Reimagining Global Health Governance in the Age of COVID-19

The COVID-19 pandemic reminds us that no country acting alone can respond effectively to health threats in a globalized world. Global governance is necessary to coordinate the global health response. Yet, the COVID-19 pandemic has revealed deep fissures in global health governance, with international organizations facing obstacles from nationalist governments in managing a common threat. The COVID-19 pandemic is reframing global health governance. Considering key structural limitations in meeting enormous challenges, how can we best realize global solidarity in an age of populist nationalism? With the sheer scale of human, social, and economic upheaval, we face an imperative to strengthen global health institutions and governance.

In this editorial, we reflect on the challenges that nationalism poses in the COVID-19 response, conceptualizing how we could reimagine global health governance. We begin by examining how international organizations have sought to bring nations together in responding to global health threats. However, international institutions are facing increasing pressures from nationalist governments, and we analyze these nationalist obstacles to global solidarity. The structural limitations of the pandemic response are reframing the global health governance landscape. Given this historic opportunity to reimagine global health governance in the age of COVID-19, we consider the rise of new institutional structures that reflect the realities of a divided world. We conclude that a new governance landscape will be crucial to strengthening global public health—rising out of crisis to secure a safer future.

BRINGING NATIONS TOGETHER

The modern global health architecture arose from the ashes of crisis. The United Nations (UN) was formed 75 years ago out of the ruins of World War II, bringing nations together to address collective threats through international action. Signed on June 26, 1945, the UN Charter called for the establishment of a new international health organization, the World Health Organization (WHO), which has evolved over the years to build a healthier world.¹ The UN system strives toward a cosmopolitan vision of a global community that provides a foundation for international cooperation to advance global health.² The COVID-19 pandemic has challenged this international system as never before.

WHO is at the forefront of the global response to health threats, as it seeks to direct and coordinate international action to realize the highest attainable standard of health. The 1946 WHO constitution empowers WHO to negotiate international agreements on a wide range of health issues. The International Health Regulations (IHR) is the primary WHO instrument governing pandemic threats, codifying national obligations “to prevent, protect against, control and provide a public health response to the international spread of disease.”^{3(art. 2)} Last revised in 2005 following concerns over the global response to SARS (severe acute respiratory syndrome), the IHR provides a framework to build national health system capacities and strengthen WHO authority to respond to public health emergencies of international concern.

WHO has long sought to strengthen its institutional authority to coordinate national health efforts, with the WHO director general calling for “collaboration and partnership” through a strengthened WHO.⁴ Now facing its greatest pandemic challenge, WHO is seeking to galvanize “global solidarity” in the COVID-19 response.⁵ Calling for solidarity across nations to facilitate equity in the global response, WHO has supported national strategies to prepare for, rapidly detect, and respond to COVID-19 by providing technical information, coordinating health research, and raising emergency funds.

Complementing WHO, the larger UN system has established global health initiatives for international health cooperation. UN action on global health has increased dramatically over the past two decades. The UN General Assembly has devoted high-level special sessions to both infectious disease and noncommunicable disease, with recent action on antimicrobial resistance and universal health coverage.⁶ The UN Security Council has weighed in on health emergencies, elevating the political response to health security threats, beginning in response to the HIV/AIDS pandemic and extending through recent Ebola epidemics.⁷

In responding to the global threat of COVID-19, the UN has developed a COVID response plan, a humanitarian response plan, and a framework to mitigate social and economic impacts.⁸ Recognizing the economic consequences of earlier Ebola outbreaks in sub-Saharan Africa, the UN is striving to minimize the effects of the current pandemic on lives, livelihoods, and the economy and to build a more inclusive and sustainable future. To help nations remain resilient under this socioeconomic framework, the UN secretary general launched the United Nations COVID-19 Response and Recovery Fund to aid low- and middle-income countries in the pandemic response.

Yet even as the UN system seeks to bring the world together, governments have too often responded alone, as the universal system of international organizations has faced continuing obstacles in realizing global solidarity.

OBSTACLES TO GLOBAL SOLIDARITY

Contrasted with the cosmopolitan vision of global solidarity through international organizations, nationalist governments have subverted global health governance in the COVID-19 response. Nationalist leaders have weakened WHO’s authority, blocked a coordinated UN response, and imposed isolationist policies that divide the world. These challenges to international law and institutions have escalated the pandemic threat.

WHO’s global health mandate has been challenged by the rising reluctance of national governments to adequately support global health governance. This is seen most clearly in member state attacks on WHO’s leadership and refusal to meet national financial obligations to WHO’s programming in the pandemic response—with the United States, WHO’s largest donor, seeking to withdraw from WHO entirely.⁹ Beyond explicit attacks, nationalist governments have also weakened global governance through violations of IHR obligations, including failures to share timely and accurate information with WHO and failures to act on WHO’s warnings and recommendations. The IHR aims to harmonize national health responses while facilitating international coordination, yet governments have failed to comply with IHR obligations, prioritizing political ideology over epidemiologic reality.¹⁰

The UN system similarly relies on international cooperation, but ongoing political conflicts have paralyzed the UN, preventing it from leading a coordinated global response.¹¹ Limiting its influence in global health governance, the UN Security Council has been hobbled by conflicts between the United States and China about the origins of the pandemic and the adequacy of the early response. As a result, the Security Council struggled for six months to adopt its first resolution on COVID-19—backing the secretary general’s repeated call for a ceasefire in armed conflict to aid in addressing the pandemic in humanitarian settings. Despite continuing support among many nations for multilateral governance, permanent members of the Security Council have employed power politics to block cooperative UN efforts in the global response.

