key: cord-0036257-l6ruaucu
authors: Hein, Wolfgang
title: The New Dynamics of Global Health Governance
date: 2012-11-07
journal: Global Health Diplomacy
DOI: 10.1007/978-1-4614-5401-4_5
sha: 4058f501befb12058bf03f1044e438f2bc3a3fd1
doc_id: 36257
cord_uid: l6ruaucu

This chapter considers the impact of globalization on international health policies and the emergence of new approaches to Global Health Governance (GHG). The first part of the chapter describes the changes in institutional structures since the 1990s that have had a fundamental impact on GHG. These structural changes have occurred as the discourse on trans-boundary health has broadened and engaged more public, private and voluntary sector actors in the debate. This has brought greater recognition of the need to mobilize a range of financial and other resources and to adopt a more flexible approach to problem solving. But the proliferation of public and private actors has also brought greater complexity that could inhibit the effective application of these resources and solutions.

This chapter considers the impact of globalization on international health policies and the emergence of new approaches to Global Health Governance (GHG) . The fi rst part of the chapter describes the changes in institutional structures since the 1990s that have had a fundamental impact on GHG. These structural changes have occurred as the discourse on trans-boundary health has broadened and engaged more public, private and voluntary sector actors in the debate. This has brought greater recognition of the need to mobilize a range of fi nancial and other resources and to adopt a more fl exible approach to problem solving. But the proliferation of public and private actors has also brought greater complexity that could inhibit the effective application of these resources and solutions. The second part of the chapter discusses ways of improving the coordination, accountability and legitimacy of GHG while preserving the engagement of non-state actors and the ability to respond fl exibly to global health challenges. In particular it explores the concept of nodal governance and its implications for the role of the World Health Organization (WHO) in the new dynamics of GHG.

The term global health governance (GHG) did not appear in global health discourse before 2002 (Dodgson et al. 2002 ) , but since then it has become a sort of buzzword. Whatever its precise de fi nition (see Box 1), it obviously re fl ected a change in international health politics which demanded a new term. Since the mid-1990s the number of public-private partnerships ( Global Health Partnerships ) established to deal with speci fi c international health problems has grown rapidly. New actors became increasingly important in fi nancing global health activities including organizations such as the Global Fund. These new actors often developed structures and processes which were signi fi cantly different from classical intergovernmental organizations (IGOs) due to their highly focussed results oriented approach to single issues. In addition, one of the fi ercest con fl icts in global health, concerning the TRIPS agreement and access to medicines, unfolded with WHO playing only a marginal role. The leading role of WHO had been challenged.

All three de fi nitions in Box 1, whether explicitly or implicitly, refer to a plurality of actors, processes and regulations which operate in a contested arena and produce health policy outcomes as a result of activities which are not coordinated by conventional institutions. Within a few years, the post-war architecture of international health seemed to have been overturned.

What has led to this change and what does it mean for the future of global health? The rise of GHG is closely linked to the process of globalization ,

The de fi nition of GHG. • The impact of globalization on health. •

The triangle of GHG. •

The rise of new actors in global health and its governance. •

The importance of open transnational networks and nodal leadership for the • engagement of all actors in new forms of global governance for health.

"Global governance for health describes the structures and processes through which the global health issues are addressed" (European Perspectives on Global Health. A Policy Glossary, Brüssel 2006 , p. 35) . GHG is the "totality of collective regulations to deal with international and transnational interdependence in the context of health issues" ( Hein/ Kohlmorgen 2008 , p. 84) .

(continued) understood as an intensi fi cation of cross-border fl ows of goods, services, fi nance, people, and ideas. Globalization has been facilitated by new technologies and by changes in the institutional and policy regimes at the international and national levels, for example by the promotion of trade liberalization (Held et al. 1999 ) . It extends far beyond the economic realm to political, cultural, environmental, and security issues and implies an increasing transnational interconnectivity of people and communities, leading to a growing density of transnational social relations and the creation of common identities based on characteristics other than nationality-for example among people in civil society networks fi ghting for justice in global health. Globalization has increased the need for inter-and transnational cooperation to "govern" the many global forces that can effect human health. Yet, in the absence of a central political authority beyond the nation state, there are multiple sets of often con fl icting rules and norms. How can the interaction of these rules and norms be resolved? How can relations of legitimacy and accountability be established when the demos is spilling over beyond the territorial foundations of democratic rule?

