Universal Participation Without Taiwan? A Study of Taiwan’s Participation in the Global Health Governance Sponsored by the World Health Organization

Abstract

This chapter focuses on the health risk of Taiwan’s absence in intergovernmental health governance networks. It provides a review of Taiwan’s bidding strategies for the World Health Organization between 1997 and 2009. The country’s participation in the World Health Assembly (WHA) and the International Health Regulations (IHR) network since 2009 was a significant improvement, but this experience failed to extend to other governing bodies. The chapter goes on to discuss the global public health risk of excluding Taiwan from cross-national health cooperation, and why such a conundrum remains difficult to resolve. Taiwan’s compliance regarding health governance relies heavily on self-regulation and the help of its allies. The United States has played a key role in enforcing global health regulations on Taiwan. Unlike other sources of threat in health governance, Taiwan currently does not represent a high health risk to other countries. As a result, Taiwan finds it difficult to persuade WHO members to manifest “universal participation” by including Taiwan in various intergovernmental health networks. This pattern of governance, however, lacks transparency. Other countries will find it difficult to monitor or intervene in the event Taiwan’s health authority is unable to deal with a transnational health emergency.

1 The Missing Link in International Health Governance

Established in 1948, the World Health Organization (WHO) is a United Nations (UN) specialized agency that regulates international health affairs. Looking back at its history, Taiwan used to have close relations with WHO. Chiang Kai-Shek’s Republic of China (ROC) government was the founding member of WHO in 1948. After Chiang was defeated in the Chinese civil war and retreated to Taiwan, the ROC government maintained its membership for more than two decades. Under the aid and programs directed by WHO, Taiwan gradually improved its primary healthcare system. This connection was cut off when the Taiwanese government lost its UN seat to the People’s Republic of China (PRC) in 1971 under UN resolution No. 2758. In the following year, the World Health Assembly (WHA), the main decision body of WHO, passed Resolution 25.1. In this Resolution, PRC also restored its rights as the representative of China in WHO. Taiwan’s formal communication with the organization stopped. Taiwanese health officials interacted with WHO through indirect means, usually bridged by unofficial channels.¹

As the Cold War ended, Taiwan sought to return to the UN and its specialized agencies in 1993. The WHO bidding was first suggested by the public. There were many unofficial activities pushing for Taiwan’s return to WHO before the Taiwanese government took the initiative. The most significant example was the efforts made by the Foundation of Medical Professionals Alliance in Taiwan (FMPAT). FMPAT held lobbies for Taiwan’s representation in WHO since 1995.² These efforts initially received a cold response from the Taiwanese government. The government at the time believed it did not require professional assistance from WHO. The necessity of Taiwan’s participation in WHO was relatively weak in terms of health policies (Chang 2010b).

It was not until 1997 that the Taiwanese government developed an interest in WHO. Taiwan specifically chose WHO as its main foreign policy objective (Li 2006). It was a strategic decision with careful consideration. The policy was meant to end Taiwan’s diplomatic isolation in intergovernmental organizations. WHO was a good candidate because it dealt with professional issues concerning vital humanitarian needs. The campaigns for WHO observer status were, as Lee summarizes, “a potential means of leveraging participation in other international organisations and, in time, regaining recognition and legitimacy as a sovereign state” (Herington and Lee 2014, p. 6). The Taiwanese government had set up policies to return to the UN since 1993. The participation in WHO activities would set an example for Taiwan’s participation in other UN-related activities. Being one of the UN specialized agencies, a successful breakthrough in WHO might have brought positive effects on Taiwan’s UN bidding.

The Taiwanese government claimed that its pursuit of WHO participation was non-political and focused on defending the health security of its people. Indeed, the claim to “pursue the health of millions of people” became a common propaganda throughout the following years where Taiwan argued that exclusion from WHO would constitute a grave health risk for residents of Taiwan. In addition to the negative effect of excluding Taiwan, the government emphasized the positive role that Taiwan could play in cross-national health affairs. Its modernized primary healthcare system, medical achievements, and the successful national healthcare insurance supported the claim that Taiwan’s involvement could be constructive to other countries through WHO.

Nevertheless, the most important reason behind Taiwan’s WHO bidding was that WHO regulations offered Taiwan a viable opportunity to participate. Specifically, Taiwan’s effort focused on joining the World Health Assembly (WHA), the ministerial intergovernmental meeting held every year in May. Taiwan did not apply for WHO membership because WHA Resolution 25.1 rejected Taiwan’s legal status as a state. Taiwan would face the same sovereignty problem in the UN bidding if it attempted to overrule the WHA Resolution. It would be extremely difficult, if not impossible, to successfully obtain a WHO membership. And there was no observer status in WHO. However, the WHA received observers. The WHO Constitution and Rule of Procedure of the WHA regulated an observer status that left a grey area for Taiwan. Under article three of the Rule, Taiwan might participate in the WHA under an invitation from WHO Director-General (DG) without being officially recognized as state or territory. In practice, WHA observers included a variety of sovereignty statuses. They included internationally recognized states like the Holy See, self-governing territories like Palestine, and international non-governmental organizations (INGOs) like the International Committee of the Red Cross (ICRC). The rules offered Taiwan an opportunity to participate in the WHA without clarifying its legal status. Therefore, being a WHA observer was an opportunity to participate in intergovernmental governance that was not available in other intergovernmental organizations (IGOs). This made the WHA bid a primary target for Taiwan’s foreign policy.

