of

International Public Health Series); and Weindling P. ed. (1995), International Health Organizations and

Movements, 1918-1939 (Cambridge: Cambridge University Press).

10

opium. Between 1851-1913, eighteen international conferences on health

were held (Box 1.1), and twelve health-related international institutions

7

had

been established by 1914 (Murphy 1995). Among the most prominent were

the International Sanitary Bureau (later the Pan American Sanitary Bureau) in

1902 and Office International d’Hygiene Publique (OIHP) created in Paris in

1907. The OIHP was a milestone in IHG in that it provided a standing (rather

than periodic) forum for countries to exchange ideas and information on

public health (Roemer 1994). This was followed in 1920 with the formation of

the Health Organization of the League of Nations. While a lack of resources

and political support restricted its activities, and inter-organizational

competition with the OIHP hindered the scope of its work, the organization

emerged from the interwar period with a strong reputation for data collection

and public health research.

BOX 1.1: WORLD AND EUROPEAN CONFERENCES ON HEALTH: 1851-1913

1851 First Sanitary Conference, Paris

1859 Second Sanitary Conference, Paris

1866 Third Sanitary Conference, Instanbul

1874 Fourth, Sanitary Conference, Vienna

1881 Fifth Sanitary Conference, Washington

1885 Sixth Sanitary Conference, Rome

1887 Liquor on the North Sea, venue unrecorded

1892 Seventh Sanitary Conference, Venice

1893 Eight Sanitary Conference, Dresden

1894 Ninth Sanitary Conference, Paris

1897 Tenth Sanitary Conference, Venice

1899 Liquor Traffic in Africa, Brussels

1903 Eleventh Sanitary Conference, Paris

1906 Liquor Traffic in Africa, Brussels

1909 Opium, Shanghai

1911 Twelfth Sanitary Conference, Paris

1911 Opium, The Hague

1913 Opium, The Hague

Source: Murphy, C.N. (1994), International Organization and Industrial Change: Global

Governance since 1850 (Cambridge: Polity Press), p.59.

From the mid nineteenth century, the nongovernmental sector also began to

grow and contribute to IHG, essentially filling gaps or supplementing

government action. For example, religious missions and The Rockefeller

Foundation's International Health Division (established in 1913) led the way in

supporting health services and disease control programmes in many parts of

the developing world. The International Committee of the Red Cross

(established in 1863) succeeded in establishing the Geneva Convention, a

precursor of future international health regimes in setting out norms of

behaviour and ethical standards for treating casualties of war. Other notable

NGOs created during this period were the League of Red Cross Societies (1919)

and Save the Children Fund (1919).

By the 1920s, governmental and nongovernmental health organizations were

contributing to a vision of IHG that was increasingly defined by

humanitarianism. Many medical practitioners and public health officials

building national public health systems at the national level (e.g. Margaret

Sanger) became closely involved in designing these early international health

institutions. Many of attended international scientific conferences from the

mid nineteenth century, bringing with them a strong belief that international

The twelve health-related international institutions established compares with five on human rights,

three on humanitarian relief and welfare, and ten on education and research (Murphy 1995).

11

health cooperation should seek to provide health to as many people as

possible. To achieve this vision of ‘social medicine’ required a strong emphasis

on universality as a guiding principal, achieved through the inclusion of as

many countries as possible in any international system of health governance

that was formed.

1.3.2 International Health Governance after the Second World War

The postwar period brought a significant expansion in IHG through the

establishment of new institutions and official development assistance for

health purposes. Within the UN system, the World Health Organization (WHO)

was created in 1948 as the UN specialised agency for health. Other

organizations contributing to health were the UN Relief and Rehabilitation

Administration (UNRRA) in 1943, UN International Children’s Emergency

Fund (UNICEF) in 1946 and UN High Commissioner for Refugees (UNHCR) in

1949. WHO was similar in a number of ways to the Health Organization of the

League of Nations that preceded it. Above all, the ideal of universality was,

and remains, central to its mandate and activities. As stated by the

Constitution of WHO (1946), the overall goal of the organization is “the

attainment by all peoples of the highest possible level of health”. Even in the

face of scepticism at the attainability of such a mandate, and challenges to the

appropriateness of social medicine (Goodman 1971), WHO was founded with a

strong commitment to addressing the health needs of all people. The

universalism of WHO has been reaffirmed on a number of occasions since

1948, most clearly during the 1970s with the Health for All strategy and

Renewing Health for All Strategy in the 1990s (Antezana et al. 1998).

WHO’s pledge to universality, however, has been strongly defined by the

sovereignty of its member states. The working assumption of the organization

has been that "health for all" can be achieved by working primarily, if not

exclusively, through governmental institutions, notably ministries of health.

Universality, in this sense, is measured by number of member states. Where a

large number of countries participate, such as the World Health Assembly

(WHA), it is assumed that the health needs of all peoples are represented. The

role of WHO, in turn, is designed as supporting the efforts of governments to

promote and protect the health of their populations.

