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International Organization and Health/Disease

Summary and Keywords

Patterns of health and disease have been relevant to international studies for as long as human populations have migrated across large territorial spaces. After World War II, international health cooperation was accepted as a key function of the newly established United Nations system, with the creation of the World Health Organization (WHO) as the UN specialized agency for health alongside other UN bodies. However, social science scholarship paid little attention to the perceived technical field of health, and thus international health organizations, until the 1970s. The limited scholarship produced during the postwar period was largely by those engaged with international health organizations and was primarily descriptive of technical and legal issues. It was not until debates emerged about the role and effectiveness of WHO, beginning in the 1980s, that scholars began considering the politics of international health cooperation. The adoption of the Declaration of Alma Ata, List of Essential Drugs, and International Code of Marketing of Breast-Milk Substitutes spurred debates about the “politicization” of WHO’s technical mandate. Public health practitioners and social historians contributed reflections on how structural inequalities shape health outcomes, and international organization scholarship introduced critical theoretical approaches to the study of health institutions. Scholars began to locate patterns of health and disease within the broader international political economy. The subsequent proliferation of new institutional arrangements for collective action on health issues, involving both state and non-state actors, generated studies of the distribution of power and responsibilities in an increasingly complex institutional landscape. This led to the concept of global health governance (GHG), with health becoming located within globalization processes, encouraging scholarly links across international relations, social policy, law, and anthropology. A wider range of international organizations, with health-related impacts, were incorporated into GHG scholarship. Concurrently, new theoretical approaches to understanding collective action for global health emerge, notably realist notions of global health security and critical approaches to the construction of GHG. The study of international organization and health since the mid-2000s has focused intense attention on the reform or creation of new institutional arrangements amid major global health crises, acute health inequities, and shared risks. This increasingly rich literature has been informed by diverse normative perspectives.

Keywords: global health, public health, global health governance, globalization, global health crises, international health cooperation, international health organizations

Introduction

Patterns of health and disease have been relevant to international studies for as long as human populations have migrated across large territorial spaces. The history of international organization, to protect and promote human health, can be traced to ancient times. Major epidemics, such as the Plague of Athens during the Peloponnesian War (430 BC), Black Death that swept through Europe in the 1340s, cholera epidemics of the 19th century, and influenza pandemic after the First World War, led to the creation of formal institutional arrangements to support health cooperation. Collective health action expanded from the mid-19th century alongside the increased disease risks stemming from growing population movements, political conflict, and trade relations. New institutional arrangements included International Sanitary Conferences and Conventions, the Office International d’Hygiène Publique, the Health Organization of the League of Nations, and regional health bodies.

After World War II, international health cooperation was accepted as a key function of the newly established United Nations (UN) system, with the creation of the World Health Organization (WHO) as the UN specialized agency for health. Over the next several decades, other UN bodies also developed substantial health-related activities. This was accompanied by growth in funding and activities by bilateral agencies, along with a substantial number of non-governmental organizations (NGOs). By the 1980s, the World Bank and regional development banks began to lend substantial sums for health development, as well as to shape international health policy. This expansion of international health cooperation reflected a broad definition of “health,” and recognition of the range of factors contributing to patterns of health and disease.

Since the mid-1990s, there has been an explosion of new institutional arrangements for protecting and promoting health worldwide. Collective action has expanded beyond primarily intergovernmental organizations to embrace a range of non-state actors (both for profit and not for profit), as well as “public–private partnerships.” “International health” has given way to the widely used, and often imprecisely defined, term “global health” to reflect this new reality. Correspondingly, the study of international organization and health has grown rapidly, extending far beyond the public health community, to form the subfield of global health governance (GHG).

Here we chart the development of the field of study of international organization and health since the postwar period. Social science scholarship paid little attention to health or health organizations until the 1970s, when scholars began considering the social, political, and economic aspects of international cooperation around health issues. Public health practitioners and social historians contributed reflections on how structural inequalities shape health outcomes, and political economy and international organization scholarship introduced critical theoretical approaches to the study of health institutions. By the turn of the millennium the concept of GHG was established, further integrating international relations, law, and anthropology scholarship into the field. Most recently, international studies scholarship on health has taken a normative turn, reflecting on health crises and institutional reform processes in an attempt to conceptualize more effective GHG arrangements within the shifts in global power relationships and the broader context of globalization.

The Postwar Study of International Health Cooperation

The study of international organization and health until the 1970s is surprisingly thin despite the boom in international organization scholarship during this period. The main source of detailed analyses of international health cooperation dating before 1945 is medical historians, notably the seminal A History of Public Health by Rosen (1958). Despite the long history of international health cooperation, perhaps representing the earliest forms of intersocietal cooperation, postwar scholars of international organization neglected health. In part, this may reflect the secondary attention given to health by the architects of the UN. As disease rates soared in the aftermath of conflict, and countries rebuilt basic infrastructure including health systems, there was initial recognition of the importance of international health cooperation. However, the higher priority initially given by major powers to peace and security, and economic reconstruction, led to health being omitted from the agenda of the UN Conference on International Organization of 1945. As Murphy writes, while the United States “took charge of the conferences concerned with managing potential conflicts generated by the industrial system,” namely, the Bretton Woods institutions, countries occupied during the war “had to be content with sponsoring conferences that strengthened society” (1994, p. 185). This gave the impression that international health cooperation was something of an afterthought.

The scholarly neglect of international organization and health during this period is also attributable to a perception that the work of WHO, and other health-related international organizations, is largely technical. Gutteridge (1963, p. 13), for example, describes international health organizations as a functional extension of the “creation and maintenance of a proper organization at the national and local levels in which those directly responsible for the promotion of public health.”

This view fit with the prevailing notion of UN specialized agencies as embodying “the functional approach [which] circumvents ideological and radical divisions, as it does territorial frontiers” (Mitrany, 1975, p. 226). Where health issues strayed into politics, this was deemed within the realm of domestic social policy (“low politics”), rather than within the intellectual boundaries of international relations. Early accounts of WHO were commissioned by the organization itself (WHO, 1958, 1968), or written by former officials (Chisholm, 1951), consultants (Clements, 1952; Winslow, 1951), or legal experts (Alexandrowijz, 1962; Levy, 1954; Sharp, 1947). Much of this work was published within the fields of public health or law, rather than international studies, focused on technical or procedural niceties. While offering insights into the internal workings of the organization, for the most part, these accounts describe administrative processes and program areas.

Notable exceptions are several studies that analyze the structure, functions, financing, and membership of WHO. Written during a period of postwar optimism toward international organization, combined with major strides in medical science, these studies considered the institutional arrangements for collective health action. For example, Berkov analyzes how WHO “executes its programs by means of regional arrangements virtually unique in the international field” (1957, p. 2). He concludes that, despite organizational fragmentation, the decentralized structure of WHO enables member states to “feel themselves less separated from the source of control, and more readily regard the WHO as an organization in which they have a direct interest.”

