Wolfgang Hein

Addressing Global Health Governance Challenges through a New Mechanism: The Proposal for a Committee C of the World Health Assembly

The field of global health has reached a critical juncture, where both its visibility and the complexity of its challenges are unprecedented. The World Health Organization, as the only global health actor possessing both democratic and formal legal legitimacy, is best positioned to capitalize on this new, precarious situation in public health and respond with the governance innovation that is needed to bring the increasingly chaotic network of activities and entities affecting health outcomes under the fold of a centralized, standard-setting agency. One such proposed innovation to guide normative and strategic coordination in global health is the creation of a Committee C of the World Health Assembly that would promote consensus building and multi-stakeholder decision-making within the unique convening power of the World Health Organization.

Conceptual Models for Global Health Governance

Globalization has led to an appreciation of a global politics beyond the control of nation-states and the traditional system of international relations. Global politics is characterized by a pluralization of governance mediated by a constant effort to establish shared norms of global public goods and bads to constrain the exercise of power or, expressed in another way, to attain a more equitable access to power resources. Traditional state institutions of national and international governance have become more diversified as a reaction to their inherent limitations and the increasing power of new forms of governance built by private actors. Though the state remains a powerful, often dominant, actor in governance, it competes with and sometimes is itself governed by a diverse set of non-state actors, including corporations, foundations, religious groups, social advocacy organizations and ‘dark networks’, such as al-Qaeda or narcotics cartels. States and traditional institutions of international governance are increasingly seen as complex assemblages in and of themselves, comprised of more or less well-networked nodes operating somewhere on the spectrum between cooperation and competition. States have actively embraced this pluralization, seeking to increase or protect their power by vigorous use of governance devices such as privatization and partnerships. These developments are clearly visible in the health sector, which has witnessed an institutional change from a structure that consisted primarily of independent national health systems and some international agencies devoted to controlling the cross-border effects of ill-health towards a system of global health governance (GHG). Contemporary GHG is characterized by a polycentric, distributed structure and a substantive concern with issues that affect populations worldwide directly (for example, the global spread of infectious diseases or antibiotic resistance) or indirectly (for example, political instability and global insecurity arising from extreme socio-economic inequality). Global health governance now requires management not merely of specific transborder epidemics, like SARS or avian influenza, but of the host of issues in health that arise at the intersection of a globalized economy and lives lived in particular localities. Dealing with ‘global’ health challenges increasingly requires attention not only to ‘horizontal’ coordination of global politics, but also to more effective vertical integration of global-level governance with governance at the national and local levels. Both practitioners and students of health policy require new conceptual tools to understand and influence GHG. During recent years, two models have been developed that, from different perspectives, address these characteristics of multiplicity of actors, flexibility of institutional arrangements and fluidity of relationships. The ‘nodal governance’ framework builds on network theories to describe distributed governance and the ways in which institutions project power across networks to govern the systems they inhabit. The concept of ‘interface’, refers to ‘a specific space, where two different social systems or fields of social order interact (here: global/national systems; institutional systems related to modes of regulation), which are characterized by specific institutions and specific backgrounds. Independently, the concepts of nodal governance and interfaces can help us to understand what constitutes the binding forces and the types of power mobilized among the multitude of actors in global health governance. Taken together, they illuminate key challenges to good GHG: improving democracy, efficacy and coordination. This chapter uses these two frameworks to understand the emerging dynamics of GHG and then illustrate their usefulness through a discussion of the global governance of HIV/AIDS.

The global health concept of the German government: strengths, weaknesses, and opportunities

Recognising global health as a rapidly emerging policy field, the German federal government recently released a national concept note for global health politics (July 10, 2013). As the German government could have a significant impact on health globally by making a coherent, evidence-informed, and long-term commitment in this field, we offer an initial appraisal of the strengths, weaknesses, and opportunities for development recognised in this document. We conclude that the national concept is an important first step towards the implementation of a coherent global health policy. However, important gaps were identified in the areas of intellectual property rights and access to medicines. In addition, global health determinants such as trade, economic crises, and liberalisation as well as European Union issues such as the health of migrants, refugees, and asylum seekers are not adequately addressed. Furthermore, little information is provided about the establishment of instruments to ensure an effective inter-ministerial cooperation. Finally, because implementation aspects for the national concept are critical for the success of this initiative, we call upon the newly elected 2013 German government to formulate a global health strategy, which includes a concrete plan of action, a time scale, and measurable goals.Recognising global health as a rapidly emerging policy field, the German federal government recently released a national concept note for global health politics (July 10, 2013). As the German government could have a significant impact on health globally by making a coherent, evidence-informed, and long-term commitment in this field, we offer an initial appraisal of the strengths, weaknesses, and opportunities for development recognised in this document. We conclude that the national concept is an important first step towards the implementation of a coherent global health policy. However, important gaps were identified in the areas of intellectual property rights and access to medicines. In addition, global health determinants such as trade, economic crises, and liberalisation as well as European Union issues such as the health of migrants, refugees, and asylum seekers are not adequately addressed. Furthermore, little information is provided about the establishment of instruments to ensure an effective inter-ministerial cooperation. Finally, because implementation aspects for the national concept are critical for the success of this initiative, we call upon the newly elected 2013 German government to formulate a global health strategy, which includes a concrete plan of action, a time scale, and measurable goals.