Since its withdrawal from the UN and its specialized agencies, Taiwan was excluded from rules and institutions that became increasingly important in global governance. In terms of health governance, WHO had become the main body where states formulated and enforced health-related regulations (Frenk and Moon 2013). Global health governance focuses on transnational health risk, such as the spread of infectious diseases, border control and examination, food safety, and joint research and laboratory standards on examinations and treatments. In practice, WHO health governance consists of various networks or regulations, including International Health Regulations (IHR), the Framework Convention on Tobacco Control (FCTC), the International Food Safety Authorities Network (INFOSAN), and the International Medical Products Anti-Counterfeiting Taskforce (IMPACT). WHO contains the negative externalities of transnational health threats by providing public goods or medical services sponsored by developed countries. The networks it established since the end of Cold War allow health policy makers to exchange health information. They create professional cooperation among professional medical experts. WHO members regularly convene to review the progress of WHO projects. This makes WHO an effective monitoring power in global health governance. Although non-governmental organizations (NGOs) are also important contributors to global health, their governing power and ability to build networks between national health authorities cannot match the scale of WHO.³

Taiwan was not required to implement rules established among WHO members, but it maintained good records of compliance. Instead of being a deserter of global health regulations, Taiwan showed great interest in conforming to the decisions made in the health governing bodies. Its compliance was grounded in two reasons. The first one was voluntary implementation. Taiwan voluntarily conformed to health-related rules and standards for two reasons. First, it wanted to improve its own health governance by “catching up” to the global standards. These rules created short cuts for health policy formulation or provided reference for law-making in Taiwan. For example, the Taiwanese government voluntarily enforced the guidelines made by FCTC. Taiwan’s tobacco control policy depends on the recommendations and research reports developed under FCTC conferences. Secondly, from Taiwan’s perspective, its voluntary participation demonstrated the country’s resolution to join intergovernmental health bodies such as the WHA and FCTC Convention of Parties. Taiwan’s compliance echoed the government’s foreign policy, showing that Taiwan was willing to take its part in global health governance. As a result, Taiwan’s exclusion made its health authority more willing to implement international standards.

The second reason underlying Taiwan’s compliance was the support/pressure from its allies, mainly the US. The US health administration maintained very close relations with its Taiwanese counterpart. The Centers for Disease Control in the two countries, for example, regularly exchanged information. The US usually provided consultations that facilitated the work of Taiwan Centers for Disease Control (CDC). Taiwan gained the latest information about WHO activities from the US representatives who took part in WHO. Taiwan’s diplomatic allies also create professional channels that connected Taiwan’s internal health governance with the global one. In addition to being privy to information concerning intergovernmental meetings, Taiwanese health officials attended intergovernmental meetings by joining the delegations of its diplomatic allies.

The discussion above shows that Taiwan’s participation in global health governance is not entirely isolated.⁴ Taiwan closely follows the progress of global health governance, though such involvement is quite limited. And Taiwan’s representatives are absent in almost every intergovernmental meetings. Therefore, the Taiwanese government adopts indirect channels to acquire information regarding WHO activities. The most significant problem of Taiwan’s current mode of participation is efficiency. The lack of a direct communication channel between Taiwan and the governing body creates an information gap. Taiwan cannot obtain the latest information released by WHO, neither can WHO obtain the latest health information inside Taiwan. Taiwan has no obligation to report its health information to WHO, and WHO will not request information from the Taiwanese government. According to the UN resolution, China is responsible for Taiwan’s internal affairs, but in reality Beijing does not administer Taiwan’s health affairs and therefore it is unable to report health figures regarding Taiwan. Even if the Taiwanese government voluntarily report its health figure to WHO, WHO might not accept because of the political dispute.

This becomes a problem when it comes to the spread of infectious diseases and food security. As WHO gradually becomes the major governing institution that regulates and shares information on these topics, the disadvantage of Taiwan’s exclusion becomes more evident. Taiwan relies on indirect channels to access updates on health emergencies. The delay of information increases the risk of a tardy response to transnational health crises. This was particularly evident during the spread of SARS, which will be elaborated in the following section.