Globalization has had important consequences for the dynamics of global problems such as health as well as on the architecture of international relations, as summarized in Box 2:

• Health threats such as HIV/AIDS, in fl uenza, SARS or avian fl u threaten every country and the global community as a whole due to the rapid spread based on global travel and mobility; their impact is frequently very serious in economic terms. The • globalization of lifestyles has led to common chronic disease challenges such as diabetes and is linked to the impact of global industries such as tobacco and alcohol as well as the food industry. The health sector is a • critical sector for stability in many countries, healthcare fi nancing is a key political issue in all countries; the mobility of patients and health-care professionals is a global issue (continued) Box 1 (continued) "For us GHG is viewed as a contested space which is much broader and deeper than current scholarship acknowledges. Instead of existing in a separate sphere to globalisation, we view GHG as immanent in the critical processes of globalisation and marked by sharp divisions in policy and competing worldviews of global health which have not yet settled or reached an identi fi able conclusion" (Kay and Williams 2009 , p. 3) .

The dynamics of global governance can be understood as a recon fi guration of political actors in dealing with new forms of global problems, which have turned out to be dif fi cult to handle by any one of the three main types of actors in global politics (see Fig. 5 .1 ) for a variety of reasons:

(a) The increasing urgent need to deal with global problems which are beyond the control of national governments . (b) The limited capacity of most IGOs to intervene effectively in trans national affairs, due to a lack of resources and a limited fl exibility for cooperation with non-state actors, but: 

Health is • one of the largest industries worldwide , critical issues-for example around intellectual property and trade in goods and serviceshave major economic consequences for companies and countries, and major consequences in terms of access for poor people and countries. The access issue has gained large attention in particular concerning access to anti-retrovirals (ARVs) and the con fl icts related to the TRIPS Agreement and the production and marketing of generic versions of medicines.

• Inequality of access to health around the world is gaining more attention and has become a major subject of discourses on human rights and social justice, more investment in health is critical for all nations, especially the poor. Inequality (and the immense resources needed for global redistribution) can be roughly characterized by the gap between annual health expenditures per person of $7,285 in the USA and less than $10 in Myanmar, Eritrea and Ethiopia (World Bank data, http://data.worldbank.org/indicator/SH.XPD.PUBL ).

(c) While strong efforts by nation states and IGOs frequently led to little or no effect on problem-solving, it has been increasingly easy for international non-state actors (INAs) to operate in the transnational space and-due to (a) and (b)-their contributions have generally been welcome within the relevant policy fi eld. Global governance has developed as a fi eld of cooperation and compromise between an increasing number of actors concerned, whereby in many cases-though certainly not always-con fl icts which, seemed to be paralyzed, could be resolved.

Three examples are helpful to understand the fl exibility allowed by the new openness of global governance structures:

