Governance Mechanisms

When we talk of global health with all its complexity and challenges, the issue of governance becomes very important. The concept of governance of course arose from the feudal times when you had a ruler or a ruling class and those who are ruled or are governed. But even with the advent of democracy we had elected governments which were entrusted with the responsibility of providing a method of organizing the society and insuring the rule of law in an orderly fashion so that the society could function very well.

The notion of governance goes however beyond the formal mechanisms of government and refers to the totality of ways in which a society organizes and collectively manages its affairs. Because now we are living in a state of democracy when we recognize that it is not merely for the government to decide on how the society should be run. There are multiple actors in a society and all of them need to act concertedly after adequate consultation among themselves. So it’s a collective decision in which the responsibilities are shared, but ultimately the process of governance is contributed to by every one of the stakeholder groups.

In terms of global health governance, the concept of governance now extends across countries. It has been defined as the use of formal and informal institutions, rules and processes by states, intergovernmental institutions and non-state actors to deal with challenges to health that require cross-border collective action to address effectively. Where many of the determinants of health actually act transnationally, you’ll require international cooperation- better now known as global cooperation and global concord for collective action. And when we say state, we are talking about the collective, governmental, as well as societal image that captures a country’s interest and provides governance for that particular country.

But there are non-state actors who are acting independent of the elected state and those also need to be recognized as important contributors. In terms of the governance for global health, global governance for health refers to all governance areas that can affect health, implicitly because global health is fundamentally geared towards promoting health equity and reducing inequities. Global health can make the normative claim that health equity should be an objective for all participating sectors which goes beyond the health sector as well.

So, When we are talking about governance of global health, we are talking about governance with the health systems, when we talk about governance for Global Health we are talking about all sectors of development in human activity being aligned to the objectives of global health and being geared to promote global health equity. There are multiple global challenges that we are now seeing. For example, the threats from the past, infections, maternal and child health challenge as well as a host of emerging challenges like non-communicable diseases, zoonosis, antibiotic resistance. We’re also seeing challenges arising from globalization, increasing inequity in multiple areas whether it is access to drugs or even some of the problems of health systems compounded by migration of trained health workers from countries which need them to countries which can afford to purchase their services. We’re also seeing climate change and trade policies having an increasing influence on global health. So we recognize that no single nation or organization is currently capable of single-handedly addressing all its health challenges by itself. So we do need a global health platform in which countries can work together and multiple groups which represent different societal interests can work in concert.

At the global level we have apart from the World Health Organization and the individual national governments, we also have a number of other actors who are now coming into play. We have multilateral organizations which provide technical or even economic assistance for health. We have bilateral organizations which establish country to country collaborations. We have philanthropies which are now playing a much larger role across the world. We have academia. We have the civil society organizations. We have the private sector. We have the media. And we have hybrid partnerships which often link some of these actors. But at the level of the global health we find security becoming an important issue and health security is an important challenge for most countries now.

At the same time, we are finding other issues like migration, education, agriculture, environment, and a large number of other issues like trade and investment, all of them becoming important contributors to our debate on global health governance. So we are now reaching beyond the health sector, but we’re also bringing in a multiplicity of actors into play. But there are several challenges in this complexity. First is the sovereignty challenge. There is no government at the global level obviously. Even if the United Nations exists, it is more of a platform for consultation rather than a single authority which can dictate what should happen across the world. There is inherent tension between national sovereignty and international action. Most countries would like to collaborate with each other as long as their national interests are not affected. And therefore when we ask for shared sovereignty in the area of global health, there is always a concern that nations experience whether they’re actually surrendering their sovereignty. So we do need to find a healthy way media in which nations are comfortable with working with each other rather than feeling that they’re being compelled to act in the interests of another country.

There is also a sectoral challenge. There are multisectoral influences on health and all of these are not embedded in the health sector, therefore we require cross-disciplinary policymaking which is largely absent in global health. Many of the agencies which deal within countries or across countries with agriculture and trade for example are totally insensitive to health concerns. There is also the accountability challenge. There is a democratic deficit related to the legitimacy of international government organizations, or inter-governmental organizations. Also there is a lack of clear mechanism for accountability of non-state actors. So the question is if inter-governmental organizations as well as non-state actors have a considerable influence on the health policies of a country or a group of countries, then are they really accountable in some manner just as national governments are? If they are not, then how can they actually be held to account?