Analyzing the Mandate and Functions of International Health Organizations

Underlying disagreement about WHO’s mandate remained the subject of extensive and ongoing scholarly debate among policy makers and scholars over the next two decades. Advocates of social medicine, which seek to understand and foster the social and economic conditions that lead to healthier societies, envisioned WHO addressing the broad determinants of health. Its mandate would thus go beyond previous international health organizations that focused on surveillance and reporting of selected diseases. The postwar rise of biomedicine, “characterized by the intensification of research in the life sciences, the hunt for novel molecules, and a new alliance between biologists and the state” (Quirke & Gaudillière, 2008, p. 443), supported a role for WHO fighting diseases using scientific and technical tools. Tensions between these approaches during the immediate postwar period delayed the formal establishment of WHO (Lee, 2008).

Alongside the above tensions, scholars wrote about the power struggles taking place within the organization between WHO headquarters and regional offices over resources, authority, and the work program (Calderwood, 1963). Moreover, the geopolitics of the UN system was seen as intruding on the universality of WHO membership (Allen, 1950). This reflected a subtle, but not yet fully realized, shift in scholarship toward greater analysis of the political dimensions of international cooperation for health.

Amid these disagreements, medical knowledge and practice was still assumed to be value neutral and unproblematic. As Ascher writes:

So long as membership in WHO is open only to states, there will always be politics in the formulation and execution of its work-plan. That is, decisions will be influenced by forces other than the dictates of medical science. Scientists can secrete unnecessary adrenalin over this and raise their blood pressure; but the mature and worldly among them will address themselves more subtly to the question of how politics can be kept in its proper sphere in WHO’s work. (1952, p. 41)

Similarly, Fraser Brockington (a consultant for WHO and ambassador for the organization upon retirement) argued in his book World Health (1975) that WHO was a creature of its member states, and shortfalls in its capacity to reach consensus and support clear goals should be laid at the feet of governments. As a largely descriptive account, the book attributes problems in WHO’s mandate to the state of knowledge, inadequate resources, and insufficient political will. Similarly, Goodman (1971, p. 394) set out to provide a complete account of international organization and health. In International Health Organizations and Their Work, he defined international health cooperation as “any or all of those activities for the prevention, diagnosis or treatment of disease which require the combined consideration and action of more than one country” (1971, p. 3). Unlike previous works, he considers “other influences,” namely, economic, social, political, and ideological factors. At the same time, Goodman maintains a view of WHO as an essentially technical agency faced with political interference in its basic functions: “doctors are doing their job successfully but the politicians, economists and sociologists are not” (1971, p. 230). He concludes, “The World Health Organization can hardly be blamed if others fail” (Goodman, 1971, p. 315). Notably, Goodman’s book extends attention to other international organizations concerned with health—International Labour Organization (ILO); Food and Agriculture Organization (FAO); UNICEF; United Nations Educational, Scientific and Cultural Organization (UNESCO)—as well as non-state actors including foundations. His observation of the growth in NGOs maintaining official relations with WHO between 1949 and 1971 (from 13 to over 70), marked the beginning of a clear trend toward a more crowded institutional environment, and corresponding scholarly inquiry into how civil society organizations engage in health governance.

Challenging Orthodox Approaches to International Organization and Health

The study of international organization and health, as concerned with technical, scientific, and administrative functions, began to be challenged in the mid-1970s. This is evident in studies seeking to understand the internal workings of international health organizations as sites of political processes in themselves. For example, Hoole’s Politics and Budgeting in the World Health Organization applies quantitative methods to “determine the manner in which inputs affect actions and to evaluate the relative importance of various types of inputs” (1976, p. 21). In his detailed analysis of WHO’s budgets between 1949 and 1969, Hoole observes that the Executive Board rarely recommended a change in the Director-General’s budget proposal and that no significant cuts in the budget had been recommended since 1958.

The increased assertiveness of the developing world in the UN, largely expressed through the Non-Aligned Movement (NAM), challenged how international health organizations were studied. For instance, the questioning of development models advocating large-scale investment in infrastructure was expressed within the health field through the primary health care movement and adoption of the Declaration of Alma Ata at the International Conference on Primary Health Care (1978). The declaration challenged Western models of high-technology, urban, and hospital-based health development in favor of bottom-up, community-based solutions using appropriate, low-cost technologies. The Health for All movement was not only a medical strategy, but a political ideology aligned with calls for a New International Economic Order. Within WHO, this paradigm took hold at the highest levels, led by Director-General Halfdan Mahler, who stated at the 1976 World Health Assembly, “Many social evolutions and revolutions have taken place because the social structures were crumbling. There are signs that the scientific and technical structures of public health are also crumbling.” Practitioners called for reform of health systems, with their structural inequalities, in such books as Health and the Developing World (Bryant, 1969), Health by the People (Newell, 1975), and Where There Is No Doctor (Werner, 1983).

The study of international organization and health reflected this paradigmatic shift, with the normative basis of international organizations receiving concerted attention for the first time. In The Anatomy of Influence: Decision Making in International Organization, Cox and Jacobson seek “to understand the sources of influence and the ways influence is exercised by analysing how decisions have been made” (1974, p. vii) in a number of UN organizations, including WHO. Jacobson raises questions about patterns of decision making, actors’ sources of influence (including the Director-General, staff, and representatives of other international organizations), and environmental impacts. Of particular note is how the organizational ideology of WHO led to certain activities, such as campaigns against specific diseases, and the neglect of others, such as the organization of health care services. This remains the most wide-ranging, to date, application of international organization theory to WHO.

In a similar challenge to the “infallibility of the traditional medical ethic,” C. E. Taylor calls on practitioners “to reassess our underlying values” as a “new style of international health work” (1975, p. 489). While debate about WHO’s mandate continued, questions shifted to critiquing the biomedical approach to such issue areas as family planning (eventually shifting the emphasis from population control to reproductive health). Whether WHO should be involved in the “health aspects of the population problem,” according to Partan, “sharply divided the membership and were abandoned in the face of objections that activities in the population field lay outside the proper scope of WHO action” (1973, p. 111). Finkle and Crane (1976, p. 368) attribute WHO’s “position toward population and family planning and its role in international population assistance” to “the organizational and professional values in the WHO Secretariat.” They argue that the emphasis on the technical nature of decisions and functions should be recognized, in themselves, as sources of “discretionary power from the political interference of member governments and to legitimize the central role [of technical expertise] in the WHO policy process” (1976, p. 369). These debates would later be reflected on in Connelly’s history of population control efforts, Fatal Misconception (2010), which asks how global health actors have attempted to “plan other people’s lives.” Such critical texts challenge health practitioners and organizations to examine the assumptions of good intentions and consider the broader political-ethical structures that interventions are implemented within.