1. The trends towards globalization and economic privatization supported, for example, by the creation of the World Trade Organization (WTO), have reduced the independent capacity of states and IGOs to fi ght global diseases. As an alternative, GHPs have been proposed and founded to integrate a number of different actors in different combinations as required by the speci fi c tasks and the social and political environments. Flexible forms of cooperation became possible which combine the speci fi c needs identi fi ed by governments, IGOs or Civil Society Organizations (CSOs) with the scienti fi c and technological capacities and economic interests of private corporations and the fi nancial resources of donor countries, public funds or private foundations. During recent years, GHPs made important contributions to research on neglected diseases, to fi nance health activities in fi elds like HIV/AIDS and immunization and to improve access to medicines in poor regions (see " Global Health Governance: New Challenges and New Constellations of Actors " section on GHG actors). 2. The zero-growth strategy imposed on the budget of many UN organizations by the USA (but also supported by other high-income countries)-basically an expression of hegemonic con fl icts-signi fi cantly reduced the governance capacities of WHO: The so-called United Nations Reform Act (Helms-Biden Act, a 1999 US law) set a number of conditions for the reform of the UN system before the USA would even release its total amount of arrears in payment to the UN. The principle of zero nominal growth forced WHO to raise extra-budgetary resources which are mostly ear-marked for speci fi c projects and reduce the budgetary autonomy of the organization. Nevertheless, since the end of the 1990s US contributions to global health experienced unprecedented growth. The US strongly supported the G8 initiative to create a fund to fi nance the global fi ght against HIV/AIDS, tuberculosis and malaria-provided the fund would not be managed by a UN organization. Thus, an independent fund was established, based on the PPP model (state governments, representatives of private enterprise and civil society organizations as decision makers; IGOs like WHO and the World Bank included only as non-voting members of the Executive Council). Furthermore, the US government created bilateral channels to make important contributions to global health, in 2003 PEPFAR, the President's Emergency Plan For AIDS Relief committed $15 billion for 5 years to the fi ght against HIV/AIDS; and $63 billion over 6 years to the 2010 Global Health Initiative "to improve health outcomes". In addition, contributions to global health by US private foundations (in particular, the Bill & Melinda Gates Foundation) increased rapidly and since 2006 more or less equal the level of the WHO regular budget. 3. The high prices of anti-retroviral medicines, made possible by the internationalization of intellectual property rights in the TRIPS agreement, turned out to be a major barrier to realizing the human right of universal access to essential medicines. The UN Committee on Economic, Social and Cultural Rights (CESCR), emphasized in its General Comment No. 14 (2000) that the right to "the highest attainable standard of physical and mental health" formulated in the International Covenant on Economic, Social and Cultural Rights (article 12.1) obliges member states to make available those drugs that are indispensable (as stipulated in the WHO list of essential drugs).

In addressing this challenge, it was not only the pressure of civil society organizations for access to medicines but also the response of transnational pharmaceutical companies in selling medicines to poorer countries at reduced prices or to allow generic companies to supply markets where they held patents that were vital. There were also a large number of fi nancing initiatives (such as the GFATM, internationally operating foundations, and various NGO and church initiatives), as even with reduced prices, many poor countries need additional funding to fi nance AIDS treatment (Hein and Moon 2013 ) . These concrete processes made it possible to signi fi cantly expand access to ARV therapy for people living with HIV/AIDS and to expand the "access norm" to include medicines beyond ARV drugs (e.g., for heart disease & cancer).

The rise of new actors has not only contributed to a higher degree of fl exibility in dealing with global health problems but also added expertise and fi nancial resources ( Fig. 5 .2 ). While the contributions of traditional state actors (bilateral and multilateral agencies) grew from $5.1 billion in 1990 to about $18.1 billion in 2007, i.e. by a factor of 3.5, during the same period the contributions of non-state and hybrid institutions grew nearly 15-fold (from about $0.6 billion to about $8.8 billion).

Most of the changes in international health politics discussed so far were focussed on mobilizing support for developing countries in global health. However, the WHO was not created to be a development organization, but to "act as the directing and co-ordinating authority on international health work" (Constitution of the WHO, Art. 2a). This implies the provision of global public goods, e.g. securing access to vaccines, eradicating a virus or enforcing rules to prevent the spread of infectious diseases or of unhealthy consumption habits. For decades, WHO had been very reluctant to launch initiatives concerning international treaties in the fi eld of health (in contrast to the very different attitude of ILO in this respect). The negotiation of Year 2 0 0 0 2 0 0 2 2 0 0 4 2 0 0 6 2 0 0 8 2 0 1 0 1 9 9 8 1 9 9 6 1 9 9 4 1 9 9 2 1 9 9 0 Murray et al. ( 2011 , pp. 8-10) the New International Health Regulations ( IHR 2005) and the Framework Convention on Tobacco Control (FCTC) can be seen as an indication that WHO has also felt the need to respond to the changing global environment, in particular to the increasing needs for the regulation of global public goods for health.

The negotiation of these agreements points to the need to involve Nation states in the politics of global governance: Only states can make internationally binding rules. While in many other fi elds of global politics, the principle of subsidiarity might apply, strengthening the role of private actors and "reducing" states to just one type of actor among others, there is no way of creating legitimate, universally binding rules other than through agreement between states. Nonetheless, the growing involvement of a globalizing civil society might make it easier for state governments to overcome power-based interests in favour of issue-focussed solutions, in the negotiation and implementation of agreements. Non-governmental organizations played an important role in the intergovernmental negotiating body for the FCTC and the Tobacco Free Initiative (with a strong participation of CSOs) supporting the implementation of the Convention.

