Understanding the 21st-century global health governance to truly become one

It may take us by surprise that the second-largest donor of the World Health Organisation (WHO), after the United States, is not a G7 state but a charitable organisation — The Bill and Melinda Gates Foundation. The United States contributed more than $400 million (15%) of WHO’s annual budget in 2018/19 while the foundation funded 9.8%.

The WHO program budget of 2018 unveiled that member states contributed only 51% of total revenue. Non-state actors such as philanthropic foundations held a 13% share followed by non-governmental organisations at 9%, private sector entities at 2%, and academic institutions at less than 1%.

These actors bring innovation and technological expertise through investment in research and development, enabling swift responses to challenging situations and crises through active participation and driving stakeholder engagement.

This represents a shift in global health governance which was not usual in the 20^th century — when the state was the fundamental actor in most instances and coordination with non-state actors was not common.

Undoubtedly, the 20^th century witnessed remarkable strides. The establishment of the World Health Organization (WHO) to pursue global health efforts was a pivotal effort of the United Nations (UN) and its members. This period also saw remarkable progress in vaccine development.

The global impact of two world wars led to realisation of the need for significant health cooperation for containment and prevention. Global health started to be perceived vis-à-vis developmental goals.

This epoch also kindled awareness of the issues faced by Global South, their narratives finding resonance in international forums. However, the role of non-state actors was limited because of constrained resources and state-centric international relations.

In the 21^st century, the urgent necessity for the global community to commit to the collaborative effort is highlighted by the emergence of multiple life-threatening disease outbreaks such as SARS-CoV, Swine influenza (H1N1 Virus), Ebola Virus, and COVID-19, among others, which wreaked havoc in the first quarter of the 21^st century.  

In global health governance, both state and non-state actors, along with multilateral institutions, leverage formal and informal structures of global health governance to collaboratively and effectively address cross-border health challenges.

Under this system, non-state actors including civil societies have emerged as prominent actors in addressing the challenges of today — meanwhile crowding out the state’s role — which cannot be overlooked. Funding ensures their participation and roles in the system wherein they can raise their voice globally and share their expertise.

Yet there is more to this system — notable characteristics,  trends, and shortcomings.

Democratisation of global health governance

Health issues have become inalienable to the security and economic and political challenges of the state.

David P. Fidler, Senior fellow for global health and cybersecurity at the Council on Foreign Relations, argued SARS was the political pathology of the first post-Westphalian pathogen. The modern state system is based on the Treaty of Westphalia signed in 1648 after the end of the Thirty Years’ War.

Many crucial setups materialised from the treaty shape international politics to this day, including the principles of sovereignty, the balance of power, and international law.

Post-Westphalian refers to the changing trends away from traditional discernment of Westphalian order thanks to the increase in multilateral institutions in the decision-making, transnationalism, internationalisation of human rights, and globalisation. 

The SARS virus originated in 2002 at a time when the world was more proximate than ever. Just a year back, the Twin Tower attack in New York by the militant organisation al-Qaeda became the most consequential event of the century — threats, whether pandemic or terrorism, have ever since becoming a matter of utmost importance prompting the involvement of various stakeholders from multiple disciplines and orientations.

On the other hand, the participation of non-state actors led to growth in awareness and advocacy. The collaboration of Civil Society, International Organizations, Private Sectors, Academia, and Philanthropic Organizations led to comprehensive decision-making and fair distribution of resources.

Participation and collaboration are very crucial for the global health agenda of our time. This has helped to democratise global health governance which was limited to the state apparatus.

Resources accumulation by specific disease

When pandemics such as the SARS virus, Ebola virus, and COVID-19 struck, policymakers, academia, institutions, and nation-states zeroed in on containing the spread of disease. 

Scholars such as William Aldis identified that the concept of health security has been ‘widely used but rarely adequately defined.’ It is argued that the dominant health discussion is centred around a few issues. These include infectious diseases such as HIV and AIDS and bioterrorism or biological weapons. 

During the decade of the 2010s, the Ebola virus, which originated in West Africa, had a significant impact on the affected countries. Coronavirus, the most recent pandemic, overwhelmed the healthcare system globally. The occurrence of these pandemics has diverted the focus of major stakeholders in global health governance. 

Identifying infected individuals, and developing the vaccine with the help of research is a long process that takes time. The redirection of focus results in the substantial allocation of resources. As pandemics are potential national security threats, the states spend heavily to contain the spread of pathogens.

