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Governance for Health Special Issue Paper

Global health governance e the next political

revolution
I. Kickbusch*, K.S. Reddy
Global Health Programme, The Graduate Institute of International and Development Studies, Geneva, Switzerland

article info

abstract

Article history:

The recent Ebola crisis has re-opened the debate on global health governance and the role

Received 4 February 2015

of the World Health Organization. In order to analyze what is at stake, we apply two

Received in revised form

conceptual approaches from the social sciences - the work on gridlock and the concept of

27 March 2015

cosmopolitan moments - to assess the ability of the multilateral governance system to

Accepted 20 April 2015

reform. We find that gridlock can be broken open by a health crisis which in turn generates

Available online xxx

a political drive for change. We show that a set of cosmopolitan moments have led to the
introduction of the imperative of health in a range of policy arenas and moved health into

Keywords:

high politics - this has been called a political revolution. We contend that this revolution

Global health governance

has entered a second phase with increasing interest of heads of state in global health is-

World health organisation

sues. Here lies the window of opportunity to reform global health governance.

Health security

2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

Global health
Political determinants of health
Ebola outbreak

State of play in times of Ebola

For an institution to be effective, the states that create it

have to want it to be effective, and design it accordingly
(Hale et al.1)
International cooperation in health is one of the oldest and
most successful forms of multilateral cooperation reaching
back to the mid-19th century when the first International
Sanitary Conference was established in 1851. Even before this,
cities and states had for centuries engaged in various forms of
trans-border control for the protection of health, most famous
are the quarantine measures established by the Venetian

Republic. Since the creation of the health organisation of the

League of Nations in 1920, in combination with the health
work of the International Committee of the Red Cross (ICRC)
and of the International Labour Organization (ILO), health has
been part of the multilateral system and Geneva has been the
centre of international health. The year 1948, saw the establishment the World Health Organisation (WHO), the United
Nations (UN) specialized technical agency for health with the
mandate to act as the directing and co-ordinating authority
on international health work and with unique treaty making
power. The WHO constitution2 is an extraordinary and
visionary document, the political potential of which has not
been fully realized to this day.
The recent Ebola crisis has re-opened the debate on global
health governance and the role of WHO from many

* Corresponding author.
E-mail address: ilona.kickbusch@graduateinstitute.ch (I. Kickbusch).
http://dx.doi.org/10.1016/j.puhe.2015.04.014
0033-3506/ 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Kickbusch I, Reddy KS, Global health governance e the next political revolution, Public Health
(2015), http://dx.doi.org/10.1016/j.puhe.2015.04.014

p u b l i c h e a l t h x x x ( 2 0 1 5 ) 1 e5

perspectives. Two views dominate: the first maintains that

the global health system has failed and the second hopes that
the scope of the tragedy might provide the impetus to affect
change. We believe it is helpful to attempt an initial exploration of these perspectives by applying two conceptual approaches from the social sciences to the global health debate:
Hale et al. work on gridlock' that analyses the increasing
inability of the multilateral system to respond to global challenges1 and Ulrich Beck's contribution on the relevance of
'cosmopolitan moments' which enable global collective action.3 We find that while there clearly is 'gridlock' in multilateral health governance and there has also been significant
innovation both within and outside of the WHO when there is
political pressure and will for change.
Our initial analysis shows that the gridlock' is usually
broken open by a health crisis, which in turn generates the
political drive for action beyond the ministries of health. We
propose that it is important to look at these 'cosmopolitan
moments' not just individually but to see them as a continuum which contributes to introducing the imperative of
health to an ever wider range of policy arenas and to shifting
global health from low to high politics. This leads in our
opinion to the next phase of global health's political revolution
which began about 20 years ago.4

The glass half empty: gridlock

Increasingly, the nearly seventy year old WHO is no longer
seen as fit for purpose. Indeed, the organization is beset by
problems. We find that the four pathways that have led to
gridlock in the existing multilateral system proposed by Hale
et al. more generally can also be applied to global health
governance: growing multipolarity, institutional inertia, fragmentation and harder problems.5 Indeed, much of academic
analysis of global health governance comes back to these
points in one way or another. In this short piece, we can only
highlight some of the critical elements and underline, that the
four pathways continually intersect, reinforce one another
and are all driven by political interests.
Multipolarity: Scholars have long argued that the changing
nature of state sovereignty and the growing number and diversity of actors are altering the global political landscape, and
with it the incipient global health governance architecture.6
WHO, an organisation that began with 61 member states
now has to achieve consensus between 193 countries, at very
different levels of development, with very different world
views and political interests as well as integrate a wide range
of non-state actors. Under global media scrutiny the WHO
constantly has to re-affirm its authority and legitimacy.
Today, the global health constituency is no longer easily
divided into geo-political block or donors and recipients,
problems are not confined to groups of poor countries as most
poor people live in emerging economies and many countries
that still have major health problems already have a
competitive stake in the growing global health industry.
Multipolarity has made health much more political again.
Institutional inertia: After 1989, breakdown of the balance
of power between the two big Cold War blocks it became
difficult for the WHO to manoeuvre through the need for