Transnational Norm-Building in Global Health: The Important Role of Non-State Actors in Post-Westphalian Politics

The International Compact on Economic, Social and Cultural (ESC) Human Rights constitutes codified international law, but many of its provisions are still far from being respected. This paper discusses the hypothesis that global civil society strengthens subsidiary norms (as the right to access to essential medicines) and that the successful fight for the implementation of the norm ‘universal access to essential medicines’ proves the discursive power of civil society organisations (CSOs) in the field of human rights.

AIDS, Access to Medicines, and the Different Roles of the Brazilian and South African Governments in Global Health Governance

The present article illustrates how the main actors in global health governance (GHG)— governments, nongovernmental organizations (NGOs), intergovernmental organizations (IOs), and transnational pharmaceutical companies (TNPCs)—have been interacting and, as a result, modifying the global health architecture in general and AIDS treatment in particular. Using the concept of “power types” (Keohane/Martin) and “interfaces” (Norman Long), the authors examine the conflicts among major GHG actors that have arisen surrounding the limited access to medicines for fighting HIV/AIDS basically as a result of the Agreement on Trade Related Intellectual Property Rights (TRIPS), in force since 1995. They then analyze the efforts of Brazil and South Africa to obtain fast and low-cost access to antiretroviral medication against AIDS. They conclude that while policy makers in the two countries have used different approaches to tackle the AIDS problem, they have been able, with the support of NGOs, to modify TRIPS and change some WTO rules at the global level along legal interfaces. At the national level the results of the fight against AIDS have been encouraging for Brazil, but not for South Africa, where authorities denied the challenge for a prolonged period of time. The authors see the different outcomes as a consequence of Brazil’s ability to combine discoursive, legal, administrative, and resource-based interfaces.

Interfaces: a Concept for the Analysis of Global Health Governance

In the introduction we summarized the basic aspects of the relationship between globalization, poverty and health and briefly referred to the developments that led to the emergence of the current structures of global health governance (GHG). In this chapter we will develop an analytical approach towards a better understanding of this GHG architecture, which combines International Relations theory with a concept to analyse the linkages between global governance actors.

A United Nations Global Health Panel for Global Health Governance: A commentary on Mackey

(a) to act as the directing and coordinating authority on international health work; (b) to establish and maintain effective collaboration with the United Nations, specialized agencies, governmental health administrations, professional groups and such other organizations as may be deemed appropriate; (i) to promote, in cooperation with other specialized agencies where necessary, the improvement of nutrition, housing, sanitation, recreation, economic or working conditions and other aspects of environmental hygiene; (j) to promote cooperation among scientific and professional groups which contribute to the advancement of health; (k) to propose conventions, agreements and regulations, andmake recommendations with respect to international health matters .”

Introduction: Globalization, HIV/AIDS and the Rise of Global Health Governance

After around fifteen years in which North–South relations have focused on the debt crisis, structural adjustment and global economic governance, issues of social development and, in particular, health-related concerns have emerged as central themes in the dialogue. Two issues have been at the forefront of public attention. On the one hand, infectious diseases not only constitute a threat for global public health, but also threaten the social and economic stability in the developing world (with HIV/AIDS at the centre of attention), whilst on the other hand, significant institutional changes are currently taking place, leading towards the emergence of an increasingly complex system of global governance. The prominence of these two issues reflects the fundamental changes that have occurred in global health since the Alma Ata Declaration of ‘Health for All’ and the establishment of primary health care systems under the leadership of the World Health Organization (WHO) were at the centre of international health politics.

Conclusion: Global Health Governance and the Fight Against HIV/AIDS in a Post-Westphalian World

In modem times, the fight against infectious diseases has always depended on international cooperation, requiring nations to coordinate their health and trade strategies with each other. As we have shown in the previous chapters, however, the need to create a global response has never been stronger than in the case of the HIV/AIDS epidemic, which seems in turn to have heightened global awareness in the cases of more recent epidemic threats like those of SARS and Avian Flu. After neo-liberalism and the early structural adjustment programmes had given primary attention to macroeconomic policies, the need to improve health conditions in poor countries as a precondition for economic growth (CMH 2001), fighting poverty and improving security1 again became a central part of the global political agenda during the 1990s. This new priority for health, that included the recognition of large inequalities in global health as a threat for rich countries, became one important dimension in framing the public perception of the fight against HIV/AIDS and strengthening the role of global civil society in conflicts around access to medicines.

Entwicklung messen: Ein Überblick über verschiedene Indikatoren und ihre Grenzen

Der Beitrag stellt die Vielfalt von Indikatoren und Indizes im Politikfeld „Entwicklung“ im Kontext des sich wandelnden Verstandnisses dieses Konzeptes seit den 1940er-Jahren dar. Im Laufe der Zeit entstehen neue Schwerpunkte, die zur Entwicklung von neuen Indikatorenbundeln fuhren (Wachstum und Modernisierung, soziale Entwicklung, nachhaltige Entwicklung, Governance, Gluck und Wohlbefinden). Seit Ende der 1960er-Jahre werden zunehmend Indizes gebildet, die verschiedene Indikatoren zusammenfassen. Der Beitrag schliest mit der Diskussion einiger grundlegender Fragen zum Messen von Entwicklung.