Beyond national governments NGOs have been allowed to apply for permission

to enter into official relations with WHO since 1950 if it is concerned with

matters that fall within the competence of the organization and pursues

(whose aims and purposes are in conformity with those of the Constitution of

WHO). In 1998, there were 188 NGOs in official relations (WHO 1998) from

such diverse fields as medicine, science, education, law, humanitarian aid and

industry. In principle, therefore, NGOs are recognised as important

contributors to achieving the goals of WHO. In practice, however, the actual

role NGOs have played has been limited. Lucas et al. (1997), for example,

found that WHO has engaged with NGOs in its support at country level in

contrast with trends within agencies and other UN organizations such as

UNDP and UNICEF. At the headquarters and regional levels, officially

recognised NGOs have observed proceedings of the World Health Assembly or

meetings of the regional committees, and have limited access to programme-

related meetings dealing with more specific health issues. However NGOs

have not been routinely consulted despite their importance as channels of

health sector aid since the 1980s (Hulme and Edwards 1997) increased.

This traditional focus on member states and, in particular, ministries of health

has been in a context of greater diversity of policy actors. By the mid 1990s,

12

the map of IHG was one of considerable uncertainty, as Zacher (1999bc)

describes, fractured into an “organizational patchwork quilt”. Alongside WHO

has emerged a multiplicity of players, each accountable to a different

constituency and bringing with them different guiding principles, expertise,

resources and governance structures. The World Bank maintains a prominent

place because of its unrivalled financial resources and policy influence.

Regional organizations, such as the European Union, and other UN

organizations (e.g. UNICEF, UNDP, UNFPA) retain health as an important

component of their work but are more limited in membership and/or scope.

The Organization for Economic Cooperation and Development (OECD) and

World Trade Organization (WTO) approach health from an economic and trade

perspective. Varied civil society groups, such as consumer groups, social

movements and research institutions, also make substantial contributions to

health development. Finally, the growth of the private sector actors in health,

within and across countries, is notable. New fault lines and allegiances had

emerged to form an increasingly complex milieu for health cooperation, with

interests divided within and across countries and organizations. Undertaking

a wide-ranging process of reform, WHO has sought to change some of its

traditional governance features, notably its strong focus on ministries of

health, by engaging other public and private sector actors, and creating new

consultation mechanisms. As discussed in 1.4 below, there have been clear

efforts to increase the involvement of the NGO sector in areas of WHO

activities, such as tobacco, tuberculosis and HIV/AIDS, since the late 1990s.

At the same time, it has reiterated its commitment to universality as the

defining principle of its activities. How to define, let alone achieve health for

all, remains an enduring challenge.

In summary, IHG has evolved alongside an intensification of human

interaction across national borders over a number of centuries, gradually

becoming more institutionalised from the mid nineteenth century. During the

twentieth century, this institutional framework has grown and spread,

encompassing both rich and poor countries, in all regions of the world. The

defining feature of IHG has been the primacy given to the state although non-

state actors and interests were ever present. By the late twentieth century,

however, what Held et al. (1999) calls a "thickening" of the globalization

process was challenging this statecentric system of health governance. It is

within this context that discussions and debates about global health

governance have emerged.

1.4 AN EMERGING SYSTEM OF GLOBAL HEALTH GOVERNANCE?

The precise origins of the term GHG are unclear, although many scholars and

practitioners who use the term draw upon a number of different fields. These

mixed origins mean that GHG can be difficult to define. This problem of

definition is compounded by the fact that the term GHG is used widely in a

number of different contexts. We can begin to overcome this problem of

definition by breaking GHG into its component parts – global health and

governance.

1.4.1 International versus global health

Globalization brings into question how we define the determinants of health

and how they can be addressed. In principle, the mandate of WHO is based

on a broad understanding of health

, although in practice its activities have

The Constitution of WHO defines health as “a state of complete physical, mental and social well being

and not merely the absence of disease or infirmity.”

13

traditionally been biomedical in focus. Since the 1970s, efforts have been

made to incorporate a more multisectoral and multidisciplinary approach into

the organization's activities. For example, Health for all in the 21

st

Century

links the attainment of good health to human rights, equity, gender,

sustainable development, education, agriculture, trade, energy, water and

sanitation (Antezana et al. 1998). Similarly, the replacement of the Global

Programme on AIDS by UNAIDS was in large part due to a desire to go beyond

a narrow biomedical approaches to HIV/AIDS (Altman 1999).

Globalization from the late twentieth century has emphasised even more

poignantly the need for greater attention to the basic determinants of health

including so-called non-health issue areas. In arguing for a reinvigoration of

public health, McMichael and Beaglehole (1999) point to the need to address

underlying socioeconomic (notably inequalities), demographic and

environmental changes that global change is creating. Similarly, Chen et al.

(1999) argue that globalization is eroding the boundary between the

determinants of public (collective) and private (individual) health. For

example, susceptibility to tobacco-related diseases, once strongly linked to,

and blamed on, the lifestyle choices of individuals, is increasingly seen as

attributable to the worldwide marketing practices of tobacco companies. The

distinction between global health and international health therefore is that the

former entails a broadening of our understanding of, and policy responses to,

the basic determinants of health to include forces that transcend the territorial

boundaries of states. Global health requires a rethinking of how we prioritise

and address the basic determinants of health, and engagement with the broad

range of sectors that shape those underlying determinants.