more collective global action in the face of the neoliberal trend

towards less government - and less UN - responsibility. For
many decisive years the organization was further damaged
through lack of leadership. But over the last 30 years or so, the
WHO member states - despite continuous verbal commitment
to reform - have weakened their organization through
significantly reducing its budget, refusing to change its
regional structure and not being able to agree on the key
mandate and functions of the organisation. Many of the policy
processes enshrined in the constitution - such as the Executive Board and the World Health Assembly (WHA) have
become dysfunctional; agendas are overloaded, meaningful
debates are not easy and consensus based decisions are ever
more difficult to achieve. Yet, there has been little academic
analysis of the impact of political decisions of member states
on the organisations ability to act, such as the Helms-Biden
agreement of the US Senate in 19977 or the political positions taken by member states in the most recent WHO reform
process, initiated by the Director General in 2010.
Fragmentation: After 1989, the global health leadership
vacuum was filled by well funded disease focused programmes, which matched the politically dominant mind
frame of the donors and of many health advocates particularly in HIV/AIDS. This approach was also reinforced by new
policy orientations in the World Bank to invest in better health
outcomes for the poor as well as by WHO's Commission on
Macroeconomics and Health (CMH). Some argue that this shift
was due to the lack of ability of the WHO to deliver along the
lines of this new health development paradigm, while others
saw a conscious strategy at work to generally weaken and
discredit the international norms and standard setting organisation with treaty making power. By moving outside of the
universal inter-governmental WHO, global health could be
defined mainly by Western countries and big donors as
building issue focused alliances of the willing rather than
negotiating global health agreements and dealing with
structural issues prioritized by developing countries. This was
further reinforced through the historic opportunity of the
Millennium Development Goals (MDGs) and significant additional resources, especially through the Bill and Melinda Gates
Foundation.8 New institutions e such as the Joint United Nations Programme on HIV/AIDS (UNAIDS); the Global Fund to
Fight AIDS, Tuberculosis and Malaria (GFATM); and Gavi, the
Vaccine Alliance have all been created outside of the WHO.
This was an expression of the political preferences of powerful states and their development agencies.
Harder problems: For many commentators the narrowly
focused and fragmented global health paradigm of the last 20
years is partly responsible for the extreme impact of the Ebola
crisis.9 Harder global health challenges require the contribution and action of many sectors and necessitate systemic interventions that support global public goods. WHO has tried to
spearhead such agenda setting through the launch of a global
movement for Universal Health Coverage (UHC), the
commitment to the Social Determinants of Health and Health
in All Policies (HiAP), the exploration of the complex determinants of non-communicable diseases or the health impacts of climate change. The need to deal with the complexity
of the social, political and ecological pathologies of the Ebola
crisis10 (ranging from diamonds and logging to broken health

Please cite this article in press as: Kickbusch I, Reddy KS, Global health governance e the next political revolution, Public Health
(2015), http://dx.doi.org/10.1016/j.puhe.2015.04.014

p u b l i c h e a l t h x x x ( 2 0 1 5 ) 1 e5

systems and lack of health personnel) is now one of the key

messages from the Ebola crisis. These pathologies point to a
need to consider the political determinants of health and the
difficult balancing act, WHO has to deliver between its various
functions.

