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Book Review
Governing Global Health: Challenge, Response, Innovation
Andrew Cooper, John Kirton and Ted Schrecker
ISBN: 978-0-7546-4873-4 2007 320 pages Aldershot: Ashgate Publishing
David Legge
La Trobe University, School of Public Health, Bundoora VIC
The concept of ‘governing global health’ is problematic. Is there a specific set of governance structures through which ‘global health’ is ‘governed’? Does it include the political and economic conditions which shape people’s health chances or only the policies and funding of health care? Does it apply to the health of the rich or just the health of the poor? Or is it only the health of the poor when their poor health threatens the health of the rich?
Governing global health: Challenge, response, innovation is a collection of 14 essays dealing with policies adopted by the rich countries and multilateral institutions regarding the health and health care of people in developing countries. Some of the chapters offered useful analyses, and the collection as a whole provides excellent material for a discourse analysis of conversations regarding global governance and health.
The book has three main parts, plus introductory and concluding chapters by the editors. Global challenges and responses sets out some of the background. Zacher provides a brief history of the World Health Organization’s role in the international control of communicable disease counterposed against the rise of the World Trade Organization and in particular the role of the Trade Related Intellectual Property Agreement (TRIPS) in ‘governing’ access to essential medicines. Orbinski highlights the role of social movements, featuring the role of Medicins Sans Frontieres (MSF) (and a global social movement behind it), in forcing the WTO (at the Doha Ministerial Council meeting in 2001) to amend the TRIPS Agreement to make it (slightly) easier for small poor countries to access generic medicines. In the third of the background essays, Fidler explores the idea of ‘securitisation’ of public health, which means that the health problems of poor people in the developing world are constructed as security threats to the well being of the rich countries and prioritised accordingly.
The second main part of the book deals with The central institutions: The multilateral system. Drager and Sunderland describe the role of the WHO, focusing in particular on the Commission on Macroeconomics and Health (and its conclusions regarding the productivity case for increased development assistance) and the dialogue between WHO and the WTO in pursuit of ‘policy coherence’ between health objectives and the regulation of global trade. Bradford and Hsu and White discuss the Millennium Development Goals (and the bleak prospects for their achievement), and Blouin explores the implications of the General Agreement on Trade in Services (GATS) for the achievement of the Millennium Development Goals (MDGs) (she is not positive).
The third main section focuses on the G8, the promises and declarations which have emerged from the various leaders’ meetings and the institutional initiatives that have been supported through the G8, notably the MDGs and the Global Fund for AIDS, TB and Malaria (GFATM). There is a muted debate across this section. While Kirton and Mannell celebrate the new role of the G8 in global health governance, Schrecker, Labonte and Sanders present a more broadly based and balanced assessment. Aginam returns to the role of the TRIPS Agreement and measures the G8 against the criterion of access to essential medicines and points out that little progress has been made in creating a more supportive regulatory regime despite the long drawn out negotiations to amend the TRIPS Agreement to give effect to the 2001 WTO Doha Declaration. Finally, O’Manique explores the role of the G8 in global health governance against criteria derived from the human rights paradigm.
I found this collection annoying but fascinating. My annoyance arose in part from the editors’ self-serving celebration of the achievements of the G8 in ‘global health governance’ (set against the ‘failure’ of the WHO), without any exploration of the deliberate policy of certain G8 members to hobble the WHO by not paying their assessed contributions to the WHO budget. It is self-serving in that the editors work in the G8 Research Group at the University of Toronto (a sponsor of the workshop upon which this collection is based) which specialises in research on the G8 and global governance reform.
Despite these and other irritations (such as repeated references to the ‘body count’ in describing global health status), the collection as a whole is quite fascinating as a reflection of several contending ways of answering the general question of why health in developing countries might matter. The dominant framework is that of ‘securitisation’, which prioritises health in developing countries because of perceived threats to the rich world posed by diseases such as AIDS/HIV, SARS, polio and avian influenza. The main alternative to the securitisation framework is the justice (rights and equity) framework which proposes that people in developing countries have a right to ‘the highest attainable standard of health’ and that continuing global inequalities in health are not fair. Several chapters in this collection either propound this model explicitly (O’Mannique), or couch their arguments within it (Orbinski; Aginam; and Schrecker, Labonte & Sanders). These different frameworks point to different priorities. The (rich world) security framework points to tighter surveillance of communicable disease but does not argue for a focus on maternal or child mortality. The justice framework identifies global health inequalities within the broader structures of global governance, including an unfair global trade regime (see chapters by Aginam, Blouin, and Schrecker and colleagues).
Other ways of framing policies for health development are represented little or not at all in this collection, including the basic needs framework (which dominated development assistance in earlier times), the charity and compassion framework (of certain large NGOs), the productivity framework (of the WHO Commission on Macroeconomics and Health) and the legitimation framework (foreshadowed by Habermas in 1976). The productivity argument (developed most clearly by the WHO Commission on Macroeconomics and Health), argued that improving population health status contributes to economic productivity and should be assigned higher priority for this reason. The legitimation framework suggests that the disease burden of developing countries casts doubt upon the legitimacy of the current regime of global governance in the eyes of the domestic constituencies of the rich world. In this view global health policies are in some degree designed to manage the threat of delegitimation (without substantially changing the fundamentals of the regime).
This collection is ostensibly about the governance of global health but the editorial tone is largely about what the rich world should do and in particular what the G8 leaders, individually and collectively, should do. The governments and people of developing countries are positioned as sick and vulnerable recipients of aid rather than as active political agents.
The editors state that the book adopts as a general analytical model, the ‘stimulus-response-innovation model’. According to this model, a (poorly defined) collectivity of ‘actors’ is challenged by changed circumstances and responds, conservatively at first and then through more proactive innovation. In particular the editors are calling for a permanent forum of health ministers within the G8 system, to take over the governance of global health which would further eclipse WHO and the UN system (note that one editor, Schrecker, distances himself (implicitly) from this argument in the chapter which he co-authors with Labonte and Sanders).
There are of course other ways (than the ‘stimulus-response-innovation’ model) of understanding how the global economy/polity is governed. One such alternative is the interests-power-conflict model. This model might help to make sense of the role of the covert and military actions and trade sanctions by G8 members (the US in particular) in global governance. It might help to interpret the efforts by the US in the Executive Board of the WHO to prevent the WHO from acting on the Kenya/Brazil Trade and Health resolution. It might also offer insights into the role of the G8 in mediating the economic contradictions between the US as the sole superpower and the other large capitalist economies.
There are important questions to be asked about the impact of the global economy on people’s health in developing countries and the implications of the current regime of global economic governance for health development. Some of the chapters in this collection ask such questions. As a policy text, however, this collection has limited reach because it only speaks with the elites of the rich world and does not address (or even acknowledge) the judgements and policy choices of social movements and governments in developing countries. Nonetheless, it may be of some use to counter-hegemonic movements, including the people’s movements in the South and solidarity movements linking North and South, because it refracts so clearly the different ways the global governors frame health development: securitisation, productivity and legitimation.
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