The need to address the basic determinants of health leads to the practical

question of how to do so. Since at least the early 1990s, there has been a

growing confusion of mandates among UN organizations that have substantial

involvement in the health sector - WHO, UNICEF, UNDP, UNFPA and the

World Bank. In large part, this has been due to efforts to develop

multisectoral approaches to both health and development, as well as key areas

(e.g. reproductive health, environmental health) that bring together the

activities of two or more organizations (Lee et al. 1996). Globalization invites a

further widening of the net of relevant organizations, requiring engagement

with actors that have little or no formal mandate in the health field. Notable
have been efforts to establish greater dialogue between WHO and the WTO.

While trade interests have historically defined, and in many ways confined,

international health cooperation, officially the two spheres have been

addressed by separate institutions. Nonetheless, the multiple links between

trade and health policy are well recognised (WHO 2002, Brundtland 1998;

Brundtland 1999), resulting in high-level meetings between the two

organizations since the late 1990s. At present, WHO holds official observer

status on the Council of the WTO, and committees relating to Sanitary and

Phytosanitary Measures (SPS) and Technical Barriers to Trade (TBT)

agreements. However, the capacity to articulate public health concerns

regarding, for example, the agreement on trade-related intellectual property

rights (TRIPS), has been hampered by the framing of health among trade

officials as a “non-trade issue”, and as such the reluctance of certain countries

to discuss health within the context of a trade negotiations. Moreover, the

ability of WHO to influence the WTO has been hampered by the fact that

states (many of which are members of both organizations) have accorded a

higher priority to trade issues, rather than those relating to human health. As

such, there remain considerable barriers to incorporating health as a

legitimate and worthy concern on the global trade agenda.

14

1.4.2 The different meanings of governance

As described above, the ability of a society to promote collective action and

deliver solutions to agreed goals is a central aspect of governance. As shown in

Table 1.1 the term governance has been used in a number of different ways,

ranging from the relatively narrow scope of corporate and clinical governance,

to the broader concept of global governance.

TABLE 1.1: VARIOUS USES OF THE TERM GOVERNANCE

TYPE OF GOVERNANCE CHARACTERISTICS

governance

• the actions and means to promote collective

action and deliver collective solutions

• "an exercise in assessing the efficacy of

alternative modes (means) of organization. The

object is to effect good order through the

mechanisms of governance" (Williamson 1996:

11)

• "The manner in which power is exercised in the

management of a country's economic and social

resources for development" (World Bank 1994)

corporate governance

• clear systems of transparency and

accountability to investors

• mechanisms for meeting social responsibility by

corporations

• "the framework of laws, regulatory institutions,

and reporting requirements that condition the

way that the corporate sector is governed"

(World Bank 1994)

good governance

(World Bank 1994)

• public sector management

• accountability of public sector institutions

• legal framework for development

• transparency and information

good governance (UNDP 1997)

• management of nations affairs

• efficiency, effectiveness and economy

• liberal democracy

• greater use of non-governmental sector

clinical governance

"a framework through which NHS organizations

are accountable for continuously improving the

quality of their services and safeguarding high

standards of care by creating an environment in

which excellence in clinical care will flourish"

(UK 1998)

global governance

• "not only the formal institutions and

organizations through which the rules and

norms governing world order are (or are not)

made and sustained - the institutions of the

state, inter-governmental co-operation and so

on - but also those organizations and pressure

groups - from

MNCs,

transnational social

movements to the plethora of non-governmental

organizations – which pursue goals and

objectives which have a bearing on

transnational rule and authority systems" (Held

et al. 1999)

Recent interest in governance within the development community can be

traced to the late 1980s as part of a desire among aid agencies to address the

uneven performance of low and middle-income countries to macro economic

reforms (Dia 1993). The term good governance was introduced by the World

Bank (1994) as an explanation for problems being experienced in many

countries, namely the weakness of public sector institutions and management,

and as a basis for setting further lending conditionalities. In this context,

governance is defined as “the manner in which power is exercised in the

management of a country’s economic and social resources of development.”

15

For governance to be "good", social and economic resources must be managed

by a small efficient state that is representative, accountable, transparent,

respectful of the rule of law, and supportive of human rights through

programmes of poverty reduction.

The conceptualisation and application of the term good governance by the

World Bank is seen by Leftwich (1993) as problematic in a number of ways.

First, he argues that it is an extension of neoliberal-based policies, (for

example, structural adjustment programmes) that are arguably themselves

contributing to the problems experienced by many countries since the 1980s.

Second, the World Bank focuses narrowly on the performance of public sector

administration and management, while ignoring the importance of good

governance for the private sector or donor communicty itself, along with levels

of foreign debt, in influencing how countries have fared. Third, the

prescriptive element of good governance again focuses on governments, while

at the same time adopting a technocratic view of how governments should

work.