Dividing an interconnected world, nationalist governments have implemented isolationist policies that undermine global solidarity. As governments rapidly imposed international travel bans, many nations engaged in medical protectionism that impeded the movement of health supplies in the early months of the pandemic—restricting exports of personal protective equipment, other medical supplies, and even necessary food supplies.¹² The United States purchased virtually the entire global supply of remdesivir, an early COVID-19 treatment, presaging future obstacles to the equitable distribution of other drugs and vaccines.¹³ These nationalist policies have transgressed international law, with cascading effects on international trade, health determinants, and human rights.¹⁴ Rather than working together to fight a common threat, nationalist strategies pit nations against nations, subvert global action to curb the pandemic, and grind the world to a standstill.

Nationalist challenges in the COVID-19 response highlight key structural obstacles that weaken global health governance. How can global governance respond effectively when nations place WHO in the middle of political power struggles, paralyze the UN in a fit of political theater, and isolate themselves in a globalizing world? Amid the struggle between nationalist and cosmopolitan worldviews, global health governance must be reimagined to accommodate both nationalism and globalism. Responding to the limitations inherent in the current system, COVID-19 offers an opportunity to transform the global health governance landscape.

GOVERNANCE TO REVITALIZE SOLIDARITY

The global devastation of COVID-19 highlights the critical need to reform the global health system. Pathogens threaten an interconnected world, yet the UN system has proven inadequate to meet pandemic threats and unable to realize global solidarity. Global health governance through international organizations remains essential—WHO and UN leadership are needed, now more than ever—but it is crucial to recognize what is painfully obvious: nationalism is impeding international cooperation. International organizations with universal membership are only effective if their member states are willing to cooperate.¹⁵ What does it mean to strengthen global governance in the face of resurgent nationalism? In this fragmented world, we have to reimagine global health institutions, conceptualizing the global health governance landscape with a diminished US presence, a fractured global health ecosystem, and a changing WHO role.

A Diminished United States

The United States has long stood at the forefront of global health. Beginning in 1902 with the creation of the first permanent international health organization in the Americas, the United States has led the way in establishing global health governance. The United States hosted the International Health Conference that adopted the WHO constitution, holding preeminent influence over WHO’s programming in its early years. Continuing to shape the global health agenda through bilateral and multilateral engagement, the United States has remained the single largest funder of global health initiatives through its signature global health programs, including the PEPFAR (President’s Emergency Program for AIDS Relief) and the Global Health Security Agenda. The United States has provided critical support for global health partnerships, including the Global Fund to Fight AIDS, Tuberculosis and Malaria and Gavi, the Vaccine Alliance.¹⁶

Yet, amid nationalist shifts, the US government has abdicated responsibility for global health and pulled back from global governance. In deflecting from his own domestic policy failures in the COVID-19 response, the populist US president has escalated attacks on WHO’s leadership and sought to withdraw from WHO completely. He has paralyzed UN efforts through political attacks on China while threatening the world through efforts to hoard COVID-19 treatments and prospective vaccines. As a result, US global influence has been weakened. These divisive actions have presented the United States as an untrustworthy partner in a global crisis and could lead to a permanent diminishment of US legitimacy in global health.

Without US support, global efforts will face limitations. Cutting WHO funding, obstructing the UN, and eschewing collective action during a pandemic will hamper the global response. However, as other countries step forward to support the global response and seek a larger influence in global health,¹⁷ global health governance will endure—but it will do so without the influence that the United States once wielded. Global institutions may become more responsive to a far larger set of actors and, as a consequence, could shift to focus on global health initiatives that do not align with US national interests.

Although US global health engagement has often benefitted the world, there are also times when the United States has shaped the international agenda to prioritize its own domestic economic interests over global public health. Without US corporate interests at the table, US disengagement could allow global institutions to take a more flexible approach to intellectual property rights to promote access to medicines and focus more on preventing and controlling noncommunicable diseases driven by commercial determinants of health, including alcoholic beverages, sugar-sweetened beverages, tobacco, and unhealthy foods. WHO has long understood that “efforts to prevent non-communicable diseases go against the business interests of powerful economic operators.”^18(p895) The absence of US influence could present new opportunities to regulate commercial interests that harm health through new policies across the global health ecosystem.

