A revolution in global health has occurred in the past ten to fifteen years, resulting in the creation of radically new regimes, an unprecedented growth in funding for global health, and the growing influence of policymakers, activists, and philanthropists who viewed global health as a foreign policy issue of first-order importance. Nevertheless, many deficiencies remain in global health governance, which create suboptimal outcomes for individual and population health.
This Working Paper, sponsored by CFR's International Institutions and Global Governance program, examines the complicated landscape of global health governance, assesses the capabilities of existing institutions, and recommends more effective strategies for policy implementation. Although the United States will not have the resources to contribute to global health at the same level as it did over the past two decades, the paper argues that U.S. leadership will be critical to future success in global health governance.
Three crises in 2009 revealed the inadequacy of global health governance. The outbreak of pandemic influenza A (H1N1) found countries scrambling for access to vaccines, an unseemly process that led the World Health Organization to call for a new "global framework" on equitable influenza vaccine access. The global economic crisis damaged efforts to achieve the Millennium Development Goals, most of which involve health problems or address policy areas affecting health. The year ended with the fractious Copenhagen negotiations on global climate change, a problem with fearsome portents for global health.
Unfortunately, concerns about global health governance are not limited to these epidemiological, economic, and environmental crises. Experts also warned about issues: the failure to prevent HIV/AIDS, antimicrobial resistance, counterfeit drugs, the global prevalence of noncommunicable diseases related to tobacco consumption and obesity, the migration of health workers from developing to developed countries, and the deterioration in the social determinants of health. Efforts to address these and other global health problems often acknowledge that existing institutions, rules, and processes are insufficient to support collective action.
Ironically, these questions about governance effectiveness have been raised in the wake of a revolution in global health governance over the past ten to fifteen years. This revolution encompassed the creation of radically new regimes, an unprecedented growth in funding for global health, and the growing influence of policymakers, activists, and philanthropists who viewed global health as a foreign policy issue of first-order importance. As a result, global health has become an essential part in the equation of international relations.
In addition to the use of long-standing institutions and well-established international legal regimes relevant to global health, new programs and initiatives emerged, opening the door to both competition and cooperation among states, intergovernmental organizations (IGOs), and nonstate actors. Global health governance innovations include new legal frameworks, public-private partnerships, national programs, innovative financing mechanisms, and greater engagement by nongovernmental organizations, philanthropic foundations, and multinational corporations.
These transformations have produced a complicated governance landscape, composed of overlapping and sometimes competing regime clusters that involve multiple players addressing different health problems through diverse processes and principles. Together, these regime clusters form a global health governance regime complex in which states, intergovernmental organizations, and nonstate actors apply old and new institutions, rules, and processes to strengthen collective action against health threats.
Although unprecedented in international cooperation on health, the current regime complex for global health governance suffers from defects that many experts believe are responsible for suboptimal outcomes for individual and population health. These defects include failures to prevent health problems from becoming global dangers, to produce effective responses to global health threats, to implement important treaties on global health, to develop stronger health systems in developing countries, and to stimulate sufficient progress on social determinants of health. Many proposals for addressing these defects assume that global health's importance in world affairs will continue at the same level or increase, but the potential for far-reaching reforms in global health governance in the next decade are minimal for many reasons.
The United States will influence how cooperation on health unfolds in the twenty-first century. It provided leadership in the global health governance revolution through expanded foreign assistance, bilateral engagements, regional initiatives, and participation in multilateral organizations. However, without more effective strategies and better policy implementation, the U.S. role in the next phase of global health governance will diminish under the pressures of competing priorities and shrinking financial resources. To provide leadership over the course of the next decade, the United States should take the following steps to improve global health governance:
–Craft a comprehensive global health strategy for the U.S. government;
–Focus on priority areas of global health governance, namely the International Health Regulations 2005 (IHR 2005), global tobacco control, the Millennium Development Goals, and strengthening national health systems in developing countries;
–Embed global health as a priority for the Group of 20 (G20) by creating demand for global health issues on its agenda;
–Strengthen health cooperation within regional organizations; and
–Integrate health inputs into debates about global governance problems outside the health realm, such as economic governance, trade, and climate change.