Anne Roemer-Mahler

Framing global health: The governance challenge

Abstract With the emergence of global health comes governance challenges which are equally global in nature. This article identifies some of the initial limitations in analyses of global health governance (GHG) before discussing the focus of this special supplement: the framing of global health issues and the manner in which this impacts upon GHG. Whilst not denying the importance of material factors (such as resources and institutional competencies), the article identifies how issues can be framed in different ways, thereby creating particular pathways of response which in turn affect the potential for and nature of GHG. It also identifies and discusses the key frames operating in global health: evidence-based medicine, human rights, security, economics and development.

Business conflict and global politics: The pharmaceutical industry and the global protection of intellectual property rights

ABSTRACT Most existing studies on the role of business in global governance conceive of business as one group acting vis-à-vis the state or NGOs. This article highlights that conflicts within the business community can be an important factor to explain policy outcomes. Drawing on the ‘business conflict school’ literature from International Relations, studies on the politics of markets developed in Economic Sociology, and work on corporate political strategy undertaken in Management Studies, it develops the concept of the governance-competitiveness nexus to theorize how economic competition translates into political competition. The article demonstrates how such an analytical angle can add to our understanding of the global governance of intellectual property rights for pharmaceuticals. It helps explain the motives of different actors to become politically involved at specific points in time and the policy goals they promoted. Thus, the concepts of business conflict and governance-competitiveness nexus help explain the agenda setting process on global pharmaceutical IP governance.

Making new vaccines affordable: a comparison of financing processes used to develop and deploy new meningococcal and pneumococcal conjugate vaccines

Mechanisms to increase access to health products are varied and controversial. Two innovative mechanisms have been used to accelerate the development of low-price supply lines for conjugate vaccines. The Meningitis Vaccine Project is a so-called push mechanism that facilitated technology transfer to an Indian company to establish capacity to manufacture a vaccine. The Advanced Market Commitment for pneumococcal vaccines is a so-called pull mechanism that guarantees companies a supplement paid in addition to the purchase price for vaccines for a specific period. We compare these approaches, identifying key dimensions of each and considering their potential for replication. We also discuss issues that the Global Alliance for Vaccines and Immunisation (GAVI) face now that these new vaccines are available. Progress towards GAVIs strategic aims is needed and funding is crucial. Approaches that decrease the financial pressure on GAVI and greatly increase political and financial engagement by low-income countries should also be considered.

Securing circulation pharmaceutically: Antiviral stockpiling and pandemic preparedness in the European Union

Governments in Europe and around the world amassed vast pharmaceutical stockpiles in anticipation of a potentially catastrophic influenza pandemic. Yet the comparatively ‘mild’ course of the 2009 H1N1 pandemic provoked considerable public controversy around those stockpiles, leading to questions about their cost–benefit profile and the commercial interests allegedly shaping their creation, as well as around their scientific evidence base. So, how did governments come to view pharmaceutical stockpiling as such an indispensable element of pandemic preparedness planning? What are the underlying security rationalities that rapidly rendered antivirals such a desirable option for government planners? Drawing upon an in-depth reading of Foucault’s notion of a ‘crisis of circulation’, this article argues that the rise of pharmaceutical stockpiling across Europe is integral to a governmental rationality of political rule that continuously seeks to anticipate myriad circulatory threats to the welfare of populations – including to their overall levels of health. Novel antiviral medications such as Tamiflu are such an attractive policy option because they could enable governments to rapidly modulate dangerous levels of (viral) circulation during a pandemic, albeit without disrupting all the other circulatory systems crucial for maintaining population welfare. Antiviral stockpiles, in other words, promise nothing less than a pharmaceutical securing of circulation itself.

The transformation of global health governance

The authors examine how health governance is being transformed amid globalization, characterized by the emergence of new actors and institutions, and the interplay of competing ideas about global health. They explore how this has affected the governance of specific health issues and how it relates to global governance more broadly.

