Hum Rights Rev (2015) 16:6568

DOI 10.1007/s12142-015-0352-8
B O O K R E V I E W E S S AY

Global Health Governance in International Relations

Kai-Lit Phua

Published online: 4 February 2015

# Springer Science+Business Media Dordrecht 2015

Global Health Governance by Jeremy Youde

Cambridge and Malden: Polity Press, 2012

Global Health and International Relations by Colin McInnes and Kelley Lee
Cambridge and Malden: Polity Press, 2012

Global Health Governance by Jeremy Youde and Global Health and International
Relations by Colin McInnes and Kelley Lee both cover the subjects of global health
and global health governance (GHG), but they use different approaches. Youdes book
is more descriptive, and optimistic on the impacts of civil society organizations, while
McInnes and Lee argue that current global health actions and GHG structures are the
outcome of political struggles and negotiations between various actors.
From Youdes point of view, global health governance can be defined as institutional
arrangements that deal with health issues and challenges that require cross-border
collective action. Contemporary GHG involves more than just nation-states and mul-
tilateral agencies such as the World Health Organization, the World Bank, and
UNAIDS. Increasingly, private actors and civil society organizations (CSOs) have
become involved in the process. These private actors and CSOs include the William
J. Clinton Foundation, the Bill and Melinda Gates Foundation, Rotary International, the
Carter Center, Oxfam International, and South Africas Treatment Action Campaign.
There have been innovations such as the creation of UNAIDS (Joint United Nations
Program on HIV/AIDS) and the Global Fund (Global Fund to Fight AIDS, Tubercu-
losis and Malaria). UNAIDS was formed mainly to coordinate activities of other HIV/
AIDS agencies, to raise awareness of the threat posed by the disease, to facilitate
information-sharing, and to bring governments and non-governmental organizations
together in combating this major health challenge. The Global Fund serves as a pure
funding agency, and provides no personnel or technical assistance. Funds are raised
from donor governments. Applications for funding by recipient governments must

K.<L. Phua (*)

School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Subang Jaya,
Selangor, Malaysia
e-mail: phua.kai.lit@monash.edu
66 K.-L. Phua

include CSOs as partners. In recent years, as much of 25 % of all international HIV/

AIDS funds, 67 % of TB funds, and 75 % of malaria funds have come from the Global
Fund.
Two private foundations that are prominent in GHG are the Clinton Foundation and
the Gates Foundation. These two foundations use private sector business approaches in
their operations. The Clinton Foundations technique of Bsocial entrepreneurship^
applies business strategies in the provision of social goods such as pharmaceutical
drugs. The foundations CHAI (Clinton HIV/AIDS Initiative) has helped states nego-
tiate with and obtain anti-retroviral drugs from private sector companies at lower prices.
This has increased access to anti-retroviral drugs in many countries. The Gates
Foundations philosophy and approach also borrows from the private sector. This
influential foundation focuses on funding scientific research to find technical solutions
to diseases (including so-called Bneglected diseases^). Youde notes that in spite of
questions of legitimacy and representativeness of CSOs, donors have increasingly
begun to directly fund CSOs in recipient countries rather than provide funds to
governments. This is partly ideological wanting to promote Bprivate sector solutions^
to social problems and partly pragmatic, i.e., to reduce wastage due to corruption and
public sector mismanagement.
In Global Health and International Relations, McInnes and Lee point out that
private actors and civil society organizations are not necessarily always a progressive
force. In fact, they feel that greater plurality on the global health scene may actually
increase the problem of lack of coherence in global health action. Biomedicine (and
EBM) view health problems from an individualistic angle and emphasize technical
solutions to these problems. The Gates Foundation has been criticized for adopting this
approach and ignoring the social determinants of health. It has also been criticized for
skewing research in certain directions through its research grants program. For exam-
ple, in the area of HIV/AIDS, the biomedical model concentrates on the development
of anti-retroviral therapies and clinical guidelines to treat co-morbidities such as TB.
Research on ways to reduce risky behavior by vulnerable population sub-groups
(including commercial sex workers, men who have sex with men, and injecting drug
users) and education to reduce stigma are ignored.
McInnes and Lee emphasize how political and socioeconomic forces shape GHG
structures and global health policies. They view the present situation as one of chaos
and even express their skepticism of the concept of GHG by saying that, in fact, Bit can
hardly be said that GHG exists at all^ (128). They subscribe to the view that concepts
such as Bglobal health^ and GHG are social constructions. In their eyes, Bglobal health^
is a social construction that prioritizes certain health conditions while neglecting others
(which actually harms people in greater numbers), prioritizes some interests over other
interests, legitimizes certain forms of knowledge and research methods over other
kinds, and empowers specific institutional arrangements in preference to other arrange-
ments. They list five frames and mention that although these are often in competition
with each other, they can also overlap. These five frames include: Evidence-Based
Medicine (EBM), the human rights approach to health, health as a national security
issue, economism, and development.
McInnes and Lee argue that economism, security, and biomedicine (EBM) dominate
over approaches, such as the human rights approach to health (and the social determi-
nants of health view of Michael Marmot). Economism views health provision as
Global Health Governance in International Relations 67