During unprecedented times, media and stakeholders pay attention to the emergencies marginalising other health issues. Similarly, poor and developing countries whose public health foundations are weaker, find themselves in a daunting situation to pay the cost of this international trend. 

Global North-South asymmetry

With its history of colonisation, industrialisation, technological advancement, and research and development, the Global North (the Western advanced capitalist nations) has benefitted massively from the structural privileges. 

Most of the countries of the Global South were colonised by erstwhile European powers. The latter’s culture was suppressed and resources exploited leading to power asymmetry in the 18^th, 19^th, and 20^th centuries perpetuated by the chain of dependency.

For instance, the majority of the research institutions and pharmaceutical companies responsible for developing the COVID-19 vaccines are located in advanced capitalist economies. Pfizer-BioNTech, Moderna, Oxford AstraZeneca, and Janssen vaccines — all were developed by Global North-based pharmaceutical companies.

Major institutions established after the end of the Second World War, such as the World Bank, IMF, and WTO, served the hegemonic interests of the Global North and continue to do so further reinforcing their capabilities.  

For instance, the WTO’s laws on Intellectual Property Rights became the biggest bottleneck in ensuring equitable vaccine access as only 0.2% of the 700 million globally administered vaccines went to low-income countries by May 2021. 

In October 2020, India and South Africa proposed WTO temporarily waive Intellectual Property protection (patents, copyrights, industrial designs, and undisclosed information (trade secrets)) for vaccines until everyone is safe, which sparked a global debate over the waiver’s effectiveness in alleviating the vaccine shortages.

Opponents argued that even if the patents are waived, a lack of technical expertise and critical ingredients in many countries would make the process difficult (The waiver was officially adopted in June of 2022).

Meanwhile, researchers argue that Global North’s unwillingness to commit toward multilateralism and lack of long-term vision along with their corporate interest resulted in vaccine apartheid leading to the failure of global cooperation.

Globalist vs statist perspective

Health security has been characterised by containment, not prevention — with states emphasising to contain the spread of the virus in their territory to protect their citizens first. 

Sara Davies, Professor at Griffith University, describes health security from two international relations perspectives — globalist and statist. The individual is the focal point in the globalist perspective that stresses the accessibility of an individual to health services regardless of their orientation and geography of residence. 

The statist perspective is centred on state-led prevention — how citizens can be protected from external health security threats where the state is the sole provider of health security. This perspective is aware of state sovereignty which the globalist perspective is critical of.

The US-China scuffle during the critical juncture of the COVID-19 pandemic made international collaboration uncertain. The Trump administration criticised China for its handling of the outbreak and shared disappointment in not sharing information.

The United States also accused WHO of being “a puppet of China”. This made collaboration uncertain at that time. 

Global health security is statist in nature having a close relationship with international security. Globalist perspective privileges prevention as no one is safe until everyone is safe. Meanwhile, the statist perspective overlooks the global prevention strategy at large, prioritising the containment strategy for the interest of their nation. The shadow of the Westphalian system is visible here. 

During the time of COVID-19,  both perspectives and practices were at play — the former represented by organisations and initiatives such as WHO, Bill and Melinda Gates Foundation, and COVAX while the latter was nation-state led.

Optimism and the way forward

The idea of global health governance that recognises the interrelation of security concerns and health issues has enabled multiple health professionals to sit at policy tables discussing security policy at large. National and international security institutions now invite several health experts to share their expertise on pandemics and infectious diseases control while health institutions have a larger stake in to fight against security threats.

The pivotal role of WHO, which is considered the main actor in global health governance and in health governance and policy implementation is underscored, yet oftentimes, there are instances of lapses in leadership. For instance, WHO’s delays in addressing the Ebola epidemic in West Africa.

Challenges also occur when larger global political interest is intertwined with health priorities — marked by geo-political contestation between major powers. 

Similarly, the current bureaucratic structures where big fund contributors largely occupy the executive desk (also exemplifying North-South asymmetry) need inclusive representation. Without reforms and appropriate check and balance mechanisms in these areas, WHO cannot adapt to new global health challenges and threats, which are perpetuated by the climate crisis, where developing countries are already paying higher costs.

While the developing countries' public health still needs massive reinforcement — much distinct from the developed countries — the present North-South divide and the climate crisis can make it worse for the South in the coming days.

Let’s not forget, even during the critical time of COVID-19 and in an ever-changing world, the statist perspective dominated over global or individual rights, which was unfortunate to witness.

To truly become an effective global system, the political and technical leadership at the helm of this system must reflect on past mistakes to equitably combat future uncertainties.

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Edit by Sabin Jung Pande