Scholars began to locate patterns of health and disease within the broader international political economy. In The Political Economy of Health (1979), Lesley Doyal argues that the social construction of health extended to the international level, with historical links to imperialism, the rise of capitalism, and neocolonialism. Elling (1981) extends this analysis to international health organizations by challenging the notion that disease, disability, and death in the developing world are, as regarded by Western scholars and practitioners, problems in “tropical medicine” attributable to geography or climate. He describes this perspective as “a very convenient medical/public health ideology for the established capitalist political-economic order,” and a distraction from the poverty resulting from colonial expropriation. Applying Wallerstein’s concepts of periphery and semiperipheral nations in a capitalist world order, and Gramsci’s concept of “cultural hegemony,” he challenges prevailing explanations of health inequalities and policy solutions as the dominant discourse. Using wide-ranging examples, including the marketing of breast-milk substitutes, population control, hazardous waste, and drug policy, Elling “highlights the capitalist world-system as the fundamental agent in the generation of these problems.”

Vicente Navarro makes a Marxist-based contribution to the study of international organization and health. His analyses of the health systems of Sweden, the United States, the United Kingdom, and the Soviet Union focuses on the structural features of the capitalist world order as the source of inequality (Navarro, 1980, 1986). In his critique of the 1978 Declaration of Alma Ata and 1980 Brandt Report on international development, he argues that they should be located within “the socio-economic and political context that determined them.” Like Elling, he identifies an “apolitical and technological-administrative discourse” that upholds the “hegemonic development establishments of the Western world” (Navarro, 1984, p. 159). He thus questions prevailing “understanding of the causes of underdevelopment and its major health and disease problems” (Navarro, 1984, p. 467). Similarly, Archer asks whether “existing functional organizations such as UNESCO, WHO and ILO have been riddled with ideological and racial (or at least North–South) divisions which have reflected political arguments outside the organizations, but have nevertheless adversely affected their basic work” (1992, p. 94).

While Elling and Navarro’s work is characterized by economic determinism, others pursue what might be described as early constructivist approaches to international health. A structural/functional approach is taken by Forbes, who examines “the political economy of transnational health organizations, thus illustrating how existing economic analysis of international collective action can be adapted and utilized to examine an important, albeit neglected, form of international cooperation” (1980, pp. 115–116). His analysis focuses on WHO’s role in the “production of health,” applying the economic concepts of “pure and impure international public inputs” to discuss the “institutional design and structure of WHO and transnational health organizations in general” (1980, p. 121). Foster (1987b, p. 709) assesses the nature of behavioral research supported by WHO, attributing its poor quality to the physician-dominated committees that assume “quantitative hypothesis-testing investigation is the only acceptable research model.” This, he argues, leads to a narrow understanding of behavioral research as informing how to change individual and community behavior to meet the needs of health care delivery. He concludes that “research on organization policies and programs is viewed as irrelevant and perhaps even threatening” (1987b, p. 709) by most health organizations and policy makers.

A further notable exception to the continued focus on applied research, as opposed to political theory, is the analysis of the alleged “politicization” of UN specialized agencies, including WHO. Following adoption of the Declaration of Alma Ata, List of Essential Drugs and International Code of Marketing of Breast-Milk Substitutes, the U.S. government accused WHO of exceeding its technical and scientific mandate. Scholars, in turn, reflected on this debate in terms of functional theory and liberal internationalism. For example, Harrod describes WHO as a “hybrid” between an organization supplying technical services and forum “to discuss matters not essentially transnational” (1974, pp. 189–190). He concludes that the “liberal-internationalist view is being replaced by the real-politik view in which the worth of the organisations is assessed exclusively in terms of immediate national interest” (1974, p. 203). The perception of WHO, and international health cooperation as a whole, as somehow above politics, thus persisted in both policy discussions and related literature.

Expanding the literature beyond WHO, Riggs (1980) interrogates functional theory in his survey of attitudes toward the World Bank, International Monetary Fund (IMF), and WHO. The core assumption in functionalist thinking, that “good behaviour can be learned—that people who become personally involved in the work of international agencies will develop attitudes more favourable to international cooperation,” (1980, p. 329) is tested through questionnaires and interviews with individuals who have worked with these organizations. Riggs found that “attitudes seem contingent upon the rewardingness of the experience” (1980, p. 329), which, in turn, is shaped by personal values, domestic organizational milieu, nature of the international organization, and specifics of the respondent’s experience. Attitudes toward WHO were relatively positive attributed to the perception that “Health Functions are simply less controversial” (Riggs, 1980, p. 349). Foster (1987a, p. 1039) raises similar questions in his Weberian analysis of the activities of international health organizations as “a function of their structural and dynamic characteristics, and of the professional assumptions held by administrators, planners and technical specialists.” He characterizes international health organizations as operating within the “donor-recipient model” of postwar development assistance. Foster undertakes one of the first comparative assessments of multilateral, bilateral, private-secular (e.g., Rockefeller Foundation) and private-religious (e.g., medical missions) organizations. He asks what are the strengths and weaknesses of international health organizations; does, and if so, to what extent the early enunciation of policy doctrines reduce the flexibility of international health organizations; and to what extent do professional-personality factors impinge on planning processes (Foster, 1987a, pp. 1047–1048)?

Acknowledging the world of international organizations as “vast and important,” Groom describes UN specialized agencies as “predominantly forum or service organisations.” The former serves “as a meeting place for a discussion of principles but not to negotiate the detailed design and undertake the execution of programmes” that constitutes the latter (1988, pp. 7–8). He writes:

The balance is important for it is likely to have consequences on the budget, size and style of the secretariat and the characteristics of the decision-making process. Service organisations tend to have larger budgets and secretariats than forum organisations and their decision making processes are more likely to emphasise problem-solving by experts than bargaining by diplomats. (1988, pp. 7–8)

While Groom does not specifically analyze WHO in these terms, this tension between the forum and service functions succinctly characterizes the tensions that have defined WHO from its creation. The pressure to act as a service organization, notably for developing countries, was increasingly unmatched by the resources and authority given to it by industrialized countries.

