Power asymmetries in global governance for health: a conceptual framework for analyzing the political-economic determinants of health inequities

Background Recent scholarship has increasingly identified global power asymmetries as the root cause of health inequities. This article examines how such asymmetries manifest in global governance for health, and how this impacts health outcomes. Results We focus on the political-economic determinants of global health inequities, and how these determinants operate at different levels of social action (micro, meso, and macro) through distinct but interacting mechanisms. To clarify how these mechanisms operate, we develop an integrative framework for examining the links between global neoliberalism—the currently dominant policy paradigm premised on advancing the reach of markets and promoting ever-growing international economic integration—and global health inequities, and show how these mechanisms have macro–macro, macro–meso–macro, and macro–micro–macro manifestations. Conclusions Our approach enables the design of theoretically-nuanced empirical strategies to document the multiple ways in which the political economy entrenches or, alternatively, might ameliorate global health inequities.

Overcoming gridlock

Global health governance describes when health organizations, such as the World Health Organization, hold the policy reins. The existence of too many global bodies often with too little authority and frequently with competing policy agendas is giving rise to gridlock in global health governance. At the same time, there are calls to expand this conceptualization to embrace global governance for health, where greater efforts are made to insert health priorities into the decision-making of non-health bodies such as the World Trade Organization, the International Monetary Fund, and other United Nations or international policy forums. The recently minted concept of global health diplomacy describes efforts to understand, and to encourage, greater government engagement with health issues in their international relations and foreign policy decision-making. Although such decision-making is often challenged by competing government goals or interests, the Sustainable Development Goals could be used as an anchor to create stronger global governance for health.

The Future of Global Governance for Health

This chapter argues that the current global health agenda has failed to put people and their rights at the center. With communities unable to have their voices heard, challenge injustice, and hold decision makers to account, states are ill-equipped to realize the Sustainable Development Goals (SDGs), including SDG 3 to ensure healthy lives and well-being for all. The chapter articulates a shift from a discretionary development paradigm to a rights-based paradigm for global health, building on rights-based approaches that have been proven to work—as in the AIDS response. Seven reforms are proposed, addressing: (1) priority-setting, (2) systems for health, (3) data and monitoring, (4) access to justice, (5) the need to safeguard the right to health across sectors, (6) partnerships, and (7) financing. These reforms call for a broad social movement for global governance for health, advancing and operationalizing rights-based approaches across the SDGs.

Conclusion

This concluding chapter analyzes the structural determinants of human rights mainstreaming for global health and considers common themes for the implementation of human rights through global governance for health. Human rights are implemented in global health through a dynamic global governance system—extending across the World Health Organization’s mandate to realize the right to health; United Nations specialized agency efforts to address health-related human rights; economic governance to support rights-based priorities in public health funding; and human rights governance to advance global health. The unique context of each institution is crucial to implementing human rights for global health; however, there are generalizable institutional themes that can be drawn from these experiences. By comparing the structures that facilitate organizational efforts to advance human rights across the contributing chapters in this edited volume, it becomes possible to understand the institutional determinants of the rights-based approach to health.

Governance

This chapter focuses on governance, a key building block of a health system. A government is responsible for the health of its people. It sets the health strategy and oversees the implementation of health programs. External forces and actors influence the governance of the health sector. This chapter explores governance of health from the perspective of the nation-state coordinating its own health system (sometimes called governance for global health). The chapter examines the internal and external forces that influence national governance for global health. The chapter also looks beyond the level of the nation-state to explore the concept of global governance for health. In the interconnected and globalized world, global governance for health is needed to coordinate the geopolitical forces that impact health and its social determinants.