Other development agencies have since taken up the term good governance as

important components of their policies

. The UN Development Programme

(UNDP) is a notable example. In seeking to go beyond public sector

management, UNDP (1997) has incorporated a range of principles into its

conceptualisation of good governance including legitimacy (democracy),

freedom of association, participation, and freedom of the media. As Deputy

Director of the UN Department for Development Support and Management

Services A.T.R. Rahman (1996) states, "good governance is an overall process

that is essential to economic growth, to sustainable development and to

fulfilling UN-identified objectives such as the advancement of women and

elimination of poverty".

10

Another increasingly used term is corporate governance. Williamson (1996)

defines corporate governance, for example, in terms of recent developments on

transaction-cost approaches in economic theory. He writes that governance

concerns institutional structures and accompanying practices (e.g. rules) that

facilitate economic production and exchange relations. "Good" governance

structures are those that effectively "mitigate hazards and facilitate

adaptation". These can be simple or complex depending on the degree of

hazard faced. Other writers on corporate governance similarly focus on

mechanisms that enhance economic transactions. The underlying assumption

of such approaches is that good corporate governance, in the form of improved

(more democratic) systems of accountability and transparency for investors,

will enhance the process of wealth creation and prevent greater regulation by

governments (McRitchie 1998).

A broader perspective on corporate governance is more closely related to the

definition of good governance put forth within the development community.

This approach focuses more directly on the nature of social responsibility by

business, rather than the enhancement of profits. There has been a growing

movement to encourage the corporate sector to be more responsible, not only

to shareholders, but to the wider communities within which they operate. The

notion of corporate responsibility and citizenship has thus arisen in relation to

such practices as fair trade, ethical investment and activist shareholders,

9

For the UK government’s view on good governance see Department for International Development

(DfID), Eliminating World Poverty: A Challenge for the 21

st

Century (DfID, 1997). See also UN General

Assembly, Resolution 50/225, 1996.

10

Since completion of this paper, the UNDP Poverty Report 2000, has expanded on the link between

“good governance” and poverty relief.

16

social and environmental impact assessments, improved working conditions

for workers in low-income countries, and the social auditing of companies

(Cantarella 1996).

The values of management-oriented approaches to corporate governance have

entered the health lexicon in the guise of clinical governance. In the UK,

where the term that has become especially popular, clinical governance refers

to “a framework through which NHS [National Health Service] organizations

are accountable for continuously improving the quality of their services and

safeguarding high standards of care by creating an environment in which

excellence in clinical care will flourish.” (UK 1998). Initially emerging as part

of health sector reform, it has been a response in particular to differences in

quality of care in parts of the country, and to public concerns regarding well-

publicised cases of poor clinical performance. The focus, therefore, has been

improving the quality of patient care through evidence based practice,

collecting information to measure performance against agreed standards,

providing ongoing education for health care professionals, and managing and

learning from complaints (Scally and Donaldson 1998). Institutional

mechanisms (e.g. National Institute for Clinical Excellence) and practices have
been introduced for these purposes (Paris and McKeown 1999; The King's

Fund 1999). Criticisms of clinical governance focus on whether there is

anything new about its aims. Some argue that clinical governance offers little

more than a confirmation of “the common sense message that we [doctors and

health professionals] must all strive after quality in practising medicine”

(Goodman 1998).

A further use of the term governance, and the focus of this paper, is global

governance which can be broadly defined as

not only the formal institutions and organizations through which

the rules and norms governing world order are (or are not) made

and sustained – the institutions of the state, inter-governmental co-

operation and so on – but also those organizations and pressure

groups – from MNCs, transnational social movements to the

plethora of non-governmental organizations – which pursue goals

and objectives which have a bearing on transnational rule and

authority systems.

(Held et al. 1999).

The concept of global governance has come to the health field from the

discipline of International Relations (IR) within which a diverse, and

theoretically riven, debate has developed on the specific nature of

globalization, the emerging global order, key actors, and ultimate goals of

global governance (Table 1.2). Liberal-internationalist scholars view the

purpose of global governance as ultimately moving towards a more liberal

democratic global order in which states and IGOs have equal roles. Within

such an order it is envisaged that power and influence will flow in a top-down

manner, although states and IGOs may be held accountable via a global

assembly composed of representatives from national and global civil society

(Commission on Global Governance 1995). In contrast, radical/critical

scholars believe that the direction of global governance should be guided from
the bottom-up. Emphasis is placed on the potential of actors from within

(global) civil society (in particular social movements) to bring about more

‘humane governance’ (Gill 1998). Cosmopolitan democrats pursue a vision of

global governance that embraces the diversity of people across national and

other forms of identity within a shared political community. This ideal may be

achieved, for instance, through consensus on universal principles (e.g. human

rights), increased public scrutiny of existing IGOs, global referendums and an

17

expanded international legal system (Held 1995; McGrew 1997). This is a

somewhat simplistic summary of a substantial and intellectually rich

literature.