The problem also applies to other states, particularly Taiwan’s neighbors. If Taiwan becomes a source of transnational health risk, the global governing institutions cannot intervene or demand enforcement. Taiwan is not connected to any of the information sharing networks managed by WHO. For the most part, WHO counts on the health authority of Taiwan to control infectious diseases or food safety. Once Taiwan fails to contain a health risk, WHO cannot intervene, nor can it provide assistance to prevent further spread of the health risk. Information concerning a local health risk only passes through bilateral communication channels between Taiwan and its neighboring states. WHO members are thus exposed to potential health risks brought by Taiwan, and they can only rely on Taiwan’s friendly allies to pressure the Taiwanese government to be a competent and responsible actor when dealing with transnational health emergencies.

This “loophole” in global health governance has been the dilemma for WHO. After all, its governing power is more effective if the rules apply to all actors in international society, yet Taiwan has been an exception. Moreover, Taiwan is not an isolated actor in international affairs. Its open economy and the large amount of trade and visits with other countries make a health risk easily transmittable from and to Taiwan. WHO-sponsored health governance is hardly complete without a direct channel to communicate with and regulate Taiwan’s health authority.

2 Breaking Through – Taiwan’s Past Bidding Strategy

Taiwan did make a substantial effort to end its exclusion. Despite the fact that being a WHA observer did not necessarily indicate the status of statehood, it was still a sensitive issue and the WHO/WHA bidding was difficult. The political ambition behind Taiwan’s pursuit of being a WHA observer had been very obvious. Unsurprisingly, China adamantly opposed Taiwan’s WHO/WHA bidding from the start. Between 1997 and 2008, Taiwan mobilized all its diplomatic relationships to participate in WHO, mostly aimed at attending the WHA. It rallied its diplomatic allies, lobbied foreign governments and their congresses, organized NGO support, and directed media attention to its bids. These activities aimed to raise issue salience and earn international support to fight against China’s diplomatic blockade. Every year immediately after the WHA in May, the Taiwanese government began a new round of bidding. The Ministry of Foreign Affairs (MOFA) and Department of Health (DOH, now the Ministry of Health and Welfare) jointly set up main tactics for the next year. They mobilized overseas Foreign Service offices, produced media propaganda, and organized a series of conferences and activities. Government officials regularly established connections with important INGO leaders, foreign government officers, foreign congressmen, and even WHO officers. The Taiwanese government wanted to rally enough support from the international community to outweigh China and its allies. The following table shows Taiwan’s bids from 1997 to 2016 (Table 1)

Table 1 Taiwan’s Bidding Strategies 1997–2016

In 1997, Taiwan’s first attempt to return to the WHA met with a cold response from the international community. China responded furiously as expected. It claimed that Taiwan is not an independent state under the “One China Principle” and therefore did not qualify to participate in the WHA (Li 2008). Over time, Taiwan accumulated support from the international community. Besides its diplomatic allies, Taiwan gained support from the US government in 2001, and later in 2003, the Japanese government announced its support. Taiwan also gained support from professional INGOs. For example, the World Medical Association (WMA) has been a reliable ally. The International Council of Nurses (ICN) and International Pharmaceutical Federation (FIP) also publicly supported Taiwan.⁵ Taiwan obtained much attention from international society. Its bidding efforts raised visibility and forced other states to think about the issue. Unfortunately, even with all this support, Taiwan’s attempts did not succeed over the years.

It was not until the outbreak of Severe Acute Respiratory Syndrome (SARS) that the international community began to recognize the risk of excluding Taiwan from the international health network. SARS caught Taiwan’s health administration off guard. Taiwan paid a grave cost fighting SARS. It had a total of 346 confirmed cases during the outbreak, and 73 deaths.⁶ About 150,000 people were quarantined (Chen et al. 2005). In terms of number of cases and death toll, Taiwan ranked third among all countries during the outbreak. The Taiwanese government argued that the government could have better responded to the spread of SARS if Taiwan had maintained regular contact with WHO. Political obstacle also jeopardized WHO’s ability to provide assistance to Taiwan. WHO dispatched experts to Taiwan 50 days after Taiwan called for help. The delay was due to the lack of China’s authorization (Hickey 2006). The SARS incident showed the need for establishing channels of contact between Taiwan and WHO, especially during public health crises.⁷

Since 2003, the SARS experience has become the most powerful argument in Taiwan’s bids. The members of the European Union began to urge an arrangement for Taiwan’s participation in WHO working groups and technical meetings. The EU later formed the policy of “meaningful participation” regarding Taiwan’s relations with WHO (Winkler 2013). However, as strong as the SARS argument was, member states did not form a majority support for Taiwan’s bids. Although many members recognized the need for Taiwan’s participation, they maintained that supporting Taiwan’s bids was a politically sensitive issue.