WHO must remain a strong global health leader post Ebola

The 2014 Ebola outbreak in west Africa has demonstrated again the urgent need for strong leadership and coordination in responding to global health challenges. As members of the global health scholarly community, we call upon all WHO Member States to recommit themselves to strengthening global outbreak alert and response by sustainably investing in the WHO, its departments, and personnel. As members of the WHO secretariat have admitted, mistakes were made in how the organisation initially responded to the 2014 Ebola outbreak. Ahead of the 68th World Health Assembly in May, 2015, the temptation will be to point fingers and use the extreme case of Ebola to justify further erosion of the WHO. The temptation might also be to divert voluntary contributions to other institutions. We firmly believe that any such measures must be approached with extreme care. In international forums, a proposal is being discussed to establish a new “first responder” UN agency, which will provide emergency operational assistance in humanitarian crises by rapidly deploying trained personnel, equipment, and supplies. While an enhanced rapid response would be beneficial, a new agency would be subject to the same vagaries of institutional funding and Member State interests in delivering its mandate. Even more importantly, these are functions that the WHO already fulfils via the Global Outbreak Alert and Response Network (GOARN), which maintains a roster of experts that can be deployed to assist in humanitarian disasters. The resources to create an entirely new agency would therefore be better served by strengthening the WHOs emergency response division rather than duplicating existing functions. Resources could also be more effectively used to help Member States implement the International Health Regulations (2005) via health system strengthening. An independent investigation of the WHOs handling of the 2014 Ebola outbreak is both appropriate and warranted. The investigation should focus on the structural and procedural elements of institutional practice, consider how recent funding cuts affected the WHOs ability to respond, and identify pathways to sustainable funding of the institution. The WHO can provide global health leadership that is technically informed and representative. The organisation remains a fundamental element of global health governance, and provides an indispensable service as the lead technical agency in global health. While mistakes have been made, rather than engage in the further dismantling of the WHO we call on all Member States and the international community to give the organisation the resources it needs to serve its members and the populations they represent.

The rise of companies from emerging markets in global health governance: Opportunities and challenges

The article analyses the involvement of pharmaceutical companies from emerging markets in global health governance. It finds that they play a central role as low-cost suppliers of medicines and vaccines and, increasingly, new technologies. In so doing, pharmaceutical companies from emerging markets have facilitated the implementation of a key goal of global health policy: widening access to pharmaceutical treatment and prevention. Yet, looking closer at the political economy underlying their involvement, the article exposes a tension between this policy goal and the political economy of pharmaceutical development and production. By declaring access to pharmaceuticals a goal of global health policy, governments and global health partnerships have made themselves dependent on pharmaceutical companies to supply them. Moreover, to provide pharmaceutical treatment and prevention at the global level, they depend on companies to supply medicines and vaccines at extremely low prices. Yet, the development and production of pharmaceuticals is organized around commercial incentives that are at odds with the prices required. The increasing involvement of low-cost suppliers from emerging markets mitigates this tension in the short run. In the long run, this tension endangers the sustainability of global access policies and may even undermine some of the successes already achieved.

Introduction: Ebola and International Relations

Abstract The outbreak of Ebola Virus Disease (EVD) that gripped Liberia, Guinea and Sierra Leone through much of 2014 and 2015 was an enormous and in many ways unprecedented health emergency. Yet the outbreak was not only a global health event – it was also a global political event. In this introduction to the special issue we discuss the contribution that International Relations scholarship can make to analysing and understanding the Ebola outbreak and the global response to it. We group our comments around four key themes: (1) allocating responsibility in a diffuse global health governance system; (2) the causes and effects of Ebola being perceived as a global crisis; (3) the downsides of a security-driven approach to global health emergencies; and (4) issues of inequality both between and within countries, including those around gender, resources and power.

Understanding Global Health Governance: A Review of Jeremy Youde’s Book

If you are looking for a comprehensive overview of the history and key actors involved in addressing global health issues, then Jeremy Youde’s book Global Health Governance provides an authoritative survey. Youde documents the initial origins of the field as it emerged from concern about infectious diseases and the potential impact on trade from overly restrictive quarantine measures. He captures the important post-World War II rise of the World Health Organization (WHO) as the central agency tasked to deal with international health issues. He covers its success in smallpox eradication and the organization’s gradual decline as its core budget remained flat and other actors such as the Global Fund and the Gates Foundation emerged. I assigned the first six chapters of Youde’s book for my graduate course this past spring, and for those who need to be brought up to speed in a hurry on the major actors in global health, Youde’s book is a tremendous contribution. The three final substantive chapters cover an eclectic set of substantive issues in global health, surveillance in global health and the International Health Regulations, the risks of framing health issues as security threats, and access to pharmaceuticals, focusing on AIDS drugs.

Conclusion: The Transformation of Global Health Governance

This chapter identifies how transformations in global health governance are reflected in the governances of specific health issues such as human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), pandemic influenza, tobacco control and access to medicines. It illustrates the importance of ideas such as security, rights, economics, development and bio-medicine in the formation and legitimisation of interests in global health. The chapter explains the link between global health governance and other areas of global governance. It also underscores the multisectoral nature of global health governance and how this is reflected in institutions and actors. Finally it suggests that the way forward in improving global health governance is to link health and other concerns both in the framing of issues and in institutional architecture.