11

TABLE 1.2: THEORETICAL APPROACHES TO GLOBAL GOVERNANCE

CENTRAL ISSUE OF

GLOBAL

GOVERNANCE

LIBERAL-INTER

NATIONALISM

CRITICAL/RADICAL COSMOPOLITAN

DEMOCRACY

Globalization Multi-causal

process – generates

interdependence

and ‘zones of peace’

Economically driven –

subject to contradictions

Multi-causal process

with transformative

potential
Nature of the current

global order

Emerging post-

Westphalian order

Global neoliberalism Post-Westphalian

order

Actors in global

governance

States,

international

organizations

corporations and

NGOs etc.

Transnational capitalist

class, elites through

states, International

organization and civil

society.

States, peoples,

international

organization,

corporations and

social movements

Key actors in

collective problem

solving

States and

international

organization
Transnational capitalist

class, international

organization, states and

civil society.

States, international

organization,

corporations and

social movements

Nature of global

governance

Reformist and top-

down

Revolutionary and

bottom-up

Transformationalist

and participatory

Change towards Liberal democratic

consensus politics

Humane governance Cosmopolitan

democracy

Source: Adapted from McGrew A. (1997), “Globalization and Territorial Democracy: an

introduction” in McGrew A. ed., The Transformation of Democracy? (London: Polity Press), p.20.

To summarise, the concept of governance has generally been used in two

broad ways in relation to health. The first defines governance as a problem-

solving approach to address the shortfalls of public and private institutions to

function efficiently. Strongly influenced by recent developments in

management and economic theory, good or better governance is equated with

strengthening efficiency and effectiveness within existing institutional

structures. The second takes a more transformative approach by finding

existing forms of governance falling short in its responsiveness to the needs of

society as a whole. Faced with a range of intensifying and/or new risks and

opportunities, more effective governance is believed to be needed to respond to

social change. This volume is located within this second view in its efforts to

encourage wider discussion of the challenges posed by globalization, and the

clearer vision needed to address them through global governance.

1.4.3 The essential elements of global health governance

From the above discussion, we can identify some essential elements of GHG

and the challenges for achieving them. The first is the "deterritorialisation" of

how we think about and promote health, and thus the need to address factors

which cross, and even ignore, the geographical boundaries of the state. The

formation of the international system of states in the sixteenth century, the

birth of public health during the nineteenth century, and the creation of

national health systems in the twentieth century have contributed to a system

of governance that is premised on protecting the integrity of the state. IHG

has been historically focused on those health issues that cross national

borders, with the aim of protecting domestic populations within certain

defined geographical boundaries through such practices as quarantine, cordon

11

For a more detailed discussion see Hewson and Sinclair (1999).

18

sanitaire, and internationally agreed standards governing the reporting of

infectious disease, trade and population mobility. All of these efforts have

been focused on the point of contact, the national border of states.

However, forces of global change, in various forms, have intensified

crossborder activity to such an extent as to undermine the capacity of states

to control them. The increased levels of international trade and movement of

people are examples. Moreover, a wide range of others forces render national
borders irrelevant. The worldwide flows of information and communication

across the Internet; the ecological impacts of global environmental change; the

frenzied exchange of capital and finance via electronic media; the illicit trade

in drugs, food products and even people; and the global mobility of other life

forms (e.g. microbes) through natural (e.g. bird migration) and manmade (e.g.

bulk shipping) means render border controls irrelevant. Many of these global

changes impact on health and requires forms of cooperation that go beyond

IHG.

A second essential element of GHG is the need to define and address the

determinants of health from a multi-sectoral perspective. Biomedical

approaches to health have dominated historically in the form of disease-

focused research and policy, the skills mix of international health experts and

officials, and the primacy given to working through ministries of health and

health professionals. A global system of health governance begins with the

recognition that a broad range of determinants impact on population health

including social and natural environments. In recent decades, this has been

recognised to some extent through the increased involvement of other forms of

expertise in health policy making (e.g. economics, anthropology) and links with

other social sectors (e.g. education, labour). More recently, ministries of

health and international health organizations have sought to engage more

directly with sectors traditionally seen as relatively separate from health (e.g.

trade, environment, agriculture) in recognition of “cross sectoral” policy issues

at play. Informal consultations between WHO and WTO, for example, have

been prompted by the importance of multilateral trade agreements to health.

The main challenge to achieving greater cross sectoral collaboration lies in the

danger of casting the health “net” so widely that everything becomes

subsumed within the global health umbrella. Opening up GHG too

indiscriminately can dilute policy focus and impact, and raise questions about

feasibility. The linking of traditional health and non-health issues also

demands a clear degree of understanding and empirical evidence about cause

and effect. Defining the scope of GHG, therefore, remains a balance between

recognising the interconnectedness of health with a varied range of globalizing

forces, and the need to define clear boundaries of knowledge and action.

The third essential element of GHG is the need to involve, both formally and

informally, a broader range of actors and interests. As described above, while

nonstate actors have long been an important part of the scene, IHG has been

firmly state-defined. Health-related regional organizations (e.g. PAHO,

European Union), along with major international health organizations such as

WHO and the World Bank are formally governed by member states. Their

mandates, in turn, are defined by their role in supporting the national health

systems of those member states. The universality of their activities is

measured by the number of member states participating in them. Defining

criteria and measures of progress to address the burden of disease, health

determinants and health status are focused on the state or groups of states.