The number of Taiwan’s supporters increased slowly. The support of major countries such as the US and Japan did not rally the majority of WHO members to support Taiwan. The voting records in 1997, 2004, and 2007 showed a disappointing trend. When Taiwan’s bid was put to vote in the WHA General Committee for the first time in 1997, 128 members rejected the bid to put the matter in the conference schedule; Taiwan had 19 votes. In 2004, 25 countries agreed to discuss the matter in the WHA, while 133 states voted against it. These were bids to become a WHA observer, which is less sensitive than applying for a membership. But Taiwan could not collect enough support. For the years where voting did not take place, the General Committee rejected Taiwan’s proposals, and the WHA then accepted the recommendation of the General Committee not to include the matter in the conference agenda.

The bidding in 2007 was a significant setback. Taiwan made a risky move by challenging the sensitive political issue of applying for a membership in WHO.⁸ Taiwan presented this proposal through its diplomatic allies. The WHA put forward a vote to determine whether it would entertain the proposal. There were only 17 affirmative votes. Over 70% of WHO members voted against the proposal, including the US and Japan, both long-term supporters for Taiwan. Among the 25 diplomatic allies of Taiwan, 6 allies did not vote, 1 abstained, and 1 delegate even voted against Taiwan.⁹

In the following year, Taiwan again bid to become a WHA observer. The US and Japan reaffirmed their support. The application for membership proved to be unsuccessful. This experience demonstrates that making strong sovereignty claims only makes WHO members hesitate to support Taiwan, even for the long-term supporters of Taiwan.

The Taiwanese government used to claim that it gained support from the legislatures of various countries and deemed this support a sign of increasing backing from the international community, but this so-called achievement rarely transformed into actual support in the conference hall. These non-binding resolutions failed to force foreign governments to support Taiwan’s proposals. For example, the European Parliament had adopted numerous resolutions to support Taiwan. Many parliaments in European countries also had similar resolutions.¹⁰ But the EU countries never publicly support Taiwan’s bid for the WHA observer. The “meaningful participation” did not guarantee Taiwan’s representation in the WHA.

Taiwan did have powerful allies like the US, but the number of supporters was not enough to form a majority and open the door for Taiwan’s participation. More importantly, more support from friendly countries did not equally diminish the diplomatic pressure coming from China. Every time Taiwan gained more allies or made a breakthrough, China intensified the diplomatic blockade. The number of countries supporting China actually increased as it put more efforts to fight against Taiwan’s bid.

Taiwan’s effort to join IHR were an example of the struggle. IHR was a mechanism that helped monitor and control the spread of infectious diseases. WHO first established the IHR in 1969. It was then revised in 2005 to expand its function. The 2005 revision, formally known as IHR (2005), significantly increased the governing power of WHO by setting up rules and guidelines for fighting transnational infectious diseases.

As part of WHO bidding, Taiwan sought to join the IHR. During the second IHR Intergovernmental Working Group (IGWG) meeting in 2005, Taiwan successfully proposed an amendment through its diplomatic ally. The amendment added a “universal application” clause in Article 3.3 of the new IHR.¹¹ This article vaguely left open the possibility of including Taiwan in the application of IHR because the IHR should apply to every corner of the world.

Beijing was stunned by Taiwan’s success in the IHR IGWG. It realized that Taiwan could have influence even if it did not have formal representative inside the Assembly Hall. China was determined to prevent a similar incident with WHO. At the opening of the 60th WHA, China announced in its opening address that IHR had applied to all of Chinese territory and Taiwan was included, which brought furious protest from Taiwan. Furthermore, Chinese government secretly signed a Memorandum of Understanding (MOU) with the WHO Secretariat. The actual content of the MOU was never made public. The only way to speculate as to its contents was the internal guidelines distributed by WHO.

According to the MOU, Taiwan’s participation in WHO activities was under tight control of China. Taiwanese experts who planned to attend a WHO meeting were required to apply for the meeting 5 weeks ahead of the conference date and submit the participant list to the Chinese government for approval. During those meetings, “ROC” and “Taiwan” were not to appear on the nametag or participant list. If Taiwanese experts were invited to the conference, WHO was required to also invite experts from China. Higher level officials (ranking over the level of Director-General) were restricted from attending any WHO activities.¹² All communications between Taiwan and WHO were to come through China; this meant Taiwan had to receive information concerning health emergencies through Chinese authorities. The MOU represented a significant pushback against Taiwan’s WHO bidding.

However, the MOU did not change the mode of Taiwan’s participation in global health governance. China intended to be the bridge between Taiwan and WHO in global health cooperation, in order to show its sovereignty over Taiwan. But China could not force Taiwan’s health authority to cooperate with it. China set up a contact point with the Taiwan CDC to deliver the information distributed by IHR and INFOSAN. Taiwan, on the other hand, was not obligated to submit its internal health information to its cross-Strait counterpart. Taiwan was reluctant to establish communication with WHO through Beijing. As a result, Taiwan relied more on the existing alternatives, seeking direct communication with WHO or participating in global health cooperation through the US and its allies.

