Jongbloed-Unpacking Global Health Governance

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UNPACKING GLOBAL HEALTH GOVERNANCE:

Understanding the relationship between the World Health Organization andthe Bill & Melinda Gates Foundation from a health equity perspective

“In the face of rising infectious disease such as AIDS, TB, and malaria, and theincreasing marginalization of health problems that do not affect the developed world, the importance of an international, independent organization that is brave,aggressive and vocal in its defense of global public health has never been moreimportant”

(Ford and Piedagnel quoted in Lee, et al, 2009, p.419).

INTRODUCTION

The last twenty years has seen a shift from “international” health to “global”health, where intergovernmental actors have been replaced by transnational institutions(Birn, et al, 2009; Brown, et al, 2006). Private foundations, non-governmentalorganizations (NGOs), and global health partnerships have gained power and prestige asUnited Nations (UN) organizations, such as the World Health Organization (WHO), haveseen their agency undermined. Changes in the governance structure of global health,especially the entry of extremely powerful private institutions, have affected the quest forglobal health equity in a number of ways. This paper looks at the implications of thistransition on health equity at a global level by looking specifically at the growth of the

2Bill & Melinda Gates Foundation and its relationship with the WHO.

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First, it establishesa framework within which to understand health equity. Then, it provides a historicalperspective of the diminished capacity of the WHO while examining the rise inprominence of the Gates Foundation, and also their relationship to each other. Finally,the paper discusses the impact of the rise and fall of these two institutions on healthequity at an international level.

A FRAMEWORK FOR HEALTH EQUITY

According to Braveman and Gruskin (2003), “equity in health is the absence of systematic disparities in health (or in the major social determinants of health) betweengroups with different levels of underlying social advantage/disadvantage—that is, wealth,power, or prestige.” A look at indicators of health across the globe and within countries,including life expectancy and maternal mortality, makes it clear that health equityremains a goal rather than an achievement. Since the early 20

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Century, cooperation toaddress health across national borders has occurred, but it was not until the Declaration of Alma Ata in 1978 that the notion of health for all gained prominence in public discoursesaround health (Birn, et al, 2009). In recent years, health has been viewed through ahuman rights framework and in terms of the social determinants of health (Farmer, 2005;WHO, 2008). The notion of health equity encompasses most of these perspectives andforms the basis of this paper’s argument.

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In McCoy, et al (2009b)’s recent article entitled The Gates Foundation’s grant making program for globalhealth, the authors suggest that “one investigation that would bring greater clarity to the structure of globalhealth governance is the critical examination of the nature and effets of the relationship between the GatesFoundation and the World Bank, World Health Organization and key global health partnerships” (p. 1651).This paper attempts to respond directly to this suggestion.

3Loewenson (2009) suggests that there are four elements that support theachievement of health equity: health for all; health in all policies; health equity; andsocial empowerment. First, health for all involves ensuring that every person has accessto health care. For example, that they do not face financial or geographical barriers toaccessing health care facilities. Second, health in all policies suggests that health issuesare considered in all policy development, from international financial regulations tomunicipal level housing planning. Third, health equity requires a redistribution of resources throughout the health system that cannot be left to the market. And finally, itinvolves social empowerment where there is recognition that people make up the centralrole in health systems.At an international level, there is a push for health equity from a number of sources, one of which is the Global Health Watch (GHW). The WHO is often seen as theactor best positioned to lead the quest for global health equity both because of its policysetting mandate and its representation of 193 countries. The most recent Global HealthWatch (2008) argues for a centralized, “accountable and effective multilateral globalhealth agency, driven by a desire to promote health with the understanding that thedistribution of health and health care is a core marker of social justice” (p. 224). Since itsestablishment on April 7, 1948, the World Health Organization has sought to fill this role(Birn, et al, 2009).

THE WORLD HEALTH ORGANIZATION