GHG, however, is distinguished by the starting point that globalization is

creating health needs and interests that increasingly cut across and, in some

19

cases, are oblivious to state boundaries. To effectively address these global

health challenges, there is a need to strengthen, supplement and even replace

existing forms of IHG. Importantly, this does not mean that the role of the

state or IHG will disappear or become redundant, but that they will rather

need to become part of a wider system of GHG. Many existing institutions will

be expected to play a significant role in GHG, and states will continue to be

key actors. However, states and state-defined governance alone is not enough.

Forms of governance that bring together more concertedly state and nonstate

actors will be central in a global era (Scholte 2000). As described by the

Commission on Global Governance (1995), “[global governance] must…be

understood as also involving NGOs, citizen’s movements, multinational

corporations, and the global capital market,” as well as a “global mass media

of dramatically enlarged influence.”

As described above, state and nonstate actors have long interacted on health

governance. The difference for GHG will lie in their degree of involvement and

nature of their respective roles, varying with the health issue concerned.

Three brief examples illustrate this. First, relations among the diverse NGO

community are constantly changing depending on the issue. On certain

issues, they may be willing to form strategic networks or alliances with other

NGOs, thus representing an important governance mechanism within GHG.

Such a mechanism was formed around the global campaign against the

marketing of breastmilk substitutes that led to the formation of the

International Baby Food Action Network. Cooperation among the International

Baby Food Action Network, UNICEF, WHO and selected governments led to the

International Code of Marketing on Breast-Milk Substitutes in 1981. Like-

minded NGOs also came together to form more permanent, but still highly

fluid, global social movements around the environment and women’s health.

These movements opposed each other at the UN Conference on the

Environment and Development (1992), yet worked together to propose an

alternative view of development at the World Summit for Social Development

in 1995. Close relations among the women’s health movement, national

governments and UNFPA was also a defining feature of the International

Conference on Population and Development (1994). Relations between the

women’s health movement and some states, in particular the US, were so

close that members of the women’s health movement served on some of the

official government delegations. Parties involved in the conference believed

that such close relations played a key role in shaping the resultant

commitment to reproductive health (Dodgson 1998).

A second example is the closer relations among state and nonstate actors

characterising the emerging global strategy on tobacco control. Under the

auspices of WHO, negotiations for a Framework Convention on Tobacco

Control (FCTC) have been attended by officially recognised NGOs, along with

state delegations. The Tobacco Free Initiative (TFI), WHO maintains that NGO

participation is central to the overall success of the FCTC, and has supported

the creation of a global NGO network to support the FCTC (i.e. Framework

Convention Alliance). Links were also formed with representatives of the

women’s movement to ensure that tobacco and women’s health was discussed

during the Beijing Plus 5 process. At the same time, TFI has developed links

with the business community, in particular, the pharmaceutical industry, to

explore how nicotine replacement treatments can be made more widely

available. Other coordination efforts have been focused on bringing together

different UN organizations through the formation of a UN Ad Hoc Inter-Agency

Task Force on tobacco control, and the holding of public hearings to

20

encourage the submission of a wide range of evidence from different interest

groups.

12

These efforts to build formal links with such a diverse range of stakeholders to

support global tobacco control policy is unprecedented for WHO, and a good

example of emerging forms of GHG. It represents an important challenge to

traditional ways of working for WHO in its efforts to tackle health issues with

global dimensions (Collin et al. 2002). Ensuring state and nonstate actors

work collectively on different levels of governance (i.e. global, regional,

national

13

and subnational), the FCTC is an example of how “behind-the-

border” convergence could be promoted in the future. The goal of adopting a

legally binding treaty and associated protocols is also a new development in

institutionalising global governance in the health sector. The FCTC is based

on international regimes that have emerged to promote collective action on

global environmental problems. These international regimes can be defined as

“sets of implicit or explicit principles, norms, rules and decision-making

procedures around which actors expectations converge in a given area of

international relations” (Krasner 1983). In addition to the FCTC, other

examples of international regimes in the field of health are the International

Health Regulations

14

, the International Code for the Marketing of Breast Milk

Substitutes and the Codex Alimentarius (Kickbusch 1999). These examples of

international health regimes demonstrate that they have played a significant

role in IHG. The remit and organizational structure of the FCTC and its

implementation suggest that such regimes will be a core feature of GHG in

future.

