A Non-State Centric Governance Framework for Global Health

Paper by Rachel Kiddell-Monroe (Universities Allied for Essential Medicine, UAEM) for the ISGlobal Think Tank.

Executive Summary

Something is wrong with global health. While many agree that the agenda should place a priority on improving health and achieving equity in health for all people worldwide,1 good intentions have not translated into an improved reality on the ground. Despite the promises, the money, the panoply of actors and the political will of States, countless lives are needlessly lost to tuberculosis, HIV/AIDS, sleeping sickness, diarrhoea, diabetes, to name but a few. Even when key ways to address these issues are proposed, they do not see the light of day. Take the critical proposal for a Medical Research and Development Convention to stimulate the research and development of new treatments for neglected diseases. After 14 years of efforts, it was on the brink of success and ready to be negotiated at the World Health Assembly 2013. Yet, it was delayed yet again by a global health governance process driven by political and economic national agendas rather than the interests of people, equity and social justice. As the WHO Director General Margaret Chan has said, it seems that global health is "caught in a crosscurrent, with a potentially lethal undertow."

Health and equity are compromised both by the power of different players to influence and enforce the governance of global health and by the existing governance mechanisms used to set the health agenda. The existing global governance system has proven unable to respond to global health crises such as the access to health services and medicines. This paper argues that the current system of global health governance is outmoded and inherently unable to provide a comprehensive and coherent approach that guarantees health for all. Addressing this crisis requires new normative and institutional frameworks suited to the global health reality of today's world and that have equity and social justice at their core. A new framework should (a) ensure inclusive participation which reflects meaningful and collaborative involvement by the plurality of global health actors; (b) rebalance the power asymmetries in global health, including challenging the cooptation of the global health agenda by industry; and (c) ensure that global health remains a meaningful and focused approach, which is not diluted by mainstreaming the concept in every area of the development agenda.

The severity and tenacity of global health challenges compels us to think beyond the status quo. This paper attempts to do that by looking at global health governance from the perspective of institutional innovation and political creativity. It explores the idea of a non-State-centric or multicentric global governance framework as a challenge to the current geopolitical power structure, and builds on the practical wisdom drawn from the reality of governance issues encountered through the access to medicines debate. By incorporating the descriptive insights of several scholars on open source anarchy and nodal governance, a multicentric framework is presented as a fresh and pragmatic approach that provides the space for reality and innovation in global governance to respond to the calls for equitable and just global health outcomes.
The paper is presented in three parts: (1) the reality of global health and the three realities of its governance (2) why the current system of global health governance cannot address those realities effectively and sustainably and (3) how multicentric global governance for health can provide a sustainable and innovative framework for global health.