Global Health Governance and the Challenge of Holding Power to Account

Abstract

While there is much to celebrate about the many institutions, actors, and initiatives that form the global health system, there are also problems with how the system is governed. Some of these relate to inequities and unmanaged conflicts of interest that are rooted in power imbalances and which leave certain actors with excessive and undue influence. By contrast, poorer countries and communities with the biggest stake in the global health system working equitably, effectively, and efficiently have little power by which to hold the system accountable. This intersecting issue of power, accountability, and global health governance is the focus of this Working Paper. The paper is broken into three sections. The first section discusses the meaning of global health governance and the role of accountability within governance structures and systems in general. It describes the current system of global health governance as being nested within a wider system of global political and economic governance, shaped by international relations, globalisation, and the dominance of neoliberal ideas and policies in recent decades. This has seen, among other things, shifts of power from state-based actors and institutions to more distant and less accountable global actors, as well as from democratic and public institutions to private actors and market forces. In doing so, the Working Paper draws particular attention to the power and accountability of powerful private actors and whether they are sufficiently held accountable. The second section unpacks the concept of accountability and describes five elements that are required for accountability to function (standards; data and information; answerability; sanctions; and remedy). It highlights the importance of independence in accountability and the challenges of holding powerful actors accountable. It then presents a three-layered framework to map accountability as a component of good global health governance. The final section concludes by calling for more discussion about power and accountability in global health, while also emphasising the need for rigorous research in identifying and helping correct harmful and unhealthy accountability deficits.