Who Governs Global Health?

Review of Chelsea Clinton and Devi Sridhar: Governing Global Health: Who Runs the World and Why?

The title of Chelsea Clinton and Devi Sridhar’s book “Governing Global Health” is straightforward, though figuring out the “who” and “why” of what drives shifts in global health governance is an exceedingly complex subject to tackle, even for Sridhar and Clinton who are well situated for this daunting task. If you are a newbie to global health or looking for a casual read, then this book may not be for you. If you are a global health practitioner but this is your first foray into global health policy, financing, and governance, then prepare yourself for a heavy indoctrination. If you are someone like myself, who considers himself a global health governance scholar and aficionado, then you will be in familiar, albeit not necessarily, new or novel territory.

The central narrative and approach of the book focus on the examination of four global health organizations in two distinct categories as comparative case studies: (1) the World Health Organization (WHO) and the World Bank (historic international organizations characterized as the “old” guard); and (2) the Global Fund to Fight AIDS, Tuberculosis and Malaria and GAVI, the Vaccine Alliance (characterized as the new crop of public–private partnerships that are challenging the traditional landscape of global health governance). There is no question that these are central figures in global health (more on that later), and by the end of the book you will be intimately acquainted with them. The bulk of the book is organized to present an in-depth analysis of the modalities of how these organizations cooperate (as framed within the principal-agent relationship), how they are financed, their governance characteristics, and a bit about their organizational history and leadership.

Who Runs [Global Health] and Why?

The subtitle of the book, “Who Runs the World and Why?,” might have been strategically chosen by the Oxford University Press editors to humanize the book as the word “governing” in a title hardly excites. However, this is not a book about international world order, but instead a deep dive into the inner workings of governance of four specific global health organizations, nor does it position how these organizations rank in the pecking order of the foreign policy hierarchy [for example, there is no mention in the entire book about the field of health diplomacy (Feldbaum and Michaud, 2010)]. The book starts with a short and accessible narrative history of the progression from “international” to “global” health cooperation, kicked off with a few teaser paragraphs about the recent 2014 Ebola outbreak and the spread of Zika virus. However, readers expecting to plunge into debate about how global health governance has “failed” or is “broken,” as illustrated by Ebola or Zika, will need to be patient, as that measured discussion won’t happen until near the end of the book.

Instead, readers begin their journey with a heavy dose of why public–private partnerships (PPPs) are so important in the context of global health. (This has the dual function of setting up the inclusion criteria for the case studies and the comparative analysis between the “old” and the “new” actors central to the underlining narrative.) Chapters 2–4 are then spent explaining the nuts and bolts of how these organizations are governed and funded, within the context of changes in funding flows for development assistance for health (DAH), which has led to a proliferation of new actors and mechanisms aimed at facilitating the delivery of global health interventions (illustrated by plenty of figures generated from data sources like OECD, Institute of Health Metrics and Evaluation, and the World Bank). Many of these topics are familiar for those invested in the field, including discussion of voluntary versus assessed contributions, the concept of performance-based funding, vertical versus horizontally focused initiatives, and the “democratic deficit” of global health governance (Frenk and Moon, 2013; Mackey and Novotny, 2012; Fan et al, 2013). The end of Chapter 3 summarizes this complex dynamic and the central message of the book:

The irony that this chapter brings to the fore is that states historically form and join global institutions such as WHO in recognition of the need for collective action that does not always mesh with their own national interests. Yet, as the shifts in global governance of the past two decades demonstrate, they are loath to provide the support and investment to these institutions, either for lack of trust, sovereignty concerns, or simply because they cannot control and monitor their activities as closely as they would like.

These middle chapters comprise the backbone of the book, filled with data and description, and alone would make a great mini textbook as reference material for any undergraduate or graduate-level global health policy course (including my own). The book hits its stride in Chapter 4, where particularly Sridhar’s influential work in global health financing (including conceptualizing the term “multi-bi financing”) culminates into a strong and cohesive picture of the central factor driving shifts in global health governance; i.e., the billions of dollars spent on global health in the form of bilateral, multilateral, and private funding. Though this chapter is effective, it also brings me to my first criticism; my general view that the chapters seem disjointed (including an oddly placed methods section on p. 46), with information oftentimes repetitive, as the reader is reintroduced to the four organizations of interest in the sub-sections of each chapter. Some chapters of the book are also more descriptive data heavy, with others more qualitatively focused, but lacking sufficient coherence as a collective mixed-methods approach. Organizational-wise, Chapter 4 (funding) would seem to be better placed before Chapter 3 (shifts) as changes in funding patterns in the latter is what leads to the “shifts” in governance described in the former.