mainly an economic issue and emphasizes efficient allocation of healthcare resources

rather than allocation for the promotion of social justice or other similar ends. Stronger
versions of economism propose that the public sector should only provide health
services in the form of a limited safety net of basic public health and clinical services.
The main role should be played by private industry and market mechanisms should be
enhanced so as to ensure efficiency in the use of limited resources. Economism is part
and parcel of neoliberalism and New Public Management (NPM) thinking. All these
view globalization as an inevitable, as well as progressive, development that enhances
human welfare. These perspectives view liberalization of healthcare services financing
and delivery through market mechanisms and private sector participation as desirable.
For example, the World Bank (a major advocate of neoliberal policies) promoted
policies that limit the state to the provision of core public health and curative services;
actively encouraged larger roles for the market, private sector health corporations and
private health insurance; and advocated the introduction of user fees and related cost
recovery mechanisms. The current trend is promotion of so-called public-private
partnerships (PPPs).
The NPM approach views patients as Bhealthcare consumers^. Its enthusiasts believe
that there should be competition between providers to reduce prices and increase
efficiency, and there should be contracting out of public services to the private sector.
In the National Health Service of England, NPM techniques include the introduction of
performance indicators and new incentive mechanisms for providers so as to enhance
quality of care. Globally, healthcare services have been increasingly reframed as a
commodity to be supplied by private actors in globalized markets; foreign as well as
homegrown for-profit healthcare corporations have been proliferating and expanding in
developing countries, and corporations exert significant influence on global health
policies. Many countries have also jumped on the medical tourism bandwagon as a
means of promoting economic growth. These include countries where many of their
citizens lack access to satisfactory levels of basic healthcare, such as India and the
Philippines.
Relatedly, Bsecuritization^ refers to the tendency to regard disease outbreaks (natu-
rally occurring or otherwise) as a threat to national security. This approach is state-
centric and focuses primarily on HIV/AIDS, bioterrorism, and acute epidemic infec-
tious diseases. Although HIV/AIDS does cost some developing countries heavily in
terms of human health and damage to the economy and the healthcare system and
acts of bioterrorism have occurred in wealthy countries such as Japan (Aum Shinrikyus
sarin gas attacks) and the USA (the anthrax incidents) McInnes and Lee point out that
there has been no case of state failure arising from a health crisis in recent decades.
Even so, this has not prevented some states from securitizing the issue and devoting
significant resources against perceived threats to health, such as stockpiling vaccines
against certain emerging diseases.
These perspectives stand in sharp contrast to the development and human rights
frames outlined by McInnes and Lee. The development frame views nations as lying on
a continuum ranging from the least developed countries and the developing countries of
the so-called Third World to developed/advanced nations of the First World. The latter
should serve as the benchmarks for the former. Certain versions of this frame argue that
developed nations should actively aid developing nations so as to enhance the welfare
of the citizens of the latter. This includes bilateral and multilateral aid (funding,
68 K.-L. Phua

technical assistance, etc.) given to fight against disease and more recently, assistance in
carrying out healthcare reforms and in strengthening health systems. Multilateral aid
includes the health-related activities of the World Bank which, as mentioned earlier, has
been criticized for its heavily economistic approach. The human rights frame is based
on the principles of dignity and respect for the individual. It posits that access to
healthcare is a human right. There should be no coercion or discrimination or other
kinds of violations of human rights when it comes to healthcare provision and
financing. Advocates of this frame usually link their arguments to various international
declarations of human rights.
Youde recognizes a basic tension between economics and human rights when it
comes to global health issues and GHG. He argues optimistically that Bthe logic
underlying global health governance has shifted over time, moving from one motivated
largely by economics to one that also embraces human rights and security^ (159).
McInnes and Lee, on the other hand, view economism as a frame which has grown in
influence and successfully gained the upper hand in discourse on global health and
GHG. Their social constructivist approach argues that this was not inevitable, but rather
the outcome of contending forces and interest groups. Herein lies the major difference
between these two important books on global health.
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