3 The WHA Accession and Taiwan’s Participation in Global Health Cooperation

Taiwan’s Mainland China policy had changed as the Kuomingtang (KMT) president Ma Ying-Jeou took office in 2008. Ma reestablished a communication channel based on two unofficial organizations, the Strait Exchange Foundation (SEF) and the Association for Relations across the Taiwan Straits (ARATS). The heads of the two organizations, Chiang Pin-Kung and Chen Yun-Lin held regular meetings discussing cross-Strait affairs. Ma proposed a “diplomatic truce” after his inauguration, which ended years of diplomatic conflict between Taipei and Beijing. The cross-Strait reconciliation brought hope that China would be more flexible on the matter of Taiwan’s participation in IGOs, especially Taiwan’s bid to become a WHA observer.

The sign of change took place in January of 2009. The Taiwan CDC received a notification from WHO concerning Taiwan’s participation in IHR. This suggested that Ma’s new policy received positive feedback from Beijing. The invitation offered the opportunity to bypass the limitation set up by the 2005 MOU, while the MOU was still in effect. WHO invited Taiwan to establish an IHR contact point to engage in direct communication. Taiwan CDC could receive and exchange information on health emergencies with WHO without the involvement of the Chinese government. More importantly, Taiwan was offered an account and password to log in to the “Event Information Site”, where it could review the latest public health emergencies circulated among member states. WHO also promised that it would send experts to Taiwan when a health emergency occurred.¹³ These were the primary objectives Taiwan had been asking for since the IHR (2005) was put into practice.

The IHR invitation created an optimistic expectation for the WHA bid. But it was not until 16 days before the WHA that the DOH received an official invitation from WHO Director-General Margaret Chan. The invitation stated: “I wish to invite the Department of Health, Chinese Taipei, to attend the 62nd World Health Assembly as an observer…” This was the first time the Taiwanese government received an official invitation from the DG. The invitation itself revealed WHO’s attitude toward Taiwan. It did not use the word “Taiwan”. The name “Taiwan” was not even on the address line. Instead, “Taiwan” was replaced by “Chinese Taipei”. The DOH was called “the Department of Health, Chinese Taipei”. It showed that WHO was not willing to touch on the sensitive question of sovereignty. The invitation simply gave the Taiwanese government status to participate in the WHA. It did not identify or imply any sovereignty status. Taiwan was still, from WHO’s perspective, not an independent sovereign state. WHO deliberately avoided the sensitive sovereignty issue and claimed that “DG has the authority to invite any entity which carries out the function in the field public health.” In fact, WHO did not have the concept of “health entity” in its Constitution and regulations.¹⁴ This invitation obscured Taiwan’s legal status. It suggested that Taiwan could still break through the legal constraint and participate in international events as long as political coordination was in place.

On the other hand, the title “Chinese Taipei” was not much of a surprise. Mr. Ma once said in an interview: “In terms of Taiwan’s participation in WHO, there is no better title than Chinese Taipei at this point of time.”¹⁵ This title first appeared in the International Olympic Committee (IOC) in 1981. It was the result of the representation dispute between ROC and PRC in the IOC. The Taiwanese government did not particularly prefer this title. However, this title was proven to be applicable in many intergovernmental organizations such as the Olympic Games and the Asia-Pacific Economic Cooperation. It also served as the abbreviation of “Separate Customs Territory of Taiwan, Penghu, Kinmen and Matsu” in the WTO. Nevertheless, this was the first time the Taiwanese government accepted “Chinese Taipei” as its title in an intergovernmental meeting of a UN-related agency.

Taiwan’s health officials were very concerned about how WHO would treat them as government delegates. For example, during the first attendance at the WHA, Taiwan’s health minister checked his title as soon as he received his conference badge. He went on checking other country’s badges to make sure that their titles on the badges were the same.¹⁶ The Taiwan delegates were also concerned with the participant list in the daily-issued conference documents. They went through different language versions of participant lists to cross-check how their titles were translated.

Taiwan’s participation in the WHA between 2009 and 2015 followed almost the same pattern. Taiwan sent the list of participants several months before the WHA, and the DG sent an invitation about 2 months before the Assembly opened. The 2016 invitation came rather late. The DG sent the invitation 3 weeks before the WHA meeting. It was widely assumed that the delay was due to the electoral victory of the opposition party, the Democratic Progressive Party (DPP), and the uncertain future cross-Strait relationship. The Secretariat refused to confirm this suspicion.¹⁷

As an observer of the WHA, the delegates from Taiwan were free to participate in all sessions of the General Assembly and subsidiary technical meetings. They enjoyed the privilege of entering Palais des Nations without security checks. Taiwan’s delegate seat in the Assembly Hall was next to other observers. The seating order was arranged according to the time they were granted observer status. Chinese Taipei hence occupied the last seats in the Assembly. They could walk around the Assembly Hall or the conference room and talked freely with other delegates. The delegation also had a mailbox in Palais des Nations, from which they could pick up daily conference materials issued by the WHO Secretariat.

