How environmental treaties contribute to global health governance

Several scholars found that the architecture of global health governance is increasingly fragmented [1‐4]. The number of stakeholders has risen sharply and includes non-governmental organizations (NGOs), private foundations, industrial groups and international research centers. Together, they contribute to the proliferation of various transnational actions, programs and partnerships. Far from centrally coordinating these flourishing activities, the World Health Organization (WHO) is one more actor, albeit an important one.

In the existing literature on global health governance, few studies analyze this fragmentation using the conceptual toolkit developed by scholars of international relations. In this article, we use the concept of “regime complex” to shed a new light on the transformations that have affected global health governance in recent decades. More specifically, we examine the health and environment regime complex and we argue that international environmental law makes a significant contribution to health governance.

The concept of “regime complex” arise out of the observation that there is not just one, but several international systems. The influential actors, the prevailing assumptions and the foundational institutions that govern the global trade system, for example, are quite different from those governing migration flows or the proliferation of weapons of mass destruction. To account for the specificities of each policy domain, international scholars use the concept of “international regime”, canonically defined as a “set of implicit or explicit principles, norms, rules and decision-making procedures around which actors’ expectation converge in a given area of international relations” [5].

Using this definition, global health appears as an international regime [6]. It includes international institutions devoted to infectious diseases surveillance, foreign assistance for health services, antibiotic resistance, and tobacco control, to name a few. Although these institutions have different members and functions, they share understandings of what health is about and of how health should be governed [7‐9]. The global health regime includes, among others, the principle that policy decisions should be informed by evidence-based science, the norm that high-income countries should provide health-related assistance to low-income countries, the rule for states to notify the WHO in case of public health emergency of international concern, and the procedure of establishing transnational partnerships to address global health issues. As such, the global health regime has allowed a certain convergence of expectations among key actors [10].

However, international regimes do not develop in isolation. They evolve as open systems, which interact with other regimes in conflictual and synergic ways. There is no centralized world government and, therefore, no hierarchical ways available to arbitrate these interactions between regimes. To describe these complex situations, Kal Raustiala and David Victor coined the term “regime complexes”, which are defined as arrays of partially overlapping and non-hierarchical regimes [11]. This innovative concept invites anyone interested in understanding how a particular regime is created, how it evolves and how effective it is to consider other global regimes. For example, to understand global health governance, we should look at other areas of global governance, which may affect global health in positive or negative ways.

The dynamics that drive the creation of regime complexes are relatively well understood. In many cases, normative activities in one regime have unintended consequences for another regime [12]. For example, the investment regime restricted the ability of governments to adopt health regulations [13]. In some cases, regime interactions are deliberate. States can strategically move a specific problem from one regime to another, if the latter is perceived as being more receptive to certain interests or ideas. Developing countries adopted this strategy when they wanted to negotiate access to patented pharmaceutical products in the framework of the global health regime, rather than that of the intellectual property regime [14]. Likewise, international organizations seeking to expand their sphere of influence may choose to operate in a different regime to strengthen their position in terms of relevance, visibility or resources. This partly explains how the World Bank became involved in global health governance [15].

The consequences of regime complexes are generally less clear than their causes [16]. Overlaps between regimes can generate confusion, redundancy and inefficiency [17]. The existence of different competing institutions may strengthen already powerful actors in terms of their forum shopping strategy and exacerbate existing power imbalances [18]. On the other hand, institutional diversity and competition can favor a more flexible, adaptive and innovative form of governance [19, 20].

We know little about how regime complexity affects health governance. Some studies have convincingly argued that trade, investment, intellectual property and financial regimes have unintended negative effects on global health [21, 22]. However, the potential positive contribution of other regimes remains overlooked, with the possible exception of the human rights regime [23]. Some studies have shed light on the contribution that specific environmental treaties have made to health governance, particularly the Minamata Convention on Mercury and the Paris Agreement on climate change [24, 25]. However, no assessment has yet been conducted on the international environmental regime’s contribution to global health governance. By drawing on the concept of regime complex, this article aims to conduct an empirical assessment to determine the extent to which environmental treaties also contribute to global health governance.

With the publication of this article, we are making the Health and Environment Interplay Database (HEIDI) publicly available. By making this new resource available, we hope the global health community will take it further and map the health regime complex.

The HEIDI dataset covers 2280 environmental treaties concluded between the eighteenth century and the present day (2017). All the treaties share three defining criteria: 1) they are binding under international law; 2) they were concluded by two or more states, 3) their primary purpose is to protect the natural world or develop the sustainable exploitation of natural resources. They include well-known multilateral treaties on biological diversity and climate change, but the majority are bilateral or regional treaties relating to issues, such as fisheries conservation, freshwater management, oil spill and nuclear waste. Most of the treaties were identified and collected by Ronald Mitchell (2003) [26].

