In 1999, access to medicines activists began to talk about the lack of research and development in place to address the massive burden of disease found only in low and middle-income countries. Coining the term neglected diseases, these actors pointed out that while malaria, sleeping sickness and Chagas disease killed millions of people each year, they were neglected by the research and development system. While 90% of deaths from these and other neglected diseases occurred in LMICs, only 10% of the global research funds went to addressing them. A report commissioned by the WHO proposed that a research and development fund be created by an international convention (R&D Treaty) as an important step to increase urgently-needed research and development into those diseases. Yet, after 14 years, the concept of an R&D Treaty has not even been developed let alone realized. Neglected diseases continue to be under-researched and under-funded. The reason? A handful of rich and powerful countries forming a small minority of the governing countries of the WHO have dominated the R&D Treaty debate and have been allowed to strongly and consistently oppose the proposal.
This example, just one of many in the long access to medicines journey, illustrates three key realities of the global health governance system today all of which compromise much-espoused goals of health and equity worldwide. First, the R&D agenda has revealed the lack of inclusive participation to reflect meaningful and collaborative involvement by the plurality of global health actors. Entities as diverse as humanitarian organisations, grassroots civil society and pharmaceutical companies all play a role in pushing and pulling on negotiations between States, each displaying a different power and influence. Yet, that role remains informal and lacks transparency either in process or result. The result is a system which is unaccountable to its beneficiaires and which can be driven by political and economic agendas instead of social justice and equity. Second, the reasons for the stalemate on the R&D Treaty demonstrate the impact of important power asymmetries between different State and non-State actors. It also raises questions once again about the extent of cooptation of the global health agenda by corporate interests. The role of the rich nations in stalling the process (and reigniting it) and the influence of the pharmaceutical industry in triggering those policy positions remains an underlying issue for progress in developing an equitable medical R&D system. Finally, the risk of dilution of the global health agenda by mainstreaming the concept in every area of the development agenda threatens to undermine the currency of global health.
The passage of the R&D Treaty reveals that those three realities for good global health governance have not been achieved through the existing model. The severity and tenacity of global health challenges compels us to think beyond the status quo. We need to look beyond the outmoded interpretations of how global health should be governed and beyond merely tinkering at the edges of the existing system. In Working Paper number 11 of the ISGlobal Think Tank, I make the case for a developing a new normative and institutional framework to suit the global health reality of today’s world. I challenge the status quo of a seventeenth century state-centric international governance model and attempt to demonstrate its limited practical relevance in a much changed globalized world. I use the new and refreshing perspectives of some scholarly descriptions of the reality of governance to provide compelling and hopeful insights into how a non-state centric, or multicentric, global governance for health framework built on the foundations of equity and social justice could work in some current global health issues.
It is never easy to challenge the status quo. However, the reality demands that policy makers identify and address the real reasons behind the failure of the architecture to right the global wrongs. Globalisation has impacted our world in unforeseen and fundamental ways and it is time for global governance to reflect that. We need to recognise the shifts in governance already taking place and challenge outmoded structures as the pragmatic option to meet the desperate global health needs worldwide. The ISGlobal paper is deliberately provocative – it is an effort to look beyond the status quo and to appreciate new ways of doing, ways which are already appearing in a sporadic way today. UNITAID, DNDi and the Global Fund all reveal elements of a multicentric approach to global governance for health and each is having improved and wide ranging impacts on global health outcomes on the ground.
The question now is how to create the momentum for a more systematic approach to incorporate multi-centric principles throughout the global health system. If global health needs are to be addressed, we need to start thinking outside the box.
A Non-State Centric Governance Framework for Global Health