Ma’s strategy illustrated a two level game scenario (Evans et al. 1993; Putnam 1988). The improvement of the cross-Strait relationship gave the Taiwanese government leverage to pressure Beijing through domestic politics. Under the doctrine of diplomatic truce, the government claimed in public that engaging China, rather than clashing with it, would bring more international space for Taiwan. This claim tied the hands of Ma’s government (Fearon 1997), and the WHA bidding played a key role. The public held high expectations that China would lower its diplomatic barrier and help Taiwan’s WHA accession. The failure of the WHA bidding would have resulted in a credibility crisis for Ma’s foreign policy. The “diplomatic truce” might have collapsed, and Ma’s cross-Strait policy would have drowned with it. It would have decreased Ma’s support, shaken the KMT government, and forced Mr. Ma to reconsider his Mainland policy. China would not welcome this development. China preferred KMT to remain in office rather than the DPP; it also preferred Ma’s Mainland policy to his predecessor’s. Moreover, the domestic criticism in Taiwan further strengthened the “tying hands” effect. The greater the domestic pressure on the WHA issue in Taiwanese politics, the more audience cost Ma had to suffer if the WHA bidding did not work out. China recognized that the domestic audience cost for the Taiwanese government would be high if there was no substantive outcome for Taiwan’s WHA bidding. As a result, it made a mutually acceptable arrangement for Taiwan’s observership. And it made sure that Taiwan was satisfied with the arrangement so Ma’s government could demonstrate the effectiveness of “diplomatic truce” to its people. This domestic-international level of interaction helped, rather than constrained, Taiwan in achieving its goal.

Figure 1 shows Taiwan’s interaction with other countries during the WHA meeting over the past 8 years. The Taiwanese delegates became familiar with the participation in the conference. This suggests that Taiwan became more integrated into the global health governance network since the accession to the WHA.

Fig. 1

The participation of Chinese Taipei delegation in the WHA (Source: Ministry of Health and Welfare)

4 The Cross-Strait Relationship and Taiwan’s Dilemma in WHO Participation

The WHA accession did not make it easier for Taiwan to obtain a seat in other WHO meetings. The WHO Secretariat deemed Taiwan’s participation in the WHA a unique case, and it refused to carry this experience into other WHO activities. Taiwan could not send formal delegates to WHO intergovernmental meetings. The Conference of the Parties (COP) of the FCTC was a significant example. The FCTC intended to carry out reduction strategies for tobacco products. It was under the auspices of WHO, and the COP was its main decision body. Taiwan had been following the FCTC and made its tobacco control policy based on reports and resolutions released by the COP. However, Taiwan was never formally invited after accession to the WHA despite the DOH sending multiple requests.

In the meantime, the secret MOU between China and WHO remained the most important impediment to Taiwan’s participation in WHO activities. This secret agreement between China and the WHO Secretariat had formed the principles of all interactions between WHO and Taiwan. The titles of Taiwanese participants, for example, remained to be a problem in IHR and WHO technical meetings. WHO still addressed Taiwan as “Taiwan, China” on its website and in all other official documents as it did in the past. This problem was evident when WHO issued status updates of the H1N1 pandemic on its website in 2009. The H1N1 cases reported by DOH were registered under China’s number of confirmed cases. After the Taiwanese government made a formal protest, WHO added a note specifically indicating these cases were reported by Chinese Taipei.¹⁸ Two months later, WHO replaced the number of cases with a map. The number of cases reported by Taiwan was again included in the figure reported by China.

Another incident showed that the 2005 MOU continued to constrain Taiwan’s participation in WHO. In 2010, the DG office issued an internal memo on the implementation of IHR regarding Taiwan. The memo specifically mentioned that Taiwan, being a province of China, cannot be a formal party to the IHR. This document was leaked in the following year.¹⁹ The document elaborated a standard procedure concerning a contact point between the WHO Secretariat and the Taiwanese government for the implementation of the IHR.²⁰ It set clear limitations on Taiwan’s direct contact with other WHO members and WHO-related organizations, and also established rules concerning the publication of Taiwan’s health information. Any information from Taiwan was to be published under the title of “Taiwan, China”. This document did not cover the rights and privileges Taiwan enjoyed in the WHA, but it set up rules for Taiwan’s participation in all WHO-sponsored institutions.