Throughout the 1980s, former staff of international health organizations continued to publish descriptive work of specific programs and policies (Fluss & Gutteridge, 1990, 1993; Rosenfield, Widstrand, & Ruderman, 1981). This literature takes stock of challenges faced by WHO. The wide range of problems identified included the structure of the bureaucracy, budget and financing, weak capacity within developing countries, and changing epidemiological patterns of health and disease. A notable contribution is a major tome on the Smallpox Eradication Programme (Fenner, Henderson, Arita, Jezek, & Ladnyi, 1988). Nestled within chapters on the clinical features of smallpox, and developments in vaccination and disease control strategies, is a detailed account of the establishment and conduct of the most successful story in international cooperation. While atheoretical in its description of policy making, it serves as a rare example of a detailed discussion of how international health cooperation was achieved amid diverse and competing interests.

Interest in the politics of international health grew rapidly during the 1980s, with high profile initiatives on baby milk and essential drugs, with much of this work produced by social scientists working within public health. For example, the work of Michael Reich is notable for applying key concepts from political science, such as power and influence, to map policy making actors and processes. On the politics of essential drugs, he notes:

A new pattern has emerged for setting the agenda of international health issues, with open participation in international organizations by industry associations and by consumer groups. This pattern is still evolving, but it represents a significant change and poses a complex challenge to the leadership of international agencies. The more open participation also raises questions about whose interests are being represented and whose interests should be represented at agencies such as the WHO.

(Reich, 1987, p. 55)

A rare analysis from international studies during this period is provided by Karen Mingst (1990, p. 228n), who notes the surprisingly limited research on WHO. In her study of relations between WHO and the U.S. government, she argues that the U.S. government has pursued a “strategy of adaptation”:

This approach is designed to enable the United States to maintain a lower profile, thereby stifling charges of U.S. manipulation of the organization and fortifying WHO’s own legitimacy. American officials have worked more behind the scenes to convince countries to support specific measures, building coalitions rather than using threats or financial leverage.

(Mingst, 1990, p. 219)

This has been possible because of “the organizational characteristics of WHO, including the technical orientation of the secretariat, transgovernmental networks, and the political savvy of its directors-general and other members” (1990, p. 224). Similarly, on the International Code of Marketing of Breast-Milk Substitutes, Katherine Sikkink (1986, p. 825) observes that “[t]he perception of WHO as a technical and professional organization with low politicization increased the impact of consensual scientific knowledge.” Such publications were among the first to recognize health organizations as potential subjects within international studies.

Evaluating International Organization for Health

Growing dissatisfaction with WHO among major donor governments prompted a spate of evaluations from the early 1990s. The Nordic UN Project (1991) attributed WHO’s problems to the shift from normative to technical cooperation activities with developing countries. The study considers the operational capabilities of WHO, in light of the changing nature of technical cooperation, and identifies functions the organization might best perform (Stenson & Sterky, 1994; Sterky, Forss, & Stenson, 1996). In 1991, the Danish International Development Agency (DANIDA) commissioned a review of 11 multilateral agencies, including “Effectiveness of Multilateral Agencies at Country Level: WHO in Kenya, Nepal, Sudan and Thailand.” The study seeks to understand the “comparative advantages” across agencies at the country level and considers, in particular, whether WHO “managed to formulate and support a set of activities (projects and programmes) that are relevant to the present needs of the country” (DANIDA, 1991, p. 2). Based on field visits, discussions with agency staff, and review of policy and project documents, the study takes a program evaluation approach to assess administrative and technical effectiveness. It recommends a review of the role and mode of WHO’s regional offices, noting the organizational structure was highly politicalized and that there was a need to strengthen WHO’s non-medical, professional resources in the form of health management and capacity-building expertise. Another donor concern was “value for money” leading to an analysis (funded by the United Kingdom, Australia, and Norway) of WHO finances (Vaughan et al., 1996). Under a donor-imposed policy of zero real growth from 1980 (and then zero nominal growth in the mid-1990s), WHO faced increasing pressure to tighten its belt and set priorities. Based on detailed review of budget and program documents, and semistructured interviews, the study undertook groundbreaking analysis of the shift from regular budget to extrabudgetary (voluntary) funds, with the latter giving donors a stronger (and uncoordinated) voice over agenda setting. The study highlights for the first time the mutual responsibility of international organizations and donor countries for the serious problems of poor coordination and overlapping mandates. This finding is confirmed by Koivusalo and Ollila (1997) who, funded by the Finnish government, compared the organizational structures, finances, accountability, policies, and cooperative arrangements of UN organizations concerned with health. The country level presence of WHO was then reviewed (funded by Australia, Canada, Norway, Sweden, and the United Kingdom) in 12 countries, which found the organization’s resources spread too thinly (Lucas et al., 1997). A hard-hitting series by Fiona Godlee in the influential British Medical Journal leveled unprecedented criticism at WHO, pointing to problems of nepotism and weak leadership, alongside bureaucratic inefficiencies (Godlee, 1994a, 1994b, 1994c, 1994d). The series marked the start of a decline in confidence in WHO’s lead role in international health cooperation, a subject revisited over the next two decades (Brown, Cueto, & Fee, 2006; Lee & Buse, 2006).

Writing from a more theoretical perspective, Siddiqi’s World Health and World Politics evaluates the influence of political and other factors on the WHO’s effectiveness in its efforts to achieve universal membership, a workable decentralized structure, and the eradication of malaria (1995, p. 40) Seeking to redress the non-medical analyses of programs and policies, he challenges the assumption that “politics can be segregated from the technical or ‘apolitical’ work of an organization like the WHO,” and that the failure to do so results in ineffectiveness (1995, p. 41). Dividing politics into four realms (positive, inevitable, legitimate, and negative politics), he argues that politicization specifically concerns “negative politics,” defined as that “category of politics which results in the consideration of extraneous issues such as those concerning security and power-politics within the confines of a specialized agency like the WHO” (1995, p. 51). He concludes that politics should be seen, not simply as interfering with international health cooperation, but embedded within its nature.

Growing competition for scarce resources among UN bodies extended the evaluation of international organization and health beyond WHO. For example, while WHO and UNICEF cosponsored the Declaration of Alma Ata, differences in their interpretation of the most appropriate way of achieving Health for All became apparent. The clear tension between comprehensive and selective primary health care (Walsh & Warren, 1979) pushed into view the increasing competition among UN bodies for material and ideational power. Maggie Black’s books on UNICEF (1986, 1996) provide detailed accounts of the creation of the UN fund and development of its activities. Yves Beigbeder’s New Challenges for UNICEF (2002) also delves beyond description to examine the challenges of defining the organization’s identity and relationships with other international organizations.

Also notable was the ascendance of the World Bank as a substantial funder for health development, which prompted questions about its greater influence over the policy agenda (Abbasi, 1999; Buse & Gwin, 1998). For example, Sridhar (2008) argues that the World Bank’s approach to addressing hunger in India was overly biomedical and did not account for the social and economic determinants of food insecurity. The controversial impacts of structural adjustment programs and policy conditionality on health in low and middle income countries prompted scathing critiques of the neoliberal ideology embedded within the World Bank.