The big question is which is the organization that really represents global health? The World Health Organization was established in 1948 in the aftermath of the Second World War. It is the first multilateral global health organization and the most respected. Its imprimatur is particularly valuable in the low and middle income countries which see it as an honest broker in global health. It functions through its headquarters in Geneva and six regional offices, which are located in the Americas, in the European region, and in what’s called the Eastern Mediterranean region, the Southeast Asia region, as well as the Western Pacific region and the African region. Now each of these encompasses many countries in that region. The Pan American Health Organization for example covers north, central, southern American countries as well as the Caribbean.

Many of these regions, despite the heterogeneity that exists within themselves do try to act in concert at the regional level and are accountable to the regional committees which represent the governments of those regions. And overall, they work in concert with the headquarters in Geneva. But there are often disconnects in that relationship.

The WHO remains the only actor in the current global health system that has universal membership of all sovereignty nations. There are of course several importante international treaties and initiatives that the World Health Organization has taken in the interest of global health. One of the landmark treaties, the very first public health treaty negotiated by the WHO is the framework convention on tobacco control which was adopted in 2003 by the World Health Assembly. And now 180 countries have signed up to the framework convention on tobacco control. There are also the international health regulations to address acute public health risks. There has also been a great deal of work done by the WHO for advancement of the millennium development goals. The WHO also takes the global leadership role or it is the coordination role in mobilizing emergency response, relief work, management of outbreaks, for example recently in Ebola.

While the WHO is a globally respected organization, whose leadership still remains widely acknowledged, the role of WHO has become somewhat diminished or even contested by the emergence of multiple other actors, particularly those who fund major health programs, whether it is individual high income countries, or inter-governmental organizations, or philanthropies. And we now see that there has been a call for a reform of WHO, partly because the WHO’s original role of being a predominantly normative and technical agency which provides guidelines to countries has been supplanted to some extent by having to provide response to multiple health system challenges which it may not be able to do entirely on its own.

There is also the major problem that the WHO is grossly underfunded and as a result has become increasingly donor dependent to run its own programs. To what extent are these donors influencing individual countries, or even now, using the WHO platform to advance their own prioritized agendas for health? So this concern has again started to increase within the global health community. At the same time, there is recognition that many of the regional offices are not performing very well, or perform in a manner that is quite disconnected with the headquarters and there is no real global coordination. While ‘One WHO’ was given as a slogan by the former director general, Dr. Gro Harlem Brundtland, there is little evidence to suggest that WHO functions in smooth unison across the world, because each regional office has a regional director elected by the countries of that region and therefore there is no real accountability to the global health community beyond that region. So we have multiple challenges which the WHO faces currently.

While there has been progress in health brought about by WHO initiatives, the question that has come up is, is the WHO capable of meeting the complex challenges of an altering global health scenario? The Chatham House which is an independent organization based in the United Kingdom, put together an expert group which recently reviewed the WHO’s performance and its changing role and came up with some recommendations for WHO reform. It suggested that the core functions of WHO should be much more explicit. It also suggested reviewing and restructuring regional offices and, and indicated that they should function with far greater accountability to their regions and spend lesser money for more results. It has suggested new avenues for collaboration which must be explored by WHO. It has also called for a reviewing of the skill mix that requires to go into WHO under separation of the technical and governance departments of WHO.

Now these recommendations of course will have to be considered by the countries who are member states of WHO and to see what extent the WHO can actually re-position itself as an important lead public health agency of the world. But that the global health has become a very crowded stage with multiple actors, there are about a 175 global health initiatives, funds, agencies and donors currently existing. Can WHO act as a convening platform for all of them without being unduly influenced by any of them? That’s the big question. At the same time, can WHO engage with other agencies which are dealing with issues like environment, trade, migration which have a substantial influence on health and effectively align them to the interests of global health? That again is a role that the WHO has to define for itself.

