Conceptual Models for Global Health Governance

Abstract

Globalization has led to an appreciation of a global politics beyond the control of nation-states and the traditional system of international relations. Global politics is characterized by a pluralization of governance mediated by a constant effort to establish shared norms of global public goods and bads to constrain the exercise of power or, expressed in another way, to attain a more equitable access to power resources. Traditional state institutions of national and international governance have become more diversified as a reaction to their inherent limitations and the increasing power of new forms of governance built by private actors. Though the state remains a powerful, often dominant, actor in governance, it competes with and sometimes is itself governed by a diverse set of non-state actors, including corporations, foundations, religious groups, social advocacy organizations and ‘dark networks’, such as al-Qaeda or narcotics cartels. States and traditional institutions of international governance are increasingly seen as complex assemblages in and of themselves, comprised of more or less well-networked nodes operating somewhere on the spectrum between cooperation and competition. States have actively embraced this pluralization, seeking to increase or protect their power by vigorous use of governance devices such as privatization and partnerships. These developments are clearly visible in the health sector, which has witnessed an institutional change from a structure that consisted primarily of independent national health systems and some international agencies devoted to controlling the cross-border effects of ill-health towards a system of global health governance (GHG). Contemporary GHG is characterized by a polycentric, distributed structure and a substantive concern with issues that affect populations worldwide directly (for example, the global spread of infectious diseases or antibiotic resistance) or indirectly (for example, political instability and global insecurity arising from extreme socio-economic inequality). Global health governance now requires management not merely of specific transborder epidemics, like SARS or avian influenza, but of the host of issues in health that arise at the intersection of a globalized economy and lives lived in particular localities. Dealing with ‘global’ health challenges increasingly requires attention not only to ‘horizontal’ coordination of global politics, but also to more effective vertical integration of global-level governance with governance at the national and local levels. Both practitioners and students of health policy require new conceptual tools to understand and influence GHG. During recent years, two models have been developed that, from different perspectives, address these characteristics of multiplicity of actors, flexibility of institutional arrangements and fluidity of relationships. The ‘nodal governance’ framework builds on network theories to describe distributed governance and the ways in which institutions project power across networks to govern the systems they inhabit. The concept of ‘interface’, refers to ‘a specific space, where two different social systems or fields of social order interact (here: global/national systems; institutional systems related to modes of regulation), which are characterized by specific institutions and specific backgrounds. Independently, the concepts of nodal governance and interfaces can help us to understand what constitutes the binding forces and the types of power mobilized among the multitude of actors in global health governance. Taken together, they illuminate key challenges to good GHG: improving democracy, efficacy and coordination. This chapter uses these two frameworks to understand the emerging dynamics of GHG and then illustrate their usefulness through a discussion of the global governance of HIV/AIDS.