It is also notable that in the event of a "Public Health Emergency of International Concern" the new International Health Regulations grant the WHO far-reaching powers and non-governmental organizations are assigned key roles (Fidler 2005 ) . The WHO has the right to require member states to develop appropriate capacities for monitoring possible international health risks. It can, however, also use nongovernmental information sources and, if necessary, issue recommendations for the restriction of travel and trade without the consent of the state concerned. The WHO led Global Outbreak Alert & Response Network includes the contributions of UNICEF, UNHCR, the Red Cross, non-governmental groups like Doctors without Borders and scienti fi c institutions within member states.

The discourse on GHG points to the importance of new types of actors and the growing importance of non-state actors in global health affairs. But what is actually new? The history of international health is full of non-state actors. In colonial territories, hospitals built by Faith-Based Organizations (FBOs) introduced modern health care in areas beyond the capital or port cities. The International Committee of the Red Cross was founded in 1863 very consciously in the form of an international institution to coordinate decentralized, non-state relief societies to stress the neutrality of medical services in armed con fl ict (Bugnion 2009 ) . It is also relevant to note that the Rockefeller Foundation fi nanced up to 50 % of the budget of the League of Nations Health Organization.

Nevertheless, most observers of GHG agree on a number of characteristics that are speci fi c to the last 10-15 years of institutional developments in international health:

1. A great proliferation in the number and variety of health actors. 2. Increasing interdependencies between health and other areas of global governance (trade and intellectual property rights; environment; agriculture).

3. A growing impact of CSOs. 4. A growing importance of private funders (e.g., foundations). 5. New types of hybrid actors and global initiatives (e.g., foundations, Public-Private Partnerships, the Global Fund to Fight AIDS, Tuberculosis and Malaria, GFATM) interact with national governments and international governmental organizations. 6. GHG implies a substantive concern with issues that affect populations worldwide directly (for example the global spread of disease, such as HIV/AIDS and the much-feared new pandemic in fl uenza) or indirectly (extreme inequalities in medical care, unhealthy consumption patterns). The Millennium Development Goals (MDGs) (proclaimed in 2000, including goals of fi ghting infectious diseases and improving maternal health, child mortality and access to medicines) and the Commission in Macroeconomics and Health (WHO 2001 ) are expressions of this concern. 7. To a greater extent, poor health is not only seen as a consequence of poverty but also as a cause of lack of development; investments in health are seen to offer value for money through their positive impact on development. 8. Cooperation in international health is no longer solely "governed" by state actors or inter-governmental agencies such as the WHO.

GHG can be understood as a mechanism for collective problem-solving, i.e. health improvements through the interplay of different institutional forms and actors at different levels. All of this points to a form of GHG, characterized by a polycentric, distributed structure and a substantive focus on issues that affect populations worldwide, directly (for example the global spread of disease) or indirectly (through extreme inequalities). It now requires management not merely of speci fi c transborder epidemics but of the host of issues that arise in health at the intersections of a globalized economy and individual lives in particular localities (Hein et al. 2009 ) .

Depending on the vantage point, one can see GHG as an anarchy of actors which constitutes a "creative plurality" in managing global health (at every moment raising new health issues and proposing new ways of solving them), or as waste of material and political resources through the uncoordinated fragmentation of actors and activities. Figure 5 .3 illustrates the range of actors in global health according to the public-private dimension.

