Overseeing Global Health

• Author: Devi Sridhar and Chelsea Clinton
• Position: Associate Professor at Edinburgh University’s Medical School Centre for Population Health Sciences, and is Adjunct Assistant Professor at Columbia University’s Mailman School of Public Health.

The recent outbreak in west Africa of the highly infectious and often fatal Ebola virus highlights the need for global cooperation in health. The current Ebola crisis—along with the outbreak of Middle East respiratory syndrome (MERS) and the resurgence of polio in the Middle East and Africa—is simply the latest example of governments’ inability to control the spread of infectious diseases when they act in isolation: global rules negotiated among governments are crucial to protecting the health of citizens.Â

The Ebola outbreak is precisely the type of crisis world governments had in mind when they founded the World Health Organization (WHO) in 1948 and placed it at the center of global health governance.Â

The fight against Ebola, which the WHO declared an international emergency in August 2014, requires careful reporting of the spread of the disease to allow authorities to track it, concerted international efforts to contain it, and resources to treat those infected. These needs pertain to global health governance—the rules and related formal and informal institutions, norms, and processes that govern or directly influence global health policy.Â

The essential functions of health governance, which are generally within the purview of the WHO and its governing board, include convening key stakeholders, defining shared values, establishing standards and regulatory frameworks, setting priorities, mobilizing and aligning resources, and promoting research.Â

Global governance requires governments to forgo aspects of their sovereignty by delegating certain prerogatives and authority to an international agency such as the WHO. Rules such as the International Health Regulations, which direct countries’ response to international health risks, are a clear example of such delegation of authority.Â

But in recent years new organizations have begun to crowd the global health stage. Specific concerns—about, say, HIV/AIDS or maternal mortality—have brought more money into the global health system. But those additional funds are often channeled through the new institutions. Some work within the WHO, some outside it, and others do both. In contrast to the wide, integrated mandate of the WHO, the focus of most of these new organizations is vertical, concentrated on narrow goals, such as a particular disease or condition.Â

Protecting the health of citizens across the world requires long-term investment in the WHO and its broad mandate. But donors with focused, short-term objectives are driving much WHO activity, and new partnerships aimed at specific diseases and issues are gaining prominence. Yet there is growing awareness of the need to strengthen health systems—the people, organizations, and resources at the center of health care delivery—to complement disease-specific efforts. Moreover, the recent efforts of Latin American, Asian, and African nations to play a larger role in global institutions is affecting global health governance.Â

A growing crowd

The original purpose of the World Health Organization was, among other things, to ensure that governments would collaborate on health matters with a long-term perspective. To that end it was given more authority and resources than its predecessor organization under the League of Nations. Virtually every government in the world is a member of the one-country, one-vote World Health Assembly, which governs the WHO.Â

However, the WHO is no longer the only global health institution and today faces stiff competition in some areas from new actors, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund); GAVI, The Vaccine Alliance; and the Bill & Melinda Gates Foundation, the world’s largest private foundation whose core focus is global health.Â

Over the past half century, the World Bank too has become increasingly influential in global health care, with considerable resources, access to senior decision makers in ministries of finance, and in-house technical expertise. The bank has lent billions of dollars to governments to help them improve their health services.Â

As a result of this changing environment, the WHO faces both financing and governance difficulties. Although total resources have not diminished, they have not grown much in recent years either. The organization’s 2012–13...