Global Health Governance: The Major Players in the Field and Their Challenges

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

New York, NY: Oxford University Press; 2017 282 pp.; $24.95 ISBN: 978-0190253271

When thinking about what matters most in life, few priorities stand out as much as the importance of health. In the constitution of the World Health Organization (WHO), health is defined as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”¹ The universe of global health-focused institutions nowadays is complex and rich in actors.² In a thorough and engaging way, Chelsea Clinton and Devi Sridhar’s book Governing Global Health: Who Runs the World and Why? offers remarkable insight into that complexity. In addition to being thought provoking and “a model of concise scholarship,” as praised by Paul Farmer, the book is a must-read for anyone interested in global health and international affairs.

Clinton and Sridhar discuss global health governance in a unique way by focusing on the four most significant institutions in the field as defined by their resources: the “old,” “traditional” players (WHO and the World Bank) and the relatively “new” and major public–private partnerships (the Global Fund to Fight AIDS, Tuberculosis and Malaria, and Gavi, the Vaccine Alliance). Using principal-agent theory, wherein governments are principals and health-focused institutions are agents, the authors provide a well-documented analysis of the case-study institutions: their mandate, history, governance, organization, financing, decision-making processes, reporting, transparency, and partnership policies and practices.

Governing Global Health is divided into seven chapters; the concepts it presents are well defined, and the writing is thoughtful, lively, and clear. The book is relevant, timely, and a valuable contribution to the field, especially for the classroom. It provides a compelling comparative analysis of the studied organizations against the backdrop of the main health challenges of the past and the present.

COOPERATION AND PUBLIC–PRIVATE PARTNERSHIPS

The four focal institutions are products of international cooperation, and the book begins with an examination of how global cooperation for health has evolved over the past century and a half. Its historical perspective is noteworthy, starting with the earliest cooperation efforts among countries to control infectious diseases up to the establishment of WHO. The authors offer a meticulous assessment of the balance between public and private contributions to global health. In the late 20th and early 21st centuries, alongside unprecedented funding for global health focused on disease-specific or selective interventions, a major change in international cooperation has been the emergence of public–private partnerships. The surge in funding for these partnerships in the past 15 years can be viewed as “the Golden Age” of development assistance for health, given the “largess” donors contributed to global health.³ WHO is no longer at the helm of global health governance, and as the authors have succinctly described its challenges, “arguably the greatest burden WHO bears is its name” (p. 34). Blessed with significant start-up capital and “unburdened by the history and bureaucracy of WHO” (p. 88), the Global Fund and Gavi have been leaders among the new multistakeholder institutions. They have attracted substantial funds, matched specific outcomes to investments, and achieved measurable results.

Whereas WHO and the World Bank have broad mandates and activities, many of the new organizations in global health have far more narrow mandates and a vertical focus on a specific challenge. Both Gavi and the Global Fund have problem-focused and results-based missions, and they are financing as opposed to programmatic mechanisms. Neither works on the ground in countries, in contrast to WHO and the World Bank.

The emergence and great influence of these partnerships were driven by the recognition that some health challenges (e.g., HIV/AIDS) require intergovernmental cooperation and collective action, including participation from the private sector. The new institutions also reflect the skepticism toward WHO of both member states and donors over time. “Arguably the origins of Gavi and the Global Fund lie in a persistent belief that WHO was unable to steward big global health programs any longer and that the Bank was either insufficiently focused or donors were insufficiently able to have transparency into the Bank’s activities and influence” (p. 107). According to Mark Dybul, executive director of the Global Fund (in a June 2015 interview with Clinton and Sridhar), public–private partnerships were intended to leverage new funding and to challenge the old actors in global health.

