The multiple meanings of global health governance: a call for conceptual clarity

For conceptual clarity, it is useful to review the conceptual origins of GHG, a term which began to be used in the 1990s amid angst about the shortcomings of international health cooperation and the growing impacts of globalization on health determinants and outcomes [3]. The term, coined by Dodgson et al. [1] draws from the broader concept of global governance, an already established subject area within International Relations (IR). In broad terms, governance is needed when a collective of individuals comes together to accomplish an agreed end. The resultant arrangement constitutes governance if there is recognised authority, agreed rules for decision making, and accountability. Governance through governments (state-based institutions with formal authority and powers to manage and regulate social actors) is familiar. Governance may constitute institutional arrangements involving both state and non-state actors.

When governance extends beyond one country, arrangements may involve state actors (e.g. World Health Organisation), non-state actors (e.g. International Federation of Pharmaceutical Manufacturers) or both (e.g. Global Fund to Fight HIV/AIDS, Malaria and Tuberculosis). Particular challenges arise for governance beyond the state due to what International Relations scholars call “anarchy” (the absence of overarching political authority above sovereign states). At the same time, the end of the Cold War and the acceleration of globalisation during the late twentieth century have increased calls for effective collective action to address shared challenges such as climate change, disease outbreaks and illicit activities [4]. Non-state actors have also become significantly more prominent, arguably rivalling and even eroding the capacity of states to govern. The perceived need for global governance, therefore, has coincided with shifting power between state and non-state actors. This dilemma has produced a flurry of global governance scholarship grappling with the challenge of creating institutions that effectively “govern without government” in a global era [5].

Since the early 1990s, global governance scholarship has been characterised by rich theoretical argument and empirical analysis, but also imprecision and contestation in meaning. Global governance has been variably described as an objective, a process and an ideal [6‐8]. For example, the United Nations Commission on Global Governance [9] defines the concept as

the sum of the many ways individuals and institutions, public and private, manage their common affairs. It is a continuing process through which conflicting or diverse interests may be accommodated and cooperative action may be taken. It includes formal institutions and regimes empowered to enforce compliance, as well as informal arrangements that people and institutions either have agreed to or perceive to be in their interest.

Young [10] refers to “the combined efforts of international and transnational regimes”, while Whitman [11] is more expansive:

governance can be understood as global by the way of the nature and sum of many governance systems, across sectors and at levels high and low. In the sense that all the world’s human systems can be regarded as interconnected, however patchy and incoherent in their entirety, ‘global governance’ is an established fact of the human condition.

Noting criticisms this might embrace “virtually anything”, Finklestein [12] suggests global governance is “governing, without sovereign authority, relationships that transcend national frontiers. Global Governance is doing internationally what governments do at home”.

Despite a lack of definitional consensus, common threads emerge. One agreed feature is that global governance does not equate to, nor is it considered synonymous with, global government. As Rosenau [13] argues:

Both refer to purposive behaviour, to goal-orientated activities, to systems of rule; but government suggests activities that are backed by formal authority, by police powers to insure the implementation of duly constituted policies, whereas governance refers to activities backed by shared goals that may or may not derive from legal and formally prescribed responsibilities and that do not necessarily rely on police powers to overcome defiance and attain compliance.

To speak of global governance, however, where no supranational authority exists can be confusing. What is meant by “governance without government”? Gordenker and Weiss [14] address this uncertainty by defining global governance as

efforts to bring more orderly and reliable responses to social and political issues that go beyond capacities of states to address individually. Like the NGO universe, global governance implies an absence of central authority, and the need for collaboration or cooperation among governments and others who seek to encourage common practices and goals in addressing global issues.

In this regard, authors such as Biermann et al. [15] have attempted to refine the locus of investigation by focusing on “governance architectures”, defined as “the overarching system of public and private institutions, principles, norms, regulations, decision-making procedures and organizations that are valid or active in a given issue area of world politics”.

A second characteristic that resonates throughout the global governance literature is the importance of non-state actors. As Krahmann [7] summarises, “global governance is characterized by the need for greater collaboration among governments and nongovernmental actors as the result of states being faced with new and growing demands on the one hand and shrinking resources on the other”. In general, there is an expectation for governments to engage more closely with non-state actors as a means of strengthening representation, accountability and transparency [16‐20]. For instance, Castells [21] argues that “the relationship between the state and civil society is the cornerstone of democracy”.

A third theme in the global governance literature is the search for innovative institutional arrangements to adapt to, and manage, the externalities arising from increased transboundary flows [22, 23]. The need to reform decision-making fora and processes [21, 24], representative of the transboundary nature of political constituencies and their interests, has been important debates in this literature. Since 2008, the global financial crisis has generated attention to strengthen global economic governance [17, 25, 26].

A fourth theme is that global governance is not limited to the global level but embraces the local to the supranational. Conceptualised in this way, as Betsill and Bulkeley [8] write, “[t]he development of a governance perspective involves recognising the roles of supranational and subnational state and nonstate actors, and the complex interactions between them, in the process of governing”. A key advantage of such a dynamic, it is argued, is that “power is seen to accumulate from multiple sources of authority, including expertise and moral positions, and to be a relational concept” [8]. A downside is the potential for governance systems to become overly complex, with many “voices” claiming the right to be heard across different fora. Beyond state authority, therefore, the challenge is not only achieving consensus, but determining legitimate enfranchisement. In a world of multiple sources of authority, whose voices should prevail in global governance?

