International health governance
The World Health Organization (WHO) defines health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Accordingly, it is a vast field, which goes beyond the fight against major pandemics and includes very different topics, such as access to medicines, behavioural changes (the fight against smoking and drug addiction) and improving health systems, just to name a few. The WHO’s current four priorities are ensuring health security, fighting chronic diseases, achieving the MDGs (Millennium Development Goals) and fair access to health care for all.
However, globalization is still the process that seems to have the most decisive impact on health governance by modifying the context of how players work together: by increasing cross-border health risks, contributing to the transmission of diseases, or even by changing the geographic distribution of determining health factors. Moreover, globalization encourages an increase in the number of participants in health policies and the influence of non-State players. Finally, it contributes to the decline in States’ influential power to cope with global health challenges.
State of things: the recent emergence of many political, technical and financial players.
The WHO is the guiding and coordinating health authority for international work within the United Nations system. It is responsible for guiding global health actions, defining health research programmes, setting standards and criteria, presenting political options based on conclusive evidence, providing countries with technical support and monitoring and assessing public health trends.
For a long time, health has remained the reserved sphere of national policies, only recently arousing the interest of multilateral fora. The emergence of AIDS and the occurrence of epidemics, such as SARS (severe acute respiratory syndrome) have raised the international community’s awareness of globalized health issues.
Gradually, investing in health is no longer considered to be an expenditure, but rather an investment to further development. Health is becoming a major thrust area for international policies; underestimating the issues may lead to increased global instability. Inasmuch as it challenges its regulatory modes, health appears to be a growing issue for world governance.
... that has led to many initiatives and growing involvement of non-traditional players.
The observed delay in the achievement of the MDGs in health, the need to find considerable and permanent sources of financing and to coordinate the different actions for greater efficacy, have resulted in an increase in the number of initiatives in recent years, of which the GAVI and Roll Back Malaria (RBM) were the forerunners.
The growing position held by non-governmental players stresses the limitations of States and international organizations, which must adapt their practices to health issues.
Growing role of NGOs: the predominant role of NGOs and civil society has been seen particularly in the fight against HIV/AIDS. Accordingly, recent organizations, such as the Global Fund, UNITAID and UNAIDS, have included NGOS and representatives of affected persons on their boards of directors.
Growing involvement of private businesses and Foundations: the same is true of Foundations, with the major impact of the Bill and Melinda Gates Foundation, in particular, playing an increasingly important role through their involvement in the funding and governance of organizations, such as the Global Fund, Roll Back Malaria, GAVI, UNITAID, etc. The significant role of public/private partnerships is also of note: the Global forum for health research, a public-private partnership that receives public funds and works with companies, for example.
While until now it has been difficult to raise significant funding from companies, it is nevertheless likely that in a few years, they will get more involved.
The role of the pharmaceutical industry: an essential partner, the pharmaceutical industry is systematically present in most health governance fora, and accordingly can influence strategic decisions.
Limitations of current governance
Health management is scattered among the UN structure and other organizations and all of these activities lack coordination. As a result, there are redundancies, a certain amount of financial squandering and decreased effectiveness in the field. At the central level, memoranda of understanding have been signed between the Organizations (Global Fund/UNAIDS, Global Fund/WHO) but are not enough to allow for a harmonization of policies and cohesive actions in the field. However, using the framework of the Declaration of Paris, in a certain number of countries, national authorities endeavour to limit this scattering. In this respect, IHP+ is starting to apply this principle through the establishment of country agreements (“compact”) under the aegis of the WHO.
It should also be noted that with the emergence of and the growing role played by organizations that are not part of the United Nations system (Global Fund, GAVI, IDPF), the influence of the UN organizations and the WHO has been declining in the area of health. Finally, the recent proliferation of diplomatic initiatives related to innovative funding, the MDGs, etc. should be noted.
Restoring a coordinating role to the WHO in terms of defining world health policies, defending this mandate with other organizations and requiring the Organization to refocus its activities.
The WHO is the authority responsible for guiding global health actions, defining health research programmes, setting standards and criteria and presenting political options based on conclusive evidence. This mandate must be reinforced and supported in other international organizations.
Increasing inter-institutional coordination by supporting the organizations for which it is the main mandate: UNAIDS for the fight against HIV/AIDS, Roll Back Malaria for the fight against malaria, etc. and avoiding the creation of new vertical funds in the area of health.
Similarly, limiting the multiplication of diplomatic initiatives. Generally speaking, frameworks for dialogue and coordination already exist for all health-related topics. Now it entails using them as best and as effectively as possible and avoiding creating additional ones.
Applying the Declaration of Paris: this means increasing countries’ accountability in defining their health policies, expressed by a sectoral approach including assessments at the international level, the contributions of major UN and emerging institutions, but applying to the local context through the definition of priorities adapted to and adopted by the country.
Monitoring the commitments of aid-recipient countries: indeed, there is no agency, institution or independent organization responsible for monitoring the commitments of aid-recipient countries. In this respect, Abuja’s commitment is the most symbolic, but the multitude of commitments signed during international conferences should be subject to continuous monitoring, beyond the work carried out by the G8 health group.
Updated on 09.04.10