The principles of this memo were hardly new. It basically reconfirmed the contents of the 2005 MOU between China and the WHO Secretariat. The only problem here was that the Taiwan CDC had expected WHO to be flexible on Taiwan’s title in its publications. The H1N1 updates broke this expectation. And the internal memo reconfirmed that WHO’s policy on Taiwan had not changed. The fact that China insisted on following the 2005 MOU even after Taiwan’s accession to the WHA showed that Taiwan’s participation in global health governance remained limited. Since 2009, the use of “Chinese Taipei” only applied to the WHA meetings. WHO used “Taiwan, province of China” or “Taiwan, China” to represent Taiwan in other occasions. As these titles reconfirmed China’s sovereignty over Taiwan, the Taiwanese government was reluctant to expand its participation in WHO-sponsored activities. In other words, since neither China nor WHO wanted to replicate the arrangement at the WHA to other activities, it was hard to expect Taiwan to further integrate into global health governance even if the Taiwanese government was eager to participate. It was a great disappointment for the Taiwanese government. It seemed that Taiwan’s participation in WHO only became more difficult after receiving the WHA observer status.

The political turnover in Taiwan brought less promising prospects for WHO participation. Since the DPP regained office in 2016, cross-Strait tensions gradually increased. The DG reaffirmed UN resolution 2758 and WHA resolution 25.1 in her 2016 WHA invitation. This was the first time that the initiation letter emphasized the One-China principle. The DG office was unwilling to obscure Taiwan’s sovereignty issue. China also picked up its strategy of diplomatic blockade, as it had done during the previous DPP administration. In December 2016, São Tomé and Príncipe cut off diplomatic ties with Taiwan and established a formal relationship with China. Panama followed through and severed diplomatic relations with Taiwan in 2017.

This change in the cross-Strait relationship indeed impacted Taiwan’s participation in international health affairs. The deterioration of cross-Strait relations led to unfortunate result. For the first time since 2009, Taiwan was not invited to attend the WHA in 2017. This raises the concern about Taiwan's participation in WHO in the future. The problem is not that Taiwan will be blocked from all WHO activities, including the IHR (2005). Taiwan’s participation is likely to continue under the diplomatic intimidation from Beijing. There are many opportunities where China will claim its sovereignty over Taiwan; the title of Taiwan’s delegation is an example. The real problem is that China’s diplomatic coercion may force Taiwan to voluntarily withdraw from global health affairs and become less interested in participating health-related professional meetings. It is expected Taiwan will continue seeking ways to break the diplomatic pressure from China. But China’s pressure will narrow down Taiwan’s representation in global health governance.

The participation in the WHA and the IHR was an improvement on Taiwan’s previous participation in global health affairs, though these experiences could not be replicated to wider health cooperation. Current cross-Strait relations suggest that there is little chance to improve on this limited participation. The basic mode of Taiwan’s participation in global health affairs remains unaltered. Taiwan will rely on third parties such as the US and its diplomatic allies to participate in global health affairs.

Will this passive, indirect, and unofficial mode of participation cause a negative effect on global health governance? Indeed, the SARS experience is powerful evidence that Taiwan may suffer from the exclusion. Being left outside the increasingly developed global health network means that Taiwan may not obtain information vital to its health policy making. This is particularly acute in the spread of infectious diseases.

Aside from violating the principle of “universal participation”, what impact will Taiwan’s exclusion bring to other countries? One must understand how much Taiwan’s participation is vital to global health governance. Although Taiwan has shown strong dedication to global health affairs, it does not occupy a key role in global health governance because it is not a source of global health threats. Its absence does not invalidate the governing network established by WHO. On the other hand, Taiwan has good performance in public health administration and a record of voluntary compliance with international standards. Zacher and Keefe (2008) argue that health governance arises when governments feel the threat of transnational health crises. The cost of non-compliance encourages states to increase surveillance and strengthen governance power. Taiwan is the opposite side of the story. The Taiwanese government makes substantive efforts to create a robust public health system, which makes Taiwan less likely a source of public health threats. Consequently, neither WHO members nor the WHO Secretariat find it necessary to include Taiwan in the current health governance system.

To be sure, Taiwan’s participation would make global health prevention more effective and more complete. But the inclusion of Taiwan brings a political risk that neither the WHO Secretariat nor the majority of WHO members are willing to take. As long as Taiwan continues to catch up with global health regulations and receives support from the US, WHO does not see the exclusion of Taiwan as bringing a significant risk to member countries.

The dilemma for Taiwan is ironic. It strives to follow the health regulations set up by WHO in order to demonstrate its capacity to become a responsible member of the international community. The Taiwanese government believes that health cooperation and transparency will break its diplomatic isolation. Taiwan’s high compliance, however, is the key reason that WHO feels unnecessary to allow Taiwan’s regular presence in WHO activities. Even if WHO is willing to invite delegates from Taiwan, it can only offer titles that the Taiwanese government finds hard to accept.