A third example of state-nonstate governance is so-called global public-private

partnerships (GPPPs) defined as “a collaborative relationship which transcends

national boundaries and brings together at least three parties, among them a

corporation (and/or industry association) and inter-governmental

organizations, so as to achieve a shared health creating goal on the basis of a

mutually agreed division of labour” (Buse and Walt 2001). Among the most

prominent GPPPs are the Albendazole Donation Programme, Medicines for

Malaria Venture and International AIDS Vaccine Initiative. The idea of building

partnerships with business is at the centre of UN-wide views on the

governance of globalization (Global Compact). For this reason, and the fact

that GPPPs bring much needed resources to major health issues, the number

of GPPPs is likely to grow in future. At the same time, like the FCTC process,

GPPPs require a period of reflection on a range of governance issues. Buse

and Walt (2001), for example, raise questions about accountability,

transparency and long-term sustainability of GPPPs. They also ask who

benefits, people who seek treatment or the pharmaceutical companies that

gain good public relations. Some governments of low-income countries, a

number of NGOs and UN institutions have expressed concerns about the

viability of building links among actors with fundamentally differing objectives

and interests. For example, Carole Bellamy, UNICEF Executive Director

comments, “it is dangerous to assume that the goals of the private sector are

12

Interview with Douglas Bettcher, Framework Convention Team, Tobacco Free Initiative, Geneva, 9

December 1999.

13

Technical documents that have been written as part of the consultation process for the FCTC suggest

that all signatory states should adopt an autonomous national tobacco control commission. See for

example, A. Halvorssen, “The Role of National Institutions in Developing and Implementing the WHO

Framework Convention on Tobacco Control”, Framework Convention on Tobacco Control: Technical

Briefing Series, No.5 (1999).

14

Following a long process of review, the International Health Regulations (IHRs) are on the brink of

being reformed to make them more effective and binding on states. Most significantly, the revised IHRs

require the reporting of all “events of urgent international importance related to public health”.

21

somehow synonymous with those of the United Nations, because they most

emphatically are not.”

15

Thus, global health emphasises the need for governance that incorporates

participation by a broadly defined “global” constituency, and engaging them in

collective action through agreed institutions and rules. The challenges of

achieving GHG, defined in this way, are considerable. At the heart lies the

need to define the core concept of democracy in the context of globalization in

terms of political identity and representation. If existing forms of health

governance are seen to be undemocratic, alternatives that appropriately

balance actors and interests are needed. Systems for ensuring accountability

and transparency must be agreed. There requires greater clarity about what

contributions different actors make to GHG, and what governance

mechanisms can ensure that these roles are fulfilled. The issue of meaningful

participation and responsibility remains problematic. For example, the WHA is

attended by WHO member states but there are inequities in capacity to follow

proceedings and contribute to decision making. This is a challenge for many

international organizations including the WTO. Conflicts are also likely to

emerge and need to be resolved. The familiar yet enduring problem of

coordination of international health cooperation remains unresolved. Overall,

the principle of closer state-nonstate cooperation is an increasingly accepted

one, but the “nitty gritty” of what this should look like in practice is only

beginning to be explored within the health sector. This theme is taken up by

discussion papers on the potential role of civil society and the private sector in

this series.

1.5 CONCLUSIONS: BEGINNING TO DEFINE AND SHAPE THE

ARCHITECTURE FOR GHG

The task of defining and shaping a system of GHG in further detail, both as it

appears to be currently evolving and more prospectively, begins with a number

of important challenges for research and policy. The first, and perhaps the

most fundamental, is the need to agree the normative framework upon which

GHG can be built. There is a need to reach some degree of consensus about

the underlying moral and ethical principles that define global health

cooperation. As discussed in this paper, universalism has been a strong ethos

guiding the emergence of social medicine, the Health for All movement from

the late 1970s and, more recently, calls for health as a human right.

Alongside such communitarian ideas have been approaches informed by

principles of entitlement (economic or otherwise) and utilitarianism. Despite

recent high-profile initiatives on “global health”, an informed discussion about

their normative basis remains to be carried out.

A second challenge is the need to define leadership and authority in GHG. As

discussed above, health cooperation has evolved into an arena populated by a

complex array of actors operating at different levels of policy and

constituencies, with varying mandates, resources and authority. Figure 1 is

an attempt to identify the key actors potentially concerned with GHG and their

possible positions at a given point in time. WHO and the World Bank are

shown as central because they represent the main sources of health expertise

and development financing respectively. At the same time, they are

accompanied by a cluster of institutions, state and nonstate, that fan

outwards including, but are not restricted to, the International Monetary Fund

(IMF), World Trade Organization (WTO), United Nations Children’s Fund

15

Interview with J. Ann Zammit, The South Centre, 9

th

December 1999. “UNICEF: Bellamy

warns against partnership with private sector”, UN Wire, 23

rd

April (1999).

22

(UNICEF), International Labour Organization (ILO), United Nations

Development Programme (UNDP), and United Nations Population Fund

(UNFPA). Specific regional and bilateral institutions (e.g. USAID) are included

as politically and economically influential.

16

GHG also includes the wide

variety of actors within the private sector and civil society, the latter defined as

“a sphere of social interaction between economy and state, composed above all

of the intimate sphere (especially family), the sphere of associations (especially

voluntary associations) and forms of public communication” (Jareg and Kaseje

1998). Some of these actors (e.g. Bill and Melinda Gates Foundation) have

become highly prominent in recent years. Others, as described above,

including NGOs, social movements, epistemic communities, professional

associations and the mass media, can be influential on a more policy specific

basis.