Walt published the first detailed analysis of the changing context of international health cooperation, in the form of major shifts in financing and activities, as “an increasingly political milieu” (1993, p. 125). Siddiqi’s examination of the increasingly “volatile atmosphere” (1995, pp. 5–6) of international health cooperation marked a shift in scholarship toward more critical interrogation. For example, mapping the formal and effective mandates, resources, and comparative advantages of four UN bodies, Lee, Collinson, Walt, and Gilson (1996) asked who should be doing what in international health. William Muraskin’s The Politics of International Health: The Children’s Vaccine Initiative and the Struggle to Develop Vaccines for the Third World (1998) offered a detailed account of how political rivalry among international health organizations shaped child immunization campaigns. Kaddar, Lydon, and Levine reach similar conclusions in their analysis of the financing of the Global Alliance for Vaccines and Immunization (GAVI). The authors describe how “funding in poor countries is often at risk and subject to the political whims of donors and national governments” (2004, p. 697). Panisset’s study of the international response to the Peruvian cholera outbreak during the 1990s (2000, p. 14) goes further by putting forth a utilitarian approach to “international health statecraft” for use by foreign and health policy makers. Importantly, this scholarship highlighted growing contestation over both material interests and the normative basis of international health policy (Sanders & Chopra, 2003). Subsequently, scholars have shifted to analysing how to raise the quality of politics rather than exclude it from an assumed apolitical issue area. Key questions concern the appropriate balance of power among institutional actors in terms of resources, authority, and responsibility (Silberschmidt, Matheson, & Kickbusch, 2008).

Since the global financial crisis of 2008, and most notably as fallout from the global response to the Ebola outbreak in 2014–2015, scholars have returned to the issue of WHO reform. While this has remained a perennial topic since the 1990s, the focus has shifted to diagnosing WHO’s problems within the broader global context. WHO’s budget crisis, which led to program and staff cuts, prompted a renewed internal reform process in 2010. Externally, several new studies have reviewed familiar territory yet have thus far fallen short of a clear road map forward. Mapping WHO’s position since 1990, Lidén (2014) argues that the organization’s decline is partly explained by competition between health-related organizations, but also by its structure. He describes a disconnect between the priorities of health ministries that govern WHO, and ministries of foreign affairs and aid agencies that provide the bulk of financing. Clift (2014) questions the direction of WHO reforms and calls for changes to WHO’s core functionality, governance, and financing. Magnusson (2009) argues that WHO’s growing attention to chronic disease, and shift from “vertical” disease programs and technical solutions, must be matched by more complex forms of organization. Graham (2014) draws on theory about the behavior of international organizations to assess WHO’s challenges in governing its regional and country offices between 1982 and 2000. Chorev (2012), taking a contradictory view, argues that the WHO has been particularly successful in balancing the influence of high income countries that provide it with resources, with the interests of the majority of lower and middle income countries who make up its membership. Similarly, Van de Pas and Van Schaik (2014) argue that WHO’s governing bodies have become more transparent and accessible to member states and non-state actors.

Conceptualizing Global Health Governance

The prescient call by Caroline Thomas (1989) for international studies scholars to give greater attention to health issues began to be heeded in the mid-1990s for two reasons. First, the end of the Cold War shifted attention to nontraditional security issues that included major disease outbreaks (e.g., Ebola, HIV/AIDS, pandemic influenza) and biological weapons. International security scholars became interested in the risks posed by these threats and the institutional arrangements for addressing them. This interest in “health security” was fueled by the media (Preston, 1998) and science journalists drawing attention to the fragile nature of public health systems worldwide (Garrett, 1994). The collapse of the former Soviet Union’s biological weapons program (Alibek & Handelman, 2000), and possible proliferation of weapons to terrorist groups, raised particular concerns (Fidler, 1999; Henderson, 1999). The realization that potentially any population, regardless of location, is vulnerable to transboundary health risks prompted a conceptual shift. As Fidler and Gostin (2008) observed:

The biological weapons threat has forced states, intergovernmental organizations, and non-state actors to build more comprehensive and complex strategies to protect against the proliferation and use of biological weapons. Similarly, traditional approaches to infectious diseases proved inadequate as microbial dangers grew in scope and seriousness. These dangers prompted policy makers to engage in the securitization of public health and to embark on unprecedented efforts to remake global surveillance and intervention policies.

Second, the increasingly complex institutional arrangements for health cooperation led Lee (1998) to apply the concept of “global governance” to the study of international organization and health. She argues that, as health determinants and outcomes are increasingly influenced by globalization, new forms of cooperation emerge. This trend is confirmed by Ravishankar, Gubbins, and Cooley (2009) who find that health funding flowing through UN bodies and development banks decreased between 1990 and 2007, while funding through other actors increased. Buse, Hein, and Drager (2009) describe GHG as concerning how health priorities are set, funds raised and allocated, and disputes settled among multiple actors. Hill (2011) argues that GHG shares the characteristics of complex adaptive systems, due to the multiple and diverse players engaged, whose relationships are constantly evolving through dynamic interactions. Harman (2011) holds that GHG includes initiatives between states and non-state actors to protect people from transborder public health risks.

Interdisciplinary scholarship particularly highlighted the increase in type and quality of actors in global health. The trend toward a multiplicity of actors was recognized as having origins in the 1992 International Conference on Population and Development, where transnational policy networks of women’s health organizations played an influential role (Dodgson, Lee, & Drager, 2002; Finkle & McIntosh, 1994). Bartsch and Kohlmorgen (2007) documented civil society organizations’ (CSO) contributions to AIDS and other health contributions through conferences, consultative relationships, decision making bodies, development projects, and advocacy. Applying Haas’s (2003) framework, Lee (2010) mapped CSO contributions to GHG functions in relation to the International Code of Marketing of Breast-Milk Substitutes, Framework Convention on Tobacco Control, International Health Regulations (IHR) and Codex Alimentarius.

Charitable foundations, led by the Bill and Melinda Gates Foundation, Wellcome Trust, and Rockefeller Foundation, became a core interest of GHG scholarship, due to the substantial resources they contribute, which have pushed health issues higher on policy agendas. In particular, the capacity of foundations to shape policy priorities, with unclear systems of transparency and accountability, raised concerns (Moran, 2008; Williams & Rushton, 2011).