We conducted a content analysis using the qualitative data analysis software NVivo to identify provisions linked to human health in these environmental treaties. We first used an extensive list of keywords relating to human health to identify a wide range of provisions. We reduced the initial sample, by applying a narrow definition of human health. For example, provisions on animal health, welfare, food supply and sanitary measures were excluded unless they explicitly referred to human health. Then, we classified genuinely health-related provisions into 14 different categories. We developed a detailed codebook with inclusion and exclusion rules for each of the 14 categories. We instructed a team of trained research assistants to read all 2280 treaties, using the codebook to identify any provisions that fitted our criteria. Different encoders analyzed the selected provisions to weed out any false positive results. Finally, to assess the frequency of false negatives, 10% of the treaties were coded a second time by a different encoder. Inter-encoder reliability for this double coding as measured by Cohen’s kappa is 0.706, which is considered a substantial level of agreement [27].

Using this method, we find hundreds of environmental treaties with health-related provisions. Not surprisingly, most treaties designed primarily to protect natural resources do not include provisions on human health. Environmental law and health law remain two distinct bodies of international law. However, no fewer than 338 environmental treaties include at least one health-related provision and some of them include up to seven of these provisions. Health-related provisions appears a total of 540 times in HEIDI.

We found that the environmental regime makes a significant contribution to the global health regime. In order to fully understand the global health regime, it is important to take into account other global regimes, such as the global environmental regime. The mapping presented in this article points to three key findings.

Firstly, we observe important links between the global health regime and the global environmental regime in terms of their principles and objectives. Negotiators of environmental treaties frequently include the protection of human health as one of their objectives. This type of linkage helps justify global collective actions on environmental issues.

Secondly, the linkages between the two regimes can also be analyzed with operational provisions. The majority of operational provisions found in environmental treaties aim to manage the potential conflicts that may arise between the two regimes. Various exceptions or safeguards allow states to arbitrate the regime interactions and prevent unintended negative consequences of the environmental regime on the global health regime.

Thirdly, we find few institutional provisions linking the two regimes. Environmental treaties seldom refer to the institutions involved in the global health regime and rarely build formal bridges with them. One explanation for this low level of institutional interaction may be due to the increasing number and diversity of institutions that are now involved in global health governance. Indeed, in such a fragmented regime, the different actors’ roles and responsibilities may not be very clear, especially for actors operating in other global regimes.

Some public health analysts might have expected stronger linkages between the global health regime and the global environmental regime, given the burden of diseases associated with certain environmental risks. The most striking case is air pollution, as it is associated with a high level of mortality and morbidity worldwide [29]. Yet, air pollution is not the subject of particularly intense rule-making in international environmental law. The trans-border nature of air pollution may not be sufficiently strong to create incentives to encourage international cooperation in this area. The sources of air pollution tend to be local and global interdependence is a powerful incentive for international cooperation, as shown by the large number of environmental treaties that focus on fisheries and transboundary water. In this sense, the fact that some of these treaties take into account health objectives comes as a surprise. While several observers of global governance express concerns for bureaucratic silos, policy incoherence, and negative externalities, the encompassing approach of some environmental treaties is an unexpected and welcome development.

The current literature on the relations between the global health regime and other international regimes focuses on negative externalities. For example, studies have found that the trade regime, the foreign investment regime, the global finance regime, and the intellectual property regime accentuate health inequities [21, 22]. These negative side effects have led to calls for global governance processes that better protect policy space for health [30].

This article finds that other areas of global governance can make a positive contribution to global health. In particular, the global environmental regime includes more than 300 treaties with health-related provisions. This contribution is particularly significant considering that the health regime includes itself very few treaties. Moreover, other environmental treaties that do not explicitly refer to health might also contribute indirectly to health governance by reducing pollution levels and creating a healthier environment.

Taking into account various regimes’ positive contributions to global health is necessary to have a complete picture of the global health regime complex. Having such a complete picture is important because decision makers can potentially use instruments beyond the realm of global health institutions to improve population health. In addition, decision makers might want to transfer lessons from positive experiences to regimes that currently subordinate health under other policy objectives.

Future research on other regimes that affect global health governance should be extended. For example, an in-depth analysis of the health implications of the labor and the human rights regimes should be conducted, following the guidelines provided by the concept of regime complex.