At the same time we recognize that the United Nations itself can also play a role as a convening platform for multisectoral action. It has indeed catalyzed broad development platforms initiating action on global health, for example the millennium development goals or the MDGs which were adopted by countries in the year 2000. And now the sustainable development goals which would be adopted by the countries in 2015 are also now likely to have a strong platform for global health action. At the same time, the United Nations held two high level summits, one on HIVAIDS in 2001 which led to the formation of the global fund for AIDS, tuberculosis and malaria and brought in considerable amount of funding into that field, with concerted donor coordination. It also had another high level political meeting on non-communicable diseases in September 2011, which is again, paving the way for global action on NCDs.

It has recently constituted a task force for concerted international action on Ebola. The Ecosoc, or the Economic and Social Council of the United Nations is again another platform where the United Nations can actually coordinate action across its multiple agencies. Whether it is the World Health Organization or the food and agriculture organization, or whether it is the World Trade Organization and the World Bank, this multi-agency platform has been effective in initiating work on tobacco control after the FTCT was adopted. And now that has been transformed into the U.N. task force on non-communicable diseases. When we are looking at multiple agencies now contributing to global health, we also have to look at not only conflicts between them, but also potential synergies. For example, the report for cancer research in U.K. in 2011 suggested that partnership between public authorities as well as charities for medical research could actually bring about great benefits in the form of shared costs, pooled risks, and more stability in family. However the issue of donor engagement brings in the whole question of accountability and responsible behavior by donors. Donors cannot set agendas which are not in the interests of the recipient countries. They also have to be accountable for the manner in which they conduct themselves.

So the Paris declaration of 2005 defined the roles and responsibilities of donor organizations to promote aid effectiveness and enunciated five principles: ownership, alignment, harmonization, managing for results, and mutual accountability. Now all of these are very important, providing ownership to the countries, a greater alignment with national priorities, harmonization among donors and effective managing for results and mutual accountability. It’s not just the countries which are accountable for the aid received, but the donors too are accountable for the way they conduct their business in the countries.

However, one of the major problems has been the multiplicity of donor organizations. With all the good intentions, there have been several donor organizations stepping into countries, for example in the area of HIVAIDS, you have had Ethiopia with 27 donor organizations in that area of health alone. Kenya with 26, or Tanzania with 25, Zimbabwe with 25, Rwanda with 23. It’s a whole crowded field. This imposes a huge burden on countries because they have to coordinate and liaise with all of these donors. They have to have separate reporting system for these donors. And the under-resourced health ministries of these countries crumble under the pressure of having to deal with multiple donors. So there is a great need for harmonization among the donors.

There is also the increasing role of civil society. Civil society groups can range from those which advocate for patient rights, or those which can advocate for better accountability of different health programs and voice the concerns of the communities. They can also participate in delivery of services. So the participation of civil society from policy to actual service delivery is becoming an important component of global health and these include both national NGOs as well as international NGOs. However, with the increasing number of NGOs we also have to differentiate between the nature of NGOs in terms of their intent and their origins. It has been humorously described that there are three categories of NGOs: the PINGOS or the public interest NGOs, the BINGOS are the business interest NGOs, or the GONGOS which are the government sponsored NGOs. So we’ll really have to deal with all of these, recognizing what their main interests are.

But there is yet another challenge in terms of global health governance, even when we recognize that the WHO could be an effective convening platform for multiple agencies, including civil society and the private sector, apart from the governments. The WHO itself is a soft governance organization. It provides guidelines and recommendations that members states can adopt or adapt based on their own discretion. They’re not mandatory. The member states can take them or leave them. Whereas organizations like the World Trade Organization are hard governance organizations. Their policies canbe much more definitive and binding for the member states. And they’re not always conducive to good health.

So we have to again, try and see how this balance of power nor asymmetry of power between different global organizations representing different interests can be reset and corrected so that the WHO get greater traction when it has to deal with agencies such as WTO or even others like FAO, or the World Bank.

So the implications are that WHO remains the lead public health agency of the world, but its influence and its role are now coming in for greater debate and to some extent, are being contested. We need to move towards a better defined global health governance system in which the WHO continues to play a very important role as a convening platform, the honest broker as I said, giving an effective role to each of these major players whether they’re individual governments or philanthropies or the private sector or the civil society, but insuring that the interests of global health predominate over any sectoral interest and also insuring that the roles played by all of these groups are complimentary rather than in conflict. And that is where the WHO has to now become a very new kind of organization, setting the agenda, coordinating and at the same time, becoming the conscience keeper of global public health.

---

---