New funding arrangements for global health attracted the interest of international relations and political economy scholars interested in the role of private actors in global governance. The coming together of state and non-state actors to form public–private partnerships (PPPs) received particular attention. Sandberg, Andresen, and Bjune (2010) adapt regime theory to conceptualize the role of non-state actors in the formation of GAVI. Similarly, Nishtar (2004) identifies six purposes, and the complex ethical and process challenges, created by the “transnational nature of … these partnership arrangements.” Trow and Reich (2002) similarly examine how organizations with different values, interests, and worldviews come together as PPPs to resolve critical public health issues; how shared objectives and values are created; and how relationships of trust are fostered and sustained.

Writing from a health policy perspective, Buse and Walt (2000a, 2000b) classify PPPs as product-based, product development-based, and issues/systems-based. Buse and Harmer (2007, pp. 259, 270) identify “seven habits” that make PPPs more or less successful in the developing world. Johnston and Finegood (2015) and Stevenson (2015) consider their relevance in high income settings. Kruk (2012) notes a doubling of funds for global health between 2000 and 2010, much of this channeled through PPPs. The proliferation of PPPs, however, is criticized by Richter (2004) for their ideological basis and compromise of core public health values. Similarly, McCoy, Chand, and Sridhar (2009) argue that increased funding for global health is often exaggerated, with limited detailed information available on private contributions. Ruckert and Labonté (2014) argue that PPPs have transformed the logic of international health responses to elevate market-based solutions over public sector approaches.

The role of international organizations not directly purposed to address health, but whose actions have health related impacts, expanded the scope of GHG scholarship. The health impact of agreements under the World Trade Organization (WTO), such as the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS), prompt Bettcher, Yach, and Guindon (2000) and Trouiller et al. (2002) to question the influence of economic globalization on health. While the 2001 Doha Declaration on the TRIPS Agreement and Public Health was celebrated for recognizing the need for affordable access to medicines in lower and middle income countries, scholars, particularly those writing from activist/advocacy perspectives, remain concerned about its practical benefit (Scott & Harman, 2013). Political developments around TRIPS also drew the attention of political scientists and political economists, who in turn intensified theoretical debates. Sell (2004) argues the unfolding of negotiations over TRIPS challenges constructivist assumptions that distinguish between transnational business networks as instrumentally versus civil society networks as normatively orientated. Further interrogation is offered by Marcellin (2010) who considers how political dynamics within the WTO, particularly between the United States and African group, influence the creation of pharmaceutical patent regimes. Williams (2012) argues that two regimes have formed—one arguing that patents are economically necessary and another championing access. Recognizing the need to better understand how and where economic and health regimes overlap, Bartels (2013) studies cooperation among the WHO, WTO, and World Intellectual Property Organization.

How health fares within the international trading system as a whole is examined in a special series by the Lancet (Fidler, Drager, & Lee, 2009; Lee, Sridhar, & Patel, 2009). As multilateral trade negotiations remain stalled, attention has shifted to regional and bilateral trade and investment agreements. Friel et al. (2013) consider how the proposed Trans-Pacific Partnership might affect health outcomes related to nutrition. Kelsey (2012) considers how new trade agreements threaten alcohol and tobacco control policies, with potentially negative impacts on public health. These analyses bridge previous distinctions between political economy and public health fields.

As part of defining the policy and institutional arrangements needed, attention has been given to principles of “good governance,” particularly from those engaged in current governance arrangements. For example, Sidibe, Ramiah, and Buse conclude that the Global Fund to Fight AIDS, Tuberculosis and Malaria “must seek to foster an environment and procedures for public and mutual accountability, involving North and South, non-state and parliamentary actors” (2006, p. 500). As part of their assessment of “public health in the new era,” Beaglehole, Bonita, Horton, Adams, and McKee call on public health practitioners “to understand the political nature of the process of developing health policy and act accordingly” (2004, p. 2086). Consensus developed on the need for new institution building, akin to the postwar period. This is reflected in the introduction to a special series in PloS Medicine on the changing nature of global health institutions (Szlezák, Bloom, & Jamison, 2010). The authors—social scientists, health scientists, and policy makers—argue that the influx of new actors, formation of partnerships with existing actors, and increasingly global political economy reflects a world in transition. Scholars acknowledge widespread negative assessments of existing institutions (Williams & Rushton, 2011), but also note the successes, such as declining child mortality, from collective action. Frenk and Moon (2013) similarly diagnose GHG as a new era in which a plurality of actors need to mediate their relationships, and achieve consensus on what roles each fulfill. An example of the renewed search for institutional innovation is the One Health Approach, which seeks to bring together human, animal, and environmental health. The One Health approach has been supported, in principle, by a wide range of state and non-state actors, leading to the creation of the One Health Network and Task Force. However, Lee and Brumme (2013) argue that the approach is hindered by institutional structures that discourage innovation.

A concise review of the shortcomings of existing institutional arrangements is provided by the Lancet-University of Oslo Commission on Global Governance for Health, another practitioner, policy maker, and academic collaboration, which concluded:

Health inequities within and between countries cannot be addressed within the health sector, by technical measures, or at the national level alone, but require global political solutions; norms, policies, and practices that arise from transnational interaction should be understood as political determinants of health that cause and maintain health inequities; power asymmetry and global social norms limit the range of choice and constrain action on health inequity; these limitations are reinforced by systemic global governance dysfunctions and require vigilance across all policy arenas.

(Ottersen, Dasgupta, & Blouin, 2014, p. 630)

Interdisciplinary Perspectives on Global Health Governance

The work of Fidler is prominent as the first international legal scholarship “to measure the impact infectious diseases have on international relations, but also to consider how the nature of the international system itself contributes to the global problem” of emerging infectious diseases (Fidler, 1997, p. 810). His work has examined a range of legal instruments as building blocks for GHG (Fidler, 2004; Fidler & Gostin, 2008). Other scholars (Aginam, 2005; Gostin, 2004, 2014; Taylor, 2002; Zacher & Keefe, 2008) argue for international legal instruments for other global health issue areas. Gostin and Sridhar (2014) note that international organization has not resulted in a formal legal system under a treaty body, but instead a collection of “soft law” instruments shaped by language of rights, duties, and rules of engagement.

Such soft laws are negotiated through what is termed global health diplomacy (GHD). Scholarship on GHD comes from both those engaged in it and scholars studying it. Kickbusch (2013) details the rise of GHD as an intersection of public health, international relations, law, economics, and management. She argues that GHD has the potential to transform international organization on health by situating health issues within human rights dialogues. Feldbaum, Michaud, and Lee (2010) more critically explore the linking of health and foreign policy, raising questions about the lack of a coherent definition of health diplomacy, how and when foreign policy priorities determine political priority and funding for global health issues, and the use of health interventions by states and non-state actors to achieve ulterior foreign policy objectives. Fidler (2010) presents an in-depth analysis of diplomatic negotiations over access to influenza vaccines, highlighting the links between the securitization of health issues and health diplomacy.