GOVERNANCE MATTERS

The book makes a convincing argument that governance in global health matters, and the four case-study institutions and their principals “make decisions that meaningfully influence what gets done in global health” (p. 216). To illuminate what motivates the behaviors of the focal institutions over time, the authors explore in a rigorous, comparative manner how the organizations' governance structures can influence their roles in the global health system, how their financing bases may affect their agenda and priorities, and how each does or does not include nonstate actors in its governance. The book examines how institutional decisions are made and how governments or nonstate actors influence the organizations and their activities. It also evaluates the inclusiveness and transparency of the case-study institutions, with a discussion of the information they obtain, produce, control, and distribute in the public domain.

The strengths of the “old” institutions are also recognized, as is the importance of their continued participation in coordinated global health efforts. Given the solely intergovernmental nature of WHO, it remains “the only global health body with the power to create international law” (p. 206), to set norms and guidelines, and to negotiate international health agreements. The World Bank serves as a “direct broker” with ministries of finance, gives loans to countries to make long-term investments, and produces crucial knowledge used by governments to pass specific legislation.⁴ Unlike the “new” institutions, WHO and the World Bank provide technical assistance to countries, whereas the Global Fund and Gavi disburse funds for others to provide such assistance.

Despite these and other strong points, the authors conclude that in order to stay relevant and address current and future challenges as leaders in global health, WHO and the World Bank must evolve and reform, striving toward transparency and engaging various stakeholders, especially nongovernmental organizations. The authors make this powerful statement by invoking the aftermath of Ebola and the ongoing crisis of Zika.

Although the Global Fund and Gavi have had, for the most part, considerable country and donor support and trust, their governance increases the possibility that donor preferences could prevail. The analysis suggests that, in the past few decades, three principals—the United States, the United Kingdom, and the Gates Foundation—have influenced the priorities of the Global Fund, Gavi, and WHO.⁵ Thus, to remain influential, the Global Fund and Gavi must continue their efforts toward transparency, efficiency, and multisectoral engagement.

The picture of global health governance would be incomplete without underlining the importance of the largest private grant-making foundation in the world, whose role is examined throughout the book as related to the four case-study organizations. As a crucial funder of global health programs, “the scale and influence of the Gates Foundation is unprecedented” (p. 77). Both its budget and “the Gates approach” of funding primarily disease-specific programs have “deeply shaped the global health policy landscape” (p. 77). The foundation and Bill and Melinda Gates have played a significant role in financing public–private partnerships (particularly Gavi), supporting the Global Fund and other vertical initiatives, and contributing funds to WHO (and the World Bank on a smaller level). Holding substantial policy leverage, as well as seats on the Global Fund and Gavi boards, the Gates Foundation influences policy decisions and the research agenda for public health priorities.⁶

The book’s final reflections on the key health challenges in the next decade invite readers to develop their own views on the future of global health. Is it possible to reconcile the need to address the deep-rooted risk factors for noncommunicable diseases with the widespread appeal of interventions with clear targets that can be tracked and met within the short to medium term? Moreover, is it possible to do so without sacrificing vital funds directed to research and prevention of infectious diseases? Will the near future see long-term investments to strengthen health systems and provide universal health coverage? Will broad, multisectoral coalitions be the way to address the challenges posed by noncommunicable diseases, climate change, and obesity, among others, in addition to combating the next pandemic?

The authors humbly acknowledge that they do not have the answers to these difficult questions. However, they hope that their book will help inform those working on such issues in all sectors: country governments, multilateral organizations, philanthropic entities, and the private sector.

WHO RUNS THE WORLD (OF GLOBAL HEALTH) AND WHY?

Governing Global Health will be an excellent resource in the education of health professionals and future leaders in global health and health care. Despite its complexity, we cannot lose sight of the big picture of the global health landscape and its governance. Going back to the book’s subtitle, it is important to note that those who work, lead, and invest in global health do so with the best intentions of effecting positive change in the world and improving the health and well-being of people everywhere. The organizational approaches to achieving these goals may vary, and there may be setbacks, reforms, and changes of direction, but the goal remains the same: to ensure a better and healthier life for all.