Moving to Chapter 5, the title, “Twenty-First-Century Governance,” appears to signal to readers that the heavy descriptive phase of the book may be ending, but this is not the case, as this later chapter is devoted to describing how membership in these organizations is decided (particularly nonstate actors) and what types of transparency policies they have pursued and enacted. The summary tables included are informative, again, for purposes of an academic text book, but there is clearly a missed opportunity for more in-depth analysis delineating the authors’ own opinions about what “twenty-first century governance” actually means and what elements of good governance could be championed, within and beyond the organizations reviewed.

It is also at this point (albeit late) that readers might notice that one organization is starting to dominant the conversation though remains relegated to the background, specifically, the Bill and Melinda Gates Foundation (Gates Foundation). Throughout the book, the Gates Foundation is positioned as a central actor, power influencer, and chief funder of modern global health, but it is perplexing that this entity should play a secondary role instead of occupying the center stage as one of the case studies examined. Alternatively, one could envision case study selection based on organization type categories that group the WHO and World Bank as international organizations, the Global Fund and GAVI as PPPs, and the Gates Foundation as a private foundation. Whether you would also include a bilateral entity in this comparison is an open question. This might lend itself to more robust comparisons, especially given the stark differences in how these organizations generate and act as channels of funding, how they govern themselves (e.g., Gates Foundation by its executive leadership team), and concerns about levels of transparency and accountability [as the authors briefly address in Chapter 7 (Lancet, 2007)].

In Chapter 6–7, the book is marked by a welcome progression to the authors own opinions and recommendations. This begins in Chapter 6 with a discussion about successes and ongoing challenges experienced by the Global Fund and GAVI, and how these lessons can inform the reform agenda for the WHO and World Bank. The major takeaways for WHO are familiar themes: (a) more engagement with nonstate actors; (b) improving transparency, performance, and accountability; (c) exercising better oversight of its regional offices; and (d) shoring up its funding for core functions. For the World Bank reform recommendations focus primarily on its lending practices, better establishing it as a knowledge-based organization, and similarly improving transparency in its financing and operations. Finally, chapter 7 ends with “reflections” on key global health challenges on the horizon and how the current governance framework is not adequately designed to meet them. This includes the complexities of addressing the rising global burden of noncommunicable diseases (NCDs), the difficulties in achieving universal health coverage (UHC), and the need for continued global commitment and reform to strengthen pandemic response and health systems.

Though reform recommendations in Chapter 6 fit logically into the narrative flow and comparative results borne from the case studies, in my opinion, they miss a much larger and complex governance challenge. This is rooted in the authors’ overarching explanation of the reasons for governance shifts that generally follows as such: WHO fails to act as an effective steward of global health funding largess while concomitantly the World Bank does not focus enough on health within its larger portfolio, resulting in global health funders migrating to more responsive, inclusive and vertically focused venues of PPPs. Hence, this governance shift to PPPs has displaced traditional global health actors (such as the WHO), who then become primary targets of reforms simply to maintain their legitimacy and relevance.

What in my view is missing from this discussion is more in-depth exploration about how this global health governance “evolution” should lead not only to reforms at WHO and the World Bank, but also more systemic reforms to the overall global health governance architecture. System-wide reforms should focus on developing facilitating mechanisms and fora to incentivize stakeholders to become more complementary and cooperative (as authors illustrate briefly in their conclusion section when discussing global polio eradication efforts) by exploring concepts such as “network” governance and establishing better global health policy coherence across the entire United Nations system (Kickbusch and Szabo, 2014; Smith and Lee, 2017; Mackey and Liang, 2013).