Economists have contributed to this debate by applying the concept of “global public goods” to the task of identifying core functions that international organizations should fulfill in the face of market failure (Smith, Beaglehole, Woodward, & Drager, 2003). Few functions, however, are recognized within the limiting categories of non-rivalrous and non-excludable, and the concept thus fell out of favor among scholars and policy makers by the mid-2000s. Political economy approaches to GHG have given greater attention to the structural nature of health inequalities created by globalization and the need for deeper institutional reform. Health funding by the Group of Eight (G8) countries has been critically reviewed by Labonté, Schrecker, Sanders, and Meeus (2004); and Kirton, Roudev, Sunderland, and Kunz (2009). Kaasch (2010) argues that the OECD influences health governance by providing guidance on national health care systems, while Cooper, Schrecker, and Kirton (2007) study the roles of central institutions such as WHO, the World Trade Organization, and the G8. Schrecker, Labonté, and Sanders (2007) argue for the promotion of health equity as a guiding principle in GHG. Kay and Williams’s (2009) edited volume on political economy approaches to GHG includes analyses of established health organizations, such as the WHO; as well as of global forces, such as financial markets; and non-state actors, such as activist groups. These contributions analyse power dynamics within and between health organizations and other regimes within the context of a neoliberalism and globalization, indicating an expansion of the scholarship from focusing on specific organizations, to how the structural contexts they operate within impact their ability to achieve their mandates.

Medical anthropologists have particularly added critical perspectives to GHG scholarship by analyzing how power dynamics at the global level impact the lives of those most affected by ill health. Prominent among this scholarship is the work of Paul Farmer (1999, 2003) who links the outbreaks of infectious disease to institutional inertia, politics of blames from developed to developing countries and international conflicts. Similarly the edited volume by Castro and Singer (2004) considers how global health policy, while purporting to protect those marginalized, actually has negative effects on their well-being.

The Social Construction of Global Health Governance

Since the late 2000s, the study of GHG has accelerated in volume and scope. A review by Lee and Kamradt-Scott (2014) finds the term GHG appearing in over 1000 scholarly publications between 2002 and 2014. The authors set out the conceptual distinctions between international versus global, government versus governance, and health-focused versus other organizations with health impacts. Importantly, the review concludes that varying definitions of GHG need to be acknowledged as reflecting normative differences. Scholars have thus begun to analyze the social construction of GHG.

Initial studies were prompted by the discrepancy between relative burden of disease and allocation of resources for global health. The work of Jeremy Shiffman asks why certain issues and population groups are given policy priority while others are neglected (Shiffman, Beer, & Wu, 2002). Comparing donor funding across 20 communicable diseases with affected numbers of people (using Global Burden of Disease data), he finds that “many funding decisions [are] based on the disease targeted, influenced by industrialized world interests and priorities of the moment. The result will be ongoing competition among diseases for attention. This dynamic makes continued research and monitoring of funding patterns essential” (Shiffman, 2006, p. 419). Shiffman (2014, p. 3) argues that both material and productive power shape policy agendas, with the latter defined as “how we create meaning, particularly through the use of categories that lead us to think about the world in some ways but not others” (2014, p. 297). He argues that productive power is rarely challenged in GHG as it is legitimized by assumptions of expertise and humanitarian motives. He asks why some health organizations are afforded legitimacy while others are not, and points to “a critical need to investigate how epistemic and normative power get exercised in the global health field” (2014, p. 299).

Concurrently, there has been an increased focus on how global health challenges and approaches are constructed or understood. Shiffman (2009) defines frames as “the way in which an issue is understood and portrayed publicly.” Lee (2010) identifies four frames that shape GHG—biomedicine, economics, security, and human rights. Labonté and Gagnon (2010) analyze six frames—security, development, global public goods, trade, human rights, and ethical/moral reasoning—and seek to understand which assert greatest influence. McInnes et al. (2012) explain contestation in GHG as arising from competing frames, which have contributed to different ways of problematizing global health and conceptualizing appropriate solutions. The result is a proliferation of institutional actors that compete, rather than cooperate, together. At the same time, they argue that effective GHG requires understanding of how health issues are framed, what makes a frame successful, what effect frames have, and how frames can be strategically combined. For example, Woodling, Williams, and Rushton (2012) argue that UNAIDS and its allies reframed HIV/AIDS by linking the security, economic, and development frames.

In particular, the framing of health as a security issue has been analyzed. Previous studies arguing that health issues are security risks (Fidler, 2003; Price-Smith, 2001, 2002; Rodier, Greenspan, Hughes, & Heymann, 2007) are distinct from more recent critical approaches to securitization. Social constructivist scholars argue that normative frames, such as security, give selected problems and their solutions priority. For example, the UN Security Council’s decision in 2000 to hold its first ever health-related meeting, on HIV/AIDS, was prompted by the casting of infectious diseases as security risks and thus “high politics.” Kamradt-Scott and McInnes (2012) argue that a similar paradigm has been applied to pandemic influenza. While securitization garners increased attention and resources (Ostergard, 2007), it also skews attention toward the treatment of acute infections with the potential to spread to high income countries. Health conditions such as road traffic accidents and waterborne infections, affecting larger numbers of people largely in low- and middle-income countries, remain relatively ignored in both policy discussions and social science literature on health/disease because they are do not lend themselves to securitization (Rushton & Youde, 2015).

Deeper understanding of normative power has been the subject of a growing body of scholarship on international organization and health. Elbe (2009) draws on Foucault’s theory of “governmentalization” to argue that health has been reframed using security paradigms as an attempt to manage the welfare of populations. Ingram (2010), writing from a human geography perspective, builds on this approach to analyze the President’s Emergency Plan for AIDS Relief (PEPFAR), arguing that the American program emerged out of accommodations between geopolitics and governmentality. He illustrates how the case of PEPFAR makes explicit the problems that arise from securitized attempts to address health concerns, including the challenges of defining the relationships between people and things that are to be intervened upon, the techniques that will be used, and how these will be calibrated in terms of cost and efficiency. Elbe (2014) extends this line of inquiry by arguing that the securitization of health has, in turn, transformed understandings of security within global politics and international relations literature.

On a practical level, the securitization of health has led to a strong emphasis on surveillance, monitoring, and reporting. The revised IHR, agreed to in 2005, obligated WHO member states to develop core capacities in surveillance and be responsible for monitoring and reporting within their borders (Katz, Sorrell, Kornblet, & Fischer, 2014). Yet Wenham (2015) argues that WHO has been increasingly pushed out of the technical management of surveillance. Critical perspectives on new surveillance regimes have emerged. Youde (2012), for instance, notes that improved bio-surveillance technology has the potential to allow states and international organizations to override individual human rights to privacy.