An important cross cutting theme in the literature is the achievement of “good” global governance [27, 28]. The normative basis of what constitutes good governance has been the subject of much scholarly and policy debate. Applied to the public sector of developing country governments, the UN Development Programme (UNDP) frames good governance principles within the context of sustainable human development and poverty alleviation [29]. In contrast, the World Bank has focused on creating efficient and effective public administration that cast democratic governments in the role of, inter alia, enabling markets to thrive as a core component of economic development [30]. Despite continued contestation surrounding different interpretations of the purpose and meaning of good governance it has remained a core expectation of donors for aid recipient countries [6]. Over time, indicators of good governance have become more broadly defined to embrace, inter alia, principles of legitimacy, strategic vision, effectiveness, accountability and transparency, and the rule of law [31].

Overall, understanding the substantial literature on global governance is useful for clarifying the boundaries of GHG scholarship. The distinction by Dingwerth and Pattberg [32], between global governance as an analytical concept and normative perspective, is especially relevant in this respect. On global governance they write:

Besides its use as an analytical concept that attempts to capture the - actual, perceived, or constructed - reality of contemporary world politics…the concept is often used to denote a specific political program, expressing either a normative perspective on how political institutions should react to the reduced steering capacity of national political systems or a critical perspective that refers to global governance as a hegemonic discourse.

As Koplan et al. [33] describe, “global health is fashionable”, as expressed in an explosion of initiatives since the late 1990s. Many governments identify global health as a key foreign policy objective [34‐36]. Philanthropies, international organisations, NGOs, private businesses and public-private partnerships have identified global health as a priority [37, 38]. Academic institutions have created new, or renamed existing, teaching and research programmes [39]. All of this has been accompanied by significant spending on global health activities [40].

Like global governance, however, there are diverse definitions of global health which, alongside its prevalent use, risks rendering it meaningless. Definitions abound but most lack conceptual rigour. Brown et al. [41] locate the historical roots of international health in nineteenth century European imperialism when the priority for collective health action was controlling epidemic diseases spreading from colonised territories. In contrast, global health encompasses a shift to thinking about “the health needs of the people of the whole planet above the concerns of particular nations”. Koplan et al. [33] distinguish public (or population), international (interstate) and global health, with the latter variably “thought of as a notion (the current state of global health), an objective (a world of healthy people, a condition of global health), or a mix of scholarship, research, and practice (with many questions, issues, skills, and competencies)”.

An alternative approach is to focus on the nature or characteristics of a health issue to categorise it as a “global health” problem requiring collective action. The issue must be caused by factors, or possess the capability to occur and/or spread in ways, that transcend territorial geography – to be “transboundary” – to be classified as a global health problem. Needless to say, not every health problem qualifies. Guinea worm, for example, remains a residual health threat in many parts of Africa. By comparison, significant political and financial capital has been expended on HIV/AIDS. The distinction drawn might be explained, at least in part, by the fact that the former is transmitted via an animal vector only prevalent in certain parts of the world. The other is a disease spread by close contact with infected bodily fluids, an event that can occur in any part of the world. In this same sense, influenza (both seasonal and pandemic) is considered global due to its transboundary transmissibility, while malaria could be classified as not a global health issue because it is limited to tropical climates. Focusing on health determinants, lung cancer or liver cirrhosis could be described as global because their causal factors are transboundary (i.e. transnational tobacco and alcohol companies). The nutritional taboos practiced in some cultures, leading to nutritional deficiencies in pregnant women and children, is a serious problem but not a global health issue by virtue of its localised practice.

Overall, the term global health has been confused by its variable use both descriptively and prescriptively. Descriptively, global health is used to describe certain health issues (e.g. epidemics, neglected diseases), or health needs within certain geographies (e.g. low-income countries) or populations (e.g. poor, HIV-infected). Prescriptively, global health is used aspirationally to advocate for certain health goals (e.g. universal health coverage, global health security) for selected geographies or populations. Importantly, as we argue elsewhere, both descriptive and prescriptive uses of the term are embedded within particular normative frameworks or world views which shape thinking and practice about what is the “problem” in global health and what are the legitimate “solutions” [42]. In other words, the theory and practice of global health must be critically understood within the context of shifting material and ideational circumstances. This social construction of the term has had direct implications for the “practice” of global health and how, in turn, it impacts on material reality [43, 44].

The ontological variations described above explain, in large part, differences in how GHG has been conceptualised to date. This paper identifies three distinct uses of the term GHG: (a) globalisation and health governance; (b) global governance and health; and (c) governance for global health. It is argued that each of these distinct concepts, often used interchangeably within the existing literature, derive from particular normative frameworks which, in turn, shape their conceptualisation of the scope and purpose of GHG. The application of these distinct concepts is often unreflexive, resulting in a lack of conceptual clarity in this rapidly emerging subject area.