During recent years the numbers of hybrid organizations (GHPs and GHIs) and private actors have considerably increased. The interconnectedness of different organizations is by far too great to be displayed here in a meaningful way. Though there can be hardly any doubt that the number and intensity of links has grown considerably since earlier decades, a large number of inter-organizational relationships already existed in the 1950s and 1960s. What can be assumed as a qualitatively new phenomenon-in correspondence with much of the globalization literature and many accounts from GHG processes-is the high volatility of organizational patterns and institutional change and the fl exible reaction of Global Health actors to new challenges. Regrettably there are few systematic analyses of the dynamics of these networks in GHG. David Fidler characterized the GHG system as a form of " open-source anarchy ", which is broadening and deepening the normative basis for global health action (2007: 9f.). "Anybody can access, use, modify and improve" (2007: 9f.) similar to open-source software. This means that the interactive space of relations between national societies is no longer dominated by inter-state relations. Transnational relations are not squeezed into diplomatic rules and traditional means of exerting pressure on other states by the application of power politics or through the complicated mechanisms of international organizations. Actors can use their speci fi c strengths to reach their goals ( fi nancial and expert resources, discourses and using them to mobilize support, including in fl uence on the process of international law-making). Transnational networks between health-oriented actors have been formed that focus on speci fi c issues (like access to medicines, neglected diseases, and tobacco control) constituting a complex web of global social relations related to the issue of global health. Jean-Michel Severino and Olivier Ray ( 2010 ) discuss similar changes in the fi eld of development aid (which is in part linked to GHG): the surge of an "institutional jungle" and a tendency towards the privatization of international cooperation. They propose the term "hypercollective action" to characterize this "new mode of production of global policies" (Severino and Ray 2010 :11). They acknowledge not only the mobilizing and creative dimension of this mode but also the "considerable costs in terms of ef fi ciency, time, coherence and … credibility" (Severino and Ray 2010 :12) . This leads straight to the points made by the critics of the advocates for effective selforganization through an "open-source anarchy":

1. International cooperation is becoming more complex. Poor countries are receiving aid from a growing number of different organizations. This has made it dif fi cult for national governments to stay in control of their own health systems or to effectively allocate aid. 2. Most of the new non-state actors in GHG can be accused of a lack of legitimacy and accountability . Large CSOs, GHPs and fi nancially strong foundations (like the BMGF) are having a great impact on global health without being accountable to people affected by their activities. While IGOs might also have legitimacy problems, they are clearly accountable to governing bodies in which sovereign states are represented. 3. GHPs are not necessarily identi fi ed with vertical strategies focussed on speci fi c diseases, but their targets are mostly linked to a chain of activities focusing on controlling and treating speci fi c diseases including the identi fi cation of pathogens, research and development of medicines and means of treatment, distribution of medicines, securing access ( fi nance, technical infrastructure) and the medical infrastructure for treatment. Horizontal activities like improving national health systems and developing systems of primary health care have been relatively neglected.

Whether the characteristics of GHG are seen from a more optimistic or a more critical perspective, "coordination" has become a major focus of discussions of the future of global health. The need for better coordination is certainly recognized in, fi rst, the processes of assessing health needs and strategies to deal with them; second, the search for more systematic institutional mechanisms for improving coordination and third, the attempts to strengthen legitimacy and accountability by engaging multiple forms of networking in the agreed processes for taking important decisions.

It is generally recognized that the broadening and deepening of discursive processes in GHG has contributed signi fi cantly to the growth of public attention and strengthening of support for global health action, as well as to the constructive processes of con fl ict resolution. The open-source character of GHG has facilitated the articulation of the concerns of very different constituencies (human rights movement, different "publics", expert networks, etc.). Examples of open discursive processes have included the International AIDS Conferences, the Global Forum on Health Research and Global Expert Commissions on urgent topics. The power of broader discourses can be contrasted with political power processes: while political processes can release the public sector resources required to address problems in a conventional way, discursive power can fi nd new solutions and call on a wider range of public and private resources. Discursive power (particularly if magni fi ed by mass media) can also put pressure on actors with political and economic power and resources.

World commissions have been established on a number of important issues in global affairs. They consist of members representing stakeholders of diverse political and cultural backgrounds and charged with producing a substantial report on a topic of farreaching importance, supported by a budget which allows them to fund the production of expert papers to shed light on the respective topic from various perspectives. Famous examples are the so-called Brandt Commission on International Development, the Brundtland Commission on the environment and development and the Commission on Global Governance which examined the social determinants of health.

Three such commissions were initiated and managed by WHO. These have been important mechanisms for policy-making, serving as fora for communication between stakeholders with con fl icting interests. They played an important role in coordinating the contributions of the multiplicity of GHG actors and to focus the international discourse on speci fi c issues.