A Fractured Global Health Ecosystem

International organizations were once at the center of the global health landscape, but the modern era has seen the rise of a far more expansive ecosystem that adds complexity to global health governance. Distinct spheres of influence have emerged in the current pandemic. These factions have led to divergent COVID-19 responses, with the United States adopting an isolationist posture, China shoring up its alliances and expanding its influence, and the European Union vigorously defending the multilateral system. This shift away from coordinated global health governance has led to political conflict and institutional disorder, undermining international cooperation.

Beyond intergovernmental relations, global health governance increasingly brings together state actors with a proliferating set of nonstate actors, including academics, celebrities, nongovernmental organizations, public–private partnerships, and philanthropic foundations.¹⁹ Although lacking the legitimacy of international organizations, these new partnerships have come together in club models of voluntary participation and financing.²⁰ Governance has thus shifted over several decades—away from the universal system of international organizations and toward these nonuniversal partnerships that undertake discrete global health initiatives.

Such a fractured ecosystem is not fit for the purpose of an effective global pandemic response. A core challenge has been that these new global health partnerships were designed for development assistance; they were never intended to be truly universal global initiatives. That is, the global health ecosystem is designed to neither receive robust support from nor meet the needs of all countries.

This dilemma is seen in the COVAX facility, jointly led by Gavi, the Vaccine Alliance, WHO, and the Coalition for Epidemic Preparedness Innovations. Gavi has long received voluntary contributions from select state and nonstate actors to ensure access to vaccines in the world’s poorest countries, but it now faces challenges in the COVID-19 response. High-income countries have already spent heavily to secure commitments to early COVID-19 vaccine candidates for their domestic needs, with this “vaccine nationalism” leaving only an inequitable fraction of the global supply available to COVAX for the large number of countries that will depend on it for access.²¹ The competitive scramble for vaccines highlights both the fragmented geopolitical landscape and the challenges that development-oriented global health partnerships face in addressing a threat facing all countries, necessitating a changing role for WHO in governing the global health landscape.

A Changing World Health Organization

States established WHO as a universal multilateral institution to coordinate intergovernmental actions in international health. In contrast with other global health actors, WHO’s mandate has always been to serve the interests of all nations across all health challenges. Although much of WHO’s programming has focused on developing countries—with this tropical medicine mindset at times criticized for neocolonial infringement on the sovereignty of recipient governments—WHO’s governance has provided a political forum for all states to come together to debate issues, negotiate norms, and resolve differences in guiding global health policy.²²

Yet even as the end of the Cold War provided an opportunity for all nations to join together in the early 1990s under WHO, high-income countries rapidly moved to establish health assistance programs outside WHO—through increased bilateral health assistance, public–private partnerships, and short-term commitments.²³ WHO has continued to provide key technical and normative standards for public health; however, states have actively limited WHO’s autonomy by earmarking funding for specific programs in conformity with their own national priorities.²⁴ With the resurgence of populist nationalism, even this limited authority is being challenged, as national leaders have accused WHO of favoring China in the COVID-19 response, questioned its public health guidance, and threatened to withdraw from WHO completely.

WHO’s central role remains absolutely essential, but WHO lacks both the authority and the resources to mount an effective response to a global emergency that affects all countries. In leading a universal response across all nations, WHO is seeking to support low- and middle-income countries (which rely more on its technical guidance and operational assistance) while simultaneously meeting the needs of high-income countries (which depend more on its information sharing, research coordination, and convening authorities). WHO now seeks an expanded and strengthened role—providing political leadership, negotiating international disputes, and coordinating technical and normative guidance in the pandemic response. Bringing together state and nonstate actors, WHO has sought to coordinate collaborative COVID-19 research, as seen in the SOLIDARITY therapeutics trials and serology studies, which seek to align research throughout the world around a unified goal, core study protocols, and a results-sharing platform.²⁵

WHO’s evolving governance could offer a new model for global collaboration, bringing together willing state and nonstate actors to respond to a common threat to humanity. The future global health architecture may resemble multipolar clubs, rather than universal approaches to governance, but there remains a central role for WHO. Governments willing to share their sovereignty through multilateral arrangements would be able to craft a more robust global system. Even if not all states engage with this new system, those that do will be able to ensure more effective global governance in responding to pandemics alongside nonstate actors. For WHO to achieve this goal, it will need a critical mass of member states to provide sustainable funding commensurate with WHO’s global mandate, powers to secure greater compliance with the IHR and other core norms, and political backing to stand up to governments that undermine international institutions and the rule of law.

CONCLUSIONS

The world is facing an unprecedented global health threat, and the response is highlighting structural limitations in the ability of international organizations to coordinate nationalist states. Global health governance is at a crossroads, necessitating a new governance model that takes into account the cosmopolitan ideal of international organizations with universal membership and the realist landscape of populist nationalism among member states. It is crucial to develop a global health governance system that reflects the challenges of a fragmented yet interdependent world. The global governance institutions that develop in the aftermath of the COVID-19 crisis will determine the response to future threats.

The world faces a clear choice: either take a “my country first” nationalist approach or work cooperatively through shared governance. Taking the latter path will require reimagining global health governance. Failure to strengthen global governance at this critical juncture could lead to permanent nationalist retrenchment and international organization collapse, dimming hopes for the future.