Future Directions

Until the mid-2000s, the vast bulk of the literature on international organization and health has been produced by international civil servants, public health practitioners, and researchers. These writings have been largely concerned with describing where problems arise and diagnosing existing institutional arrangements, particularly the WHO, for collective health action. Much of this analysis has been undertaken by individuals straddling the roles of practitioners, policy makers, and advocates. While insightful of the practical challenges facing international organization and health, such works tend to be what Strong (1986) describes as “technocratic, ahistorical, apolitical and unreflexive.”

Since the mid-2000s, significant scholarship on international organization and health has emerged from international studies scholars. Building on the work of medical historians (Packard, 1998; Weindling, 1995) and legal scholars (Aginam, 2005; Fidler, 2001), and attracted by the increased policy priority and resources given to global health initiatives, international studies scholars have contributed a broad range of theoretical perspectives and broadened the study to a variety of types and forms of organization. The influx of these scholars, alongside other writers, is likely to influence future directions in several ways.

First, technocratic and bureaucratic approaches to international organization and health are likely to be challenged further. Politics is now widely recognized, not simply as an external interference in the technical workings of intrinsically scientific bodies, but as embedded within their nature. Deeper analyses of the nature of these politics and, in particular, the distribution and exercise of different forms of power across the numerous and diverse institutional actors in global health, remains needed.

Second, building on the approaches discussed, the broader question of what international organization and health tells us about emerging forms of global governance can be raised. For example, what do innovations in GHG tell us about the shifting boundaries between the state, market, and civil society? What is the quality of global governance achieved by these institutional arrangements? How might the struggles for GHG inform efforts to address other collective action challenges?

Third, existing concepts and theories are imprecise and often inaccurate descriptors of new institutional arrangements and the transboundary nature of collective action. The term “international organization” has, in the past, described intergovernmental bodies such as the WHO. The advent of non-state actors, sometimes partnering with states to form PPPs, requires new terminology. Their membership, authority, and scope of activities are not captured by such terms as international cooperation and development assistance. The concept of “orchestration” has recently been introduced to conceptualize how international organizations might “orchestrate” intermediaries to steer global governance (Abbott, Genschel, Snidal, & Zangl, 2015), along with concerns about WHO’s ability to fulfill this type of governance function (Hanrieder, 2015). As the institutional landscape continues to evolve, there is need for new concepts and theories that capture nascent forms of GHG.

Fourth, the tension between problem solving and critical approaches to international organization and health will continue to be an analytical challenge. In many ways this tension reflects the ongoing richness of a literature informed by those writing from advocacy, policy making and activist, as well as academic, backgrounds. The long-standing operational challenges of mandates, coordination, and leadership remain relevant. However, seeking to address them through the building of new institutional structures and forms, without attention to underlying political problems, will merely lead to greater proliferation of actors. Critical approaches seek to deepen understanding of this complex institutional landscape, not as administrative or operational challenges, but as manifestations of different normative frames or worldviews (McInnes et al., 2012). These approaches reveal deeper insights into the nature of emerging global health issues and the institutional responses to them.

Relatedly, there is need to better understand how GHG is responding to and being shaped by broader shifts in the global political economy. The rise of the BRICS (Brazil, Russia, India, China, and South Africa) countries in global governance means that international organization will be shaped in future by multipolarity. This has prompted an emerging body of literature on what role the BRICS are playing in global health cooperation. Acharya and colleagues (2014) argue that the BRICS are protagonists for greater international cooperation for health. Watt, Gomez, and McKee (2014) link engagement in global health to foreign policy, in order to explore why and how the BRICS engage in the global health initiatives. Studies so far mostly focus on China or Brazil, with each country attracting attention for different reasons. Chan, Lee, and Chan (2009) and Yoon (2010) note that the SARS outbreak of 2002–2003 prompted scrutiny of China’s public health system and increased expectations that the country, as a rising superpower, should play a prominent role in GHG. Chan (2010) and Szlezák (2012) argue that China’s response to the HIV/AIDS has resulted in its greater integration into global health cooperation. Also focusing on China, Huang (2010) offers deeper understanding of how major powers engage health as a foreign policy issue. In contrast, Brazil’s engagement in global health diplomacy on access to medicines and tobacco control has been seen as “soft power” (Lee, Chagas, & Novotny, 2010). While much of the current BRICS literature remains circumscribed, and tends to focus on bilateral or regional organization, it reflects a greater future role in emerging forms of GHG (Yoon, 2010).

Debates about global health priorities, participation, and responsibilities have also been reinvigorated with processes to establish a follow-up agenda to the Millennium Development Goals (MDGs). Buse and Hawkes (2015) note the success of the MDGs in galvanizing attention, resources, and accountability on a small number of health concerns, and ask if lessons from this experience can be drawn to inform a successor framework. They argue that, in order to achieve more ambitious goals, the global health community will have to go through a paradigm shift. Similarly, Haffeld (2013) notes that new thinking is needed to conceive of goals that recognize the complexity of current health arrangements and issues. While most of the scholarly work on the MDGs and follow-up of Sustainable Development Goals have been written from an advocacy perspective and is speculative, the shift toward universal health care goals indicates that research on the limits of vertical approaches to health threats has resonated with policy makers.

Finally, there is a need for future scholarship to break the cycle of institutional reform following crises. Frenk, Gostin, Moon, and Sridhar (2014) argue that the Middle East Respiratory Syndrome outbreaks of 2014 should galvanize member states to review WHO financing. The inability of GHG to address new “global health crisis” (Ney, 2012, p. 253) then became sharply evident during the 2014–2015 Ebola outbreak in West Africa. With more than 26,000 cases and 11,000 deaths as of May 2015, the outbreak has induced a new round of soul searching and finger pointing. WHO has been subject to almost universal criticism for its slow and inadequate response (Moon et al., 2015), while the failings of the global response overall has also drawn fire from global health advocates (Friedman & Gostin, 2014; Moore, Gostin, & Osterholm, 2014). Amid renewed concern about the need for effective GHG, new scholarship is needed that offers balanced criticism of existing institutional arrangements with clear lessons for achieving collective action. In short, future scholarship will need to shift from diagnosing the weaknesses and limits of current international organization for health, to conceptualizing solutions.

Acknowledgments

The author wishes to thank Adam Kamradt-Scott for detailed comments on the first edition of this article. This review was originally funded by the European Research Council under the European Community’s Seventh Framework Programme—Ideas Grant 230489 GHG. This updated version is funded in part by the National Cancer Institute, U.S. National Institutes of Health under Grant Number CA-091021. All views expressed remain those of the authors.

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