The Commission on Macroeconomics and Health ( CMH ), launched by WHO Director-General Gro Harlem Brundtland in January 2000 and headed by Harvard professor Jeffrey Sachs: In the resulting Report on Macroeconomics and Health, "health" is seen not just as a component of development, but as a basic pre-condition for economic growth itself. The report, presented in December 2001 (WHO 2001 ) , played an important role in raising public consciousness about the need for a massive scaling-up of global health fi nancing.

The Commission on Intellectual Property Rights, Innovation and Public Health ( CIPIH ),set up in 2004: It responded to years of con fl icts on intellectual property rights and access to drugs. Following the fi nal report of CIPIH (WHO 2006 ) there was a general recognition of the need for changes in the global system of innovation in drug development and access to strengthen research on neglected diseases and to improve global access to essential medicines. It was recognized that support for innovative capacity in developing countries was an important way to reach these goals.

The Commission on the Social Determinants of Health , established in 2005: Its task was to analyse the causes and consequences of health inequality and the social conditions that cause illness as well as the need to make health systems more responsive to the needs of socially disadvantaged people. The Commission's fi nal report was published in May 2008 (WHO 2008 ) .

The CIPIH demonstrated the capacity of such commissions to produce a meaningful focus for strategic debates and to channel their results into international negotiations. The World Health Assembly (WHA) discussed in 2006 a "Global Framework on Essential Health Research and Development". In a resolution passed in May 2008, a Global Strategy, and parts of the corresponding Plan of Action were adopted (WHA 61.21). The WHA 2010 discussed ideas for fi nancing this strategy; the Taskforce on Innovative International Financing for Health Systems estimated that by 2015, US$7.4 billion annually will be needed to fund health research and development.

Today, transnational discourses on health are highly important in raising issues, setting agendas and de fi ning the terms in which problems debated in IGOs and in other international fora are understood by the public and by important political actors. They are also crucial in providing a structure and processes to shape the dynamics of transnational communication. They transform the formerly rather thin and simply structured fl ows of international communication between governments and a few other actors into a dense web of exchange.

Following the adoption of the MDGs in 2000, OECD and the World Bank organized a global discourse on the effectiveness of development cooperation, leading to the Paris Declaration on Aid effectiveness (2005) . The Declaration speci fi ed fi ve target areas for improving aid effectiveness: ownership, harmonization, alignment, results, and mutual accountability . Donor countries agreed to coordinate and harmonize their aid in order to support their recipient country partners' national development strategies. These development strategies will re fl ect national needs and priorities while recognizing internationally agreed concepts of good governance. In preparation for the Accra High Level Forum on Aid Effectiveness (a 2008 follow-up meeting to the Paris conference in Accra, Ghana), the WHO, the World Bank and OECD proposed to use the health sector to track progress on the Paris Declaration: "Aid effectiveness is particularly challenging in health. As with other sectors, dif fi culties are the result of inef fi ciencies in the global aid architecture and of poor country policies; however, problems in health are exacerbated by the inherent complexities of the sector itself" ( http://www.oecd.org/dataoecd/14/37/42254322.pdf ). Global Health is affected by the Paris-Accra-Agenda whenever country level coordination is at issue. UNAIDS promoted the "Three Ones" (2004), aimed at establishing: one agreed HIV/AIDS Action Framework for coordinating the work of all partners; one National AIDS Coordinating Authority and one agreed country-level Monitoring and Evaluation System (World Bank and WHO 2006 , p. 15 ). The High Level Forum (HLF) on the Health MDGs (World Bank and WHO 2006) held three meetings in 2004 and 2005. "Scaling up aid for health" was the HLF's main target, which called for a better coordination between GHPs, the improvement of health funding and concrete strategies to support the development of health systems in poor countries. The lack alignment of HIV/AIDS funding with government priorities, the lack of long-term support and the volatility of funding was criticized.