Indeed, Taiwan was not affected by recent transnational epidemic outbreaks such as Middle East respiratory syndrome coronavirus (MERS), Zika virus, avian influenza, and Ebola. Its geographical isolation also makes it easier for Taiwan to contain local epidemics from spreading to neighboring countries. Additionally, Taiwan finds it easier to filter foreign imported health risks given its modernized custom control and quarantine procedures. But the lack of immediate threat does not suggest that the current governance pattern is reliable, and it is certainly not risk-free. It is not inconceivable that Taiwan could pose a health threat to other countries. The food product scandals are examples. In 2011, the health authority in Taiwan accidentally found that an illegal plasticizer, DEHP, was used as a clouding agent to produce food, beverages, tablets, and powders. Later it was confirmed that the industry had used DEHP for decades. Products made of DEHP were exported to 22 countries (Wu et al. 2012; Yen et al. 2011). In 2014, another food safety incident involving cooking oil was discovered. Food made with recycled oil was exported to 12 countries (Wu 2014).

These incidents suggest that Taiwan can still pose a health threat to its trade partners despite its self-governance. The Taiwanese government has acted swiftly whenever health-related problems emerge, and it has promptly informed the affected countries through bilateral channels. The lack of monitoring mechanism means other countries depend on the merits of the Taiwanese government. There is no enforcement power that pressures the Taiwanese government to report a domestic health incident. Other countries, especially those who are affected, can only press for solutions through bilateral dialogue. The pressure from a global governance power is absent in the case of Taiwan. Moreover, WHO’s advisory group cannot intervene even if such assistance helps Taiwan to resolve a health emergency more efficiently. Due to the difficulty acquiring help from WHO, Taiwan relies heavily on the US for technical advice. In sum, Taiwan’s current pattern of participating in global health governance creates unnecessary risk for other countries. The restraint on Taiwan’s compliance is obscure and uninsured. It is not guaranteed that Taiwan is capable of dealing with the health risk spreading to or emerging from the island. There is little force, if any, to ask Taiwan to behave responsibly in transnational health emergencies.

5 Conclusion: A Latent Security Threat

This chapter reviews Taiwan’s WHO/WHA bidding and its participation in global health governance. Taiwan’s participation in WHO is not a health issue but a political one. The participation in the WHA was a practical option that avoided the sensitive sovereignty issue. The ultimate goal was increasing Taiwan’s representation in intergovernmental organizations. Nevertheless, the Taiwanese government successfully linked global health risk with the agenda of Taiwan’s participation in global health governance. The SARS experience showed that Taiwan’s exclusion could expose Taiwan to a global health threat, and WHO would have little impact on either assisting Taiwan or preventing communicable diseases from spreading across borders.

The 2009 WHA accession was undoubtedly progress towards including Taiwan in global health governance. The establishment of an IHR contact was a practical solution to Taiwan’s participation in activities sponsored by WHO. However, this experience failed to extend to other governance bodies. In the meantime, the cross-Strait relationship has frozen since the political turnover in Taiwan. It is unlikely that Taiwan will make any progress on WHO participation. The absence of Taiwan in 2017 WHA further confirmed that Taiwan’s participation in WHO returned to pre-2009 status.

Global health governance is hardly “universal participation” without Taiwan. However, the exclusion of Taiwan does not cause immediate and substantive threats at this moment. In the short run, there is no dire need to fulfill “universal participation” by including Taiwan. It is uncertain whether the current governance pattern can protect other WHO members from any health risks originating in Taiwan. The problem remains that Taiwan’s self-governance lacks transparency to the international community. The risk of Taiwan being a source of global health risk may be small, but WHO will find it difficult to contain health threats originating from Taiwan if Taiwan fails to contain a local epidemic outbreak or if it fails to secure the safety of its exported food products. Taiwan is deeply integrated into the global economy. Local health risks will easily transfer to the rest of the world. WHO has no appropriate channel to monitor health governance and health emergencies in Taiwan.

The opportunity for Taiwan’s inclusion in the WHO-sponsored global health governance system lies in the health risk Taiwan poses to other countries. WHO and its members are likely to allow greater room for Taiwan’s participation if Taiwan is unable or unwilling to maintain good governance. To be sure, the Taiwanese government is unlikely to violate health regulations in order to get the attention of international society. Violation will be a costly move that threatens Taiwan’s domestic health system, and it may even bring negative impacts on its trade. The Taiwanese government maintains that being a responsible member will bring more friendship in Geneva and therefore more chances of participation. It is expected that Taiwan will continue to follow the regulations set up by the global health governance bodies. This paints a grim picture of Taiwan’s participation in global health governance in the future.