The glass half full: cosmopolitan moments break

the gridlock
Many analysts of global health governance who focus on the
gridlock tend to despair - they see a broken system. We would
like to put the analysis of gridlock into perspective, showing
that global health governance is much more dynamic than
often supposed and can yield results quickly, if the political
coordinates are in place. To do this we use the concept of
cosmopolitan moments which Ulrich Beck developed in his
work on the global risk society.3 He contends that in a globalized world the destabilization of the existing order - for
example, a global health crisis such as AIDS or SARS -can
create space for something new. This reflects what we regularly experience in national politics - change is made possible
by crisis.
Cosmopolitan moments are short points in time in which
the global community comes together and acts to create new
institutions and mechanisms which they have otherwise not
been willing to introduce. At such a point, there is a limited
window of opportunity that supports the collective management of global public goods or bads in new ways. As indicated
these cosmopolitan moments are often linked to crisis - but
they can also relate to a unique constellation of political forces
which exert pressure for change, such as the MDGs. Our initial
analysis suggests that in the last 15 years there have been at
least four cosmopolitan moments in global health that have
helped break the gridlock. They have led not only to new
institutions and approaches in global health governance, but
(very importantly) have also increased the presence of health
in other policy arenas:
 2000: Taking HIV/AIDS to the UN Security Council for the
very first time constituted a paradigmatic shift; the threat
of HIV/AIDS led to the creation of new organisations such
as UNAIDS and financing mechanisms such as the GFATM
and UNITAID as well as to a wide range of very proactive
civil society organisations (CSOs);
 2000: The MDGs put health firmly in the centre of development through three goals - this led to a number of issue
and disease focused initiatives and also included new
governance and new financing structures, such as for
example Gavi, the Vaccine Alliance and a significant
number of public private partnerships;
 2002/2003: The SARS outbreak led to the significant revision of the International Health Regulations (IHR) adopted
in 2005, significantly broadened their scope, redefined the
powers assigned to the WHO as well as the responsibilities
of countries in relation to public health emergencies of
international concern (PHEIC);
 2007: The H5N1 influenza led to the Pandemic Influenza
Preparedness (PIP) Framework, 2011 which brings together
member states, industry, other stakeholders and WHO to

implement a global approach to pandemic influenza preparedness and response, which includes the sharing of
influenza viruses with human pandemic potential; and
aims to increase the access of developing countries to
vaccines and other pandemic related supplies.
This shows that a critique of WHO as an irrelevant global
health actor caught in total gridlock and inertia is misguided.
While the first two examples of change driven by cosmopolitan moments point in that direction and the other two do not.
WHO in the 1990s was not prepared to respond adequately to a
disease such as HIV/AIDS which required strategies that reach
far beyond the health sector and involve the whole of society,
and especially stigmatized groups; WHO was also not able to
respond effectively to the development agenda set by the
MDGs, mainly because it was set up to be a universal not a
development agency. In these two cases the inability to
change was driven by factors internal to the mandate and
management of the organisation, strong advocacy by CSOs
and other UN agencies, and significant new money combined
with a clear political interest by some countries to work
around the organization. On the other hand the adoption of
the revised IHR and the PIP Framework set new rules and
standards in relation to collective action problems through
working within the WHO - as they required a universal
membership organisation to be politically resolved. WHO did
well what it does best. Both agreements have been ground
breaking and have contributed towards shifting the approach
to global health security as well as expanding the political
imperative of health to other sectors.11

High and low politics - overcoming gridlock

Cosmopolitan moments give a clear message: for the global
health agenda to move forward there needs to be significant
support by other sectors, by heads of government and other
actors with political power and influence. This was the position of Gro Harlem Brundtland, a former prime minister, when
she was Director General of the WHO from 1998 to 2003. It is
reflected in the approach by the CMH which she initiated: It
engages Ministries of Finance, Planning and Health to act in
tandem with development agencies, civil society, philanthropic organizations, academia, and the private sector. For
her, it was clear that WHO's future lay in shifting health from
low politics to high politics. High politics in the past was understood to deal with those issues that are essential to the
survival of the state (especially national security) whereas low
politics encompassed areas such as finance, social welfare and
health. An inclusion of health in the agenda of the UN Security
Council, into foreign policy and national security strategies
can therefore be considered a shift from low to high politics.
But health also benefits politically from the trend in international relations that issues which were considered low politics
- such as finance and health - are now of increasing relevance
for the survival of states. This explains their prominence in
international political fora and on the agendas of heads of
government. It also helps explain why groups of foreign
ministers declare health as a goal of foreign policy12 and why
UN initiatives such as the MDGs and the Sustainable