The Scaling Up for Better Health (IHP+) Initiative established a network of cooperation between the most important health funders. The IHP+ process is led by the so-called Scaling-up Reference Group (SuRG), which brings together the eight most important agencies/initiatives in global health, WHO, World Bank, GAVI, UNICEF, UNFPA, UNAIDS, the GFATM, and the Gates Foundation, which under the name "Health 8", has gained importance beyond IHP+. The focus of all IHP+ initiatives is on achieving health-related MDG outcomes through efforts to increase aid effectiveness, improve policy, strategy and health systems performance, and also a broad mobilization of non-State actors.

Thus, the Paris-Accra Process has led to a number of interactive processes for GHG by strengthening the links between the activities of different actors and national decision-making institutions, and improving aspects of accountability and legitimacy. However, this only marginally affects processes of agenda-setting and health policy making at the global level. There is a lack of institutional structures and processes to support continuous interaction between the myriad processes of local, national and international decision making on global health issues and the processes for formulating binding norms and rules for GHG.

The Role of Nodal Governance

The interactive processes for GHG have created new mechanisms for coordination in this fi eld. Multiple forms of transnational links enable state and non-state actors to coordinate all kinds of activities: research, production, marketing campaigns, political strategies, CSO campaigns, and whatever might be of interest for a transnational group of actors. In very open forms of organization, networking is the logical compliment to a system which "anybody can access, use, modify and improve" (Fidler 2007 , p. 9) . In these networking processes important actors, institutions, media or venues emerge as nodes for information exchange and coordination in relation to speci fi c goals like improving access to medicines, improving support systems for Primary Health Care, etc., to link various types of actors and different fi elds of activity. This creates forms of coordination, cooperation and networked power which have been characterized by the concept of nodal governance (Hein et al. 2009 ) . Informal and formal networking in Geneva and at other regular global health events plays an important role in creating fl exible links between global health actors. The concept of interfaces between different networks can be used to analyze the "power map" of a governance system and the key characteristics of effective governance nodes. The interactions taking place may reshape the goals, perceptions, interests, and relationships of the various actors (Long 1989 , pp. 1-2) .

Nodal governance operates in a landscape of mixed social interactions and of con fl icting or merging cultural and political habits and behaviours. Nodal governance characterizes many issue-oriented programmes like the Campaign for Access to Essential Medicines, where MSF/Geneva acts as the central node linking the activities of many NGOs, the Peoples' Health Movement as a large network of grassroots organizations or Knowledge Ecology International ( kei online ) as a communication platform in the Internet, providing an information exchange on the impact of intellectual property rights on medical research and access to medicines.

The period of the WHA every May in Geneva has become one of the central nodes for GHG, quite independent from what is being discussed in the formal agenda of the assembly. Polylateral diplomacy (Wiseman 1999 , note 10) is conducted: formal and informal meetings take place, agreements are reached, deals are struck, NGOs exert in fl uence, the private sector lobbies, receptions are organizedin short key global health players participate in the Assembly in this period, even if they are not members of the WHA. On the other hand, the WHA, itself provides a decision-making process at the level of a legitimate international body, allowing nations, which are not powerfully represented in nodal governance processes, to express themselves and participate in legitimate decision making. Linking these levels of nodal governance-providing both the political space for informal negotiation and formal-legal decision-making and managing their interface-is a central task for achieving successful overall coordination in GHG (Kickbusch et al. 2010 ) .

The WHO was created in 1948 to "act as the directing and co-ordinating authority on international health work" (Constitution of the WHO, Art. 2a). WHO was entrusted with the task of "establishing and maintaining effective collaboration with the United Nations, specialized agencies, governmental health administrations, professional groups and such other organizations as may be deemed appropriate" (Constitution of the WHO, Art. 2b) (see Chap. 9 for more details). However, as an IGOs , WHO decision-making (aside from technical matters) has mostly been subject to coalition and bloc building processes among nations as well as to periodic attempts to curtail the autonomy of the organization by powerful states-at times coming close to paralysis (Kickbusch et al. 2010 ) . Gostin ( 2007 ) has proposed that the WHO take full advantage of its treatymaking capabilities and establish a Framework Convention on Global Health that ties all major stakeholders (states as well as non-state actors) to the aims of building capacity, setting priorities, coordinating activities, and monitoring progress (see also: Global Health Governance 2010 ) . A second proposal, which has recently gained considerable political attention, builds on the importance of the WHA and recommends that a Committee C of the World Health Assembly be established that-in addition to member state representatives-would include the active participation of international agencies, philanthropic organizations, multinational health initiatives, and representatives from major civil society groups, particularly those who legitimately represent the most vulnerable populations (Kickbusch et al. 2010 ) .