FIGURE 1: GLOBAL HEALTH GOVERNANCE MAPPED

In this complex arena of actors, the issue of leadership and authority is a

difficult one. As well as setting the normative framework for global health

cooperation, leadership can provide the basis for generating public awareness,

mobilising resources, using resources rationally through coordinated action,

setting priorities, and bestowing or withdrawing legitimacy from groups and

causes. The willingness of states to ‘pool’ their sovereignty and act collectively

through mechanisms of GHG is one historically significant hurdle. The

absence of a single institution, with the authority and capacity to act

decisively, to address health issues of global concern is another. The panoply

of vested interests that characterise global politics represents another clear

difficulty. After the Second World War, the agreement to establish the World

Health Organization was prompted by a strong collective recognition of the

need to improve health worldwide. The global nature of many emerging health

issues, including the threat of major threats to humankind (e.g. emerging

diseases, antimicrobial resistance) may prompt similar consensus.

16

This is not to suggest of course that these are the only bilateral actors to play a role in international
health, United Kingdom’s Department for International Development is one many other such
institutions.

ISSUE

CENTRE

WORLD

BANK

WHO

UNITED

STATES

IMF

WTO

UNICEF

DEVELOPING

COUNTRIES

DEVELOPED

COUNTRIES

UNDP

ILO

UNFPA

NGOs

SOCIAL

MOVEMENTS

MEDIA

TNCs

EPISTEMIC

COMMUNITIES

INDIVIDUALS

RESEARCH

INSTITUTIONS
RELIGIOUS

GROUPS

Figure 4: Global health governance mapped

23

A third challenge for GHG is the need to generate sufficient resources for

global health cooperation and distribute them appropriately according to

agreed priorities. The present system is ad hoc in nature, reliant on the

annual spending decisions of governments, and the goodwill of private citizens

and companies. Efforts to provide debt relief and increase development

assistance recognise the inherent inequities of current forms of globalization

(UNDP 1999). Recent discussions about the creation of a Tobin Tax or

equivalent surcharge, on global activities that rely on a secure and stable

world (e.g. financial transactions, air travel), could generate substantial and

much needed sums.

Fourth, the sovereignty of states is also a hurdle to giving “teeth” to global

health initiatives because of the lack of effective enforcement mechanisms.

With the exception of the International Health Regulations, which in itself is

highly circumscribed in remit, WHO can recommend rather than command

action by member states. The reporting of outbreaks of yellow fever, cholera

and plague, for example, is traditionally reliant on governments who may not

be willing to report such information for fear of causing adverse economic

reactions. By definition, a global health issue is one where the actions of a

party in one part of the world can have widespread consequences in other

parts of the world. Reliance on voluntary compliance with agreed practices,

such as the use of antibiotics and antimicrobials, without sufficient

monitoring and enforcement, can lead to serious and even irreversible health

impacts.

Finally, the enigma of how to achieve a more pluralist, yet cohesive, system of

GHG stands before us. As the globalization of health continues, health

governance will have to become broader in participation and scope. The proto

forms of GHG that are presently emerging (e.g. FCTC, GPPPs) might be seen as

examples of improving practice as they open up participation in health

governance to a wider range of actors. Nonetheless, a critical evaluation of

these forms of governance is yet to be undertaken, nor is it yet clear whether

these emerging forms of GHG will achieve their objectives.

The task of moving forward this complex, yet much needed, debate can be

facilitated by a number of further tasks that are the focus of future discussion

papers in this series. The purpose of this paper has been to review the

conceptual meaning of GHG and, in turn, to highlight the challenges faced in

moving towards such a system. A second task is to better understand the

historical context of IHG and GHG, and how this can inform the transition

from one to the other. Many different types of governance mechanisms for

health purposes have been tried and tested since the end of the Second World

War, and it would be useful to explore these in relation to the criteria set in

this paper. This is the subject of Discussion Paper No. 2.

The next task is to better understand the “nitty gritty” of global governance in

terms of what, in concrete terms, it looks like in practice. This moves us into

the legal realm where international lawyers have grappled with the formulation

and implementation of governance at the global level. An examination of what

currently exists within the health field, as well as other fields such as trade

and environment, may shed light on future possibilities. While such a review

can only be selective in nature, it can point to lessons for building

mechanisms for GHG. This is the subject of Discussion Paper No. 3.

Lastly, there is the task of defining more clearly the potential role of nonstate

actors within a system of GHG. Relationships, patterns of influence and

agreed roles among state and nonstate actors within an emerging system of

GHG are still emerging. This myriad of different actors, each with individual

24
spheres of activity, types of expertise, resources, interests and aspirations,

cannot yet be described as a "global society". As defined by Fidler (1998b), a

global society is "made of individuals and non-state entities all over the world

that conceive of themselves as part of a single community and work nationally

and transnationally to advance their common interests and values." The ad

hoc nature of GHG so far, however, suggests that a more concerted effort to

define and describe existing and potential roles would contribute to policy

debates on possible future directions.