Reflecting on Governing Global Health

There is no question that Clinton and Sridhar’s book takes a calculated, methodological, well executed, and objective approach to assess how changes in governance are impacting the global health landscape, leaving a book that is a valuable reference for current and future global health policy and international development practitioners and scholars. However, the narrow focus on the four case studies examined and the actual timing of the book’s publication, limits its potential and equates to lost opportunities for a more robust, impactful, and inclusive debate about why governance is important and how it needs to evolve for the future.

Critically, some very interesting issues remain under addressed or not sufficiently thematically linked. This is despite the fact that these topics are perfectly within the remit and expertize of the authors, one who is a world-renowned global health expert (Sridhar) and another who is clearly emerging as powerful scholar (Clinton) in the field. For example, though there is uncertainty regarding the association between the UN Millennium Development Goals (MDG) and historic funding for MDG-related health targets, the authors provide no hints of whether they think the adoption of the UN Sustainable Development Goals will have a similar impact on changes in global health funding flows. There is also a brief discussion about the controversy surrounding Indonesia’s refusal to share influenza virus samples in 2007 to WHO (p. 164), but the authors don’t adequately link this incident to the negotiated solution, the WHO Pandemic Influenza Preparedness Framework (PIP). PIP is arguably an excellent illustration of how WHO can effectively work with nonstate actors on collaborative governance approaches, but it isn’t until later (p. 188) that PIP is actually introduced, presented instead in the context of its limitations and the Ebola outbreak.

Additionally, the Global Health Security Agenda (GHSA), a USA-led initiative aimed at strengthening implementation of the WHO’s International Health Regulations, is also only mentioned briefly and late in the book, though could have been positioned as yet another important case study further illustrating member state trepidation with trusting WHO (perhaps similar to the circumstances around the creation of UNAIDS (Sridhar, 2013). Also, a discussion about the UN High-level Meeting on Non-communicable Diseases, which included broad participation from “civil society representatives” (which included private companies and powerful industry trade associations like AB InBev, GlaxoSmithKline, Bayer Healthcare AG, Sanofi Aventis, the International Federation of Pharmaceutical Manufacturers Association, and others), could have better elucidated the potential controversies and opportunities surrounding nonstate stakeholder participation and cooperation around NCDs in Chapter 7.

Further, at no fault of the authors, big developments in global health governance have conspired against the publication date of the book. Chief among them is the recent election of new WHO Director General Tedros Adhanom Ghebreyesus, the 2016 election of President Donald Trump and its potential negative impact on U.S. commitments to global health, and most importantly, the fallout from Ebola for WHO culminating in a myriad of reform measures suggested by several expert panels [including the Harvard Global Health Institute and London School of Hygiene & Tropical Medicine independent panel that both authors participated on (Moon et al, 2015)]. All these developments would have been difficult to incorporate as this book likely went into production as these events unfolded, but nevertheless have a significant impact on some of the conclusions drawn in Chapters 6 and 7. Particularly, the authors’ four primary recommendations for WHO reform seem rather limited, especially given that the Ebola High-level panels and commissions introduced many more (Mackey, 2016).

Finally, the central question I struggled with was figuring out the primary purpose of the book and for “who” and “why” it was written. Again, as a contribution to the academic literature in the field of global health governance, it is clearly fit for purpose, but one wonders if this approach could have been better articulated in a series of journal articles rather than a book predestined for more widespread dissemination [such as the recent 2017 article published by authors in the Lancet that is of similar design and conclusions (Clinton and Sridhar, 2017)]. Another possibility is that this book could have served as a technical roadmap and policy advocacy tool for US-based engagement in global health governance, especially given that the USA is the largest funding source for global health. This of course would have required a US political environment committed to internationalism, foreign aid, and UHC, conditions arguably not prioritized or supported by the current administration. Hence, one can only imagine “who” could have used this book to champion shared global health goals, and whether the roadmap lay out by authors would have been fully realized. For now, global health governance is likely to continue to shift and evolve, but in what ultimate direction still remains an open question.

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Correspondence to Tim Ken Mackey.

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Mackey, T.K. Who Governs Global Health?. Int Polit Rev 5, 72–76 (2017). https://doi.org/10.1057/s41312-017-0030-8

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