The proposed Committee C would debate major health initiatives and provide an opportunity for the primary players involved in health to present their plans and achievements and offer discussion of collective concerns with World Health Assembly's member state representatives. The Committee would then pass resolutions and would be held to rules of procedure and implementation that respects the mutual sovereignty of all parties. As the only legitimate supranational authority on health issues, the WHO is the appropriate vessel for such a central coordination mechanism that would bring all prominent global health actors to the table for harmonized agenda-setting and decision making. Thus, the Committee C proposal can be seen as creating a link or interface between the nodal governance processes in each sphere of action and the legitimate constitutional position of WHO within a system of sovereign nations. This would greatly improve the chances of achieving productive coordination and the harmonization of con fl icting strategies by avoiding or mitigating the clash between power blocs and national coalitions with fi xed positions.

Globalization has increased the need for international and transnational coordination to "govern" the many global forces that can impact on human health. As in all fi elds of governance, cooperation and coordination are subjects to shifting political power. New actors that can mobilize discursive political power and bring in new fi nancial and human resources offer the prospect of wider public engagement with and concern for global health, more fl exible solutions and faster resolution of issues. This may be seen as a challenge to the power of established actors, but it also offers them the chance to enhance GHG if they can take advantage of these new opportunities (Kickbusch 2009 , pp. 320-321) .

Many new actors have entered the policy fi eld of global health, bringing additional resources and facilitating the resolution of con fl icts by encouraging more fl exible approaches and wider public engagement. Yet, in the absence of a central political authority, there are multiple sets of often con fl icting rules and norms. Their collective impact on health is a central issue in the discourse on GHG. Forms of nodal governance have great potential to transform the institutional architecture. The WHO, vested with the authority to create binding regulations and treaties among member states, could strengthen its role in GHG by linking formal decisionmaking procedures with processes of nodal governance , drawing the many networks of non-governmental organizations that form around speci fi c issues to engage them in global health diplomacy with all relevant actors and publics to develop a wider governance for global health .

From Solferino to the birth of contemporary international humanitarian law

Global Health Governance: a Conceptual Review

From international sanitary conventions to global health security: The new international health regulations

Architecture amidst anarchy: Global health's quest for governance

Special issue of the Journal of Law

A proposal for a framework convention on global health

Global Health Governance

Informal Norms in Global Governance

Making sense of global health governance: A policy perspective

Global transformations. Politics, economics and culture

Global health governance: Crisis, institutions and political economy

Making sense of global health governance: A policy perspective

Addressing global health governance challenges through new mechanism: The proposal for a Committee C of the World Health Assembly

Questions 1. Which aspects of globalization lead to a transformation of international health challenges? 2. Which are the new types of actors in GHG? 3. Which are the advantages of a proliferation of actors and initiatives in GHG and how are they related to failures of IGOs to deal with new challenges? 4. What is the meaning of "open-source anarchy

What is the role of discursive processes for coordination in GHG?

How does the Paris Declaration support coordination in GHG? 7. Why does nodal governance imply a recon fi guration of power in GHG?

European perspectives on global health. A policy glossary

Health policy in a globalising world

Encounters at the interface

Development assistance for health: Trends and prospects

The end of ODA (II): The birth of hypercollective action (Working Paper 218)

Selected Papers 2003-2005 from the High Level Forum on the Health Millennium Development Goals

Macroeconomics and health: Investing in health for economic development

Public health, innovation and intellectual property rights: Report of the commission on intellectual property rights, innovation and public health

Closing the gap in a generation: Health equity through action on the social determinants of health

Polylateralism" and new modes of global dialogue (Discussion Paper No. 59)

Further Reading

Innovation in global health governance

The challenge of global health

Globalisation and health: An introduction . Basingstoke: Palgrave. People's Health Movement, Medact and Global Equity Gauge Alliance