Please cite this article in press as: Kickbusch I, Reddy KS, Global health governance e the next political revolution, Public Health
(2015), http://dx.doi.org/10.1016/j.puhe.2015.04.014

p u b l i c h e a l t h x x x ( 2 0 1 5 ) 1 e5

Development Goals (SDGs) aim to bind states to common objectives on issues that were considered low politics in the
past.
While some consider this move of global health from low
politics to high politics as a weakening of the WHO, we would
not draw this conclusion. Rather we see it as an opportunity
for the organisation to gain new relevance and break some of
the gridlock. The 1948 constitution of the WHO already puts
health firmly into the context of both high and low politics: it
considers health essential for peace and security (high politics) and it states that governments have a responsibility to
provide adequate health and social measures (low politics now high politics) for their populations. Both goals can only be
achieved if health is high on the political agenda or as Elbe11
would put it - when the imperative of health infiltrates other
policy arenas. In our view this means that the challenge for
the WHO is to reinterpret its constitutional role to act as the
directing and co-ordinating authority on international health
work.2 Until recently, this was seen mainly as coordinating
health actors at different levels of governance - today this
must be understood as positioning health in the global political landscape where decisions are taken by heads of government and in other sectors. In doing so, we clearly reject the
suggestion to separate the technical and the political function
of the WHO.13 We think that such a move would turn WHO
into a neutered global centre for disease control rather than a
significant global health actor.
Of course, health is political and has been so since the
creation of an international mechanism to address cross
border health issues. The founding fathers of the WHO had
initially introduced a distinction, which fully recognized that
international health negotiations were both technical and
political. The members of the Executive Board were to be
technical experts, whereas at the WHA, the decision makers
were the political delegations of member states. This provision of the WHO constitution was changed by the member
states in 1998 to have political member state representation in
both governing bodies - a reflection of their recognition of the
political relevance of the negotiations. The intention to depoliticize health and the work of the WHO has not really
worked - and statements by WHO member states that maintain health matters should not be politicized, do not carry
much credibility.

IMF and the World Bank, the EU foreign policy council and the
African Union. The German Chancellor has put health as a
priority on the 2015 G7 agenda and has decided to address the
WHO's World Health Assembly in May 2015. These recent high
level activities in relation to Ebola have illustrated Ulrich
Beck's points that global risks open up a complex moral and
political space of responsibility in which the others are present and absent, near and far, and in which actions are neither
good nor bad, only more or less risky. The meanings of proximity, reciprocity, dignity, justice and trust are transformed
within this horizon of expectation of global risks.3
This means the WHO must become much more agile and
astute in dealing with global forces and global flows that
impact on health and respond with strategies that address
global public goods and bads. Big challenges such as reducing
global health inequalities or ensuring global health security
cannot be achieved by one organisation or through ministries
of health only. It requires the strategic link with other transnational agendas and a strengthening of the political ability to
position health interests and defining and selecting political
spaces. Chorev's analysis shows that when WHO had strong
leadership it was able to respond to a new political environment with significant political acumen.14 Through the tragedy
of Ebola, WHO can break the gridlock - it now has the historic
opportunity to reinvent itself once more as a leader in global
health that supports countries - both poor and rich - in their
response to increasing interdependence and structural global
vulnerability. It can make use of the inclusion of the imperative of health in many domestic and foreign policy arenas and
it must exploit the present cosmopolitan moment to reform
and strengthen the organization and clarify the interpretation
of its mandate at this point in time.
The decisive factor in the second phase of global health's
political revolution is that a real change will require much
more than the involvement of the ministers of health who
usually represent the member states in the WHO governing
bodies. This shift is too serious to be left the WHO alone and
therefore requires strong leadership by the Director General in
reaching out and setting the challenge. To affirm WHO as an
agency capable to ensure health security will require the
commitment of heads of government from all the regions of
the WHO. Reform this time round means decisive action by
the member states at the highest level - they must match
WHO's constitutional authority with the political support and
the financial resources to act.

The second phase of global health's political

revolution
We propose that global health is in the second phase of political revolution, it has made it to the highest echelons of
power. Today, global health is considered critical for national
and international security, domestic and global economic
well-being, and economic and social development in less
developed countries, is also a major growth sector of the
global economy. At the national level, concepts such as
Health in All Policies or whole of government approaches to
health and well-being have gained increasing traction. The
American president is personally involved in the Ebola
response, as are the three heads of state of the Ebola affected
countries. Ebola is discussed at the UN Security Council, the

Author statements
Ethical approval
None sought.

Funding
None declared.

Competing interests
None declared.

Please cite this article in press as: Kickbusch I, Reddy KS, Global health governance e the next political revolution, Public Health
(2015), http://dx.doi.org/10.1016/j.puhe.2015.04.014

p u b l i c h e a l t h x x x ( 2 0 1 5 ) 1 e5

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Please cite this article in press as: Kickbusch I, Reddy KS, Global health governance e the next political revolution, Public Health
(2015), http://dx.doi.org/10.1016/j.puhe.2015.04.014