Global Public health paper from recent International Studies Association conference

THE INTERNATIONAL POLITICAL ECONOMY OF GLOBAL HEALTH
GOVERNANCE
Dr Adrian Kay
Centre for Governance & Public Policy
Griffith University
Nathan Campus
Brisbane QLD 4111
AUSTRALIA
Email: a.kay@griffith.edu.au
Dr Owain Williams
Centre for Health and International Relations
Department of International Politics
Aberystwyth University
Aberystwyth SY23 3DA
Wales, UK
Email: odw@aber.ac.uk
PAPER PREPARED FOR ISA ANNUAL CONFERENCE, SAN FRANCISCO, CA
26-29 MARCH 2008
WORK IN PROGRESS. PLEASE CONSULT AUTHORS BEFORE QUOTING
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The International Political Economy of Global Health Governance
In this paper we seek to provide an overarching theoretical and conceptual framework that
articulates and explains tendencies in global health governance by means of an international
political economy approach ((IPE). For an IPE of global health governance, explanations of
contemporary crises in global health and the contested space of global health policies are
explicitly rooted in contemporary processes of neoliberalisation. We seek to offer a
corrective to what is a striking absence of IPE approaches to this fundamental area of
globality and human life; striking because of the almost routine linking of new patterns of
disease, resource scarcity in healthcare and key features of globalisation (e.g. Lee and Collin
2005; Huynen et al 2005; Collins 2003). Indeed, the starting point for almost any work on
global health governance is the recognition that globalisation affects health, including, for
example, how increased volumes of international trade, investment and finance are having
direct and indirect effects on human health, not least in the more rapid transmission of
infectious diseases resulting from trade flows and spatial compression. Similarly, and in
political terms, scholars and health policy communities are increasingly sensitive to the fact
that global health governance is changing due to the increasing influence of a range of
International Organisations and economic actors with little or no previous health remit.
We develop an understanding of the relationship between economic globalisation and health
in which health risk factors, health outcomes and the consequences of ill-health are
increasingly connected on a global scale through the structure of the world economy. This is
the global system of disease. As set out more fully in section one, we prefer this concept to
the more commonly used global health because it explicitly includes and intergrates the
causes of the causes of health and thus more accurately describes the pressing and novel
governance challenge faced. We define global health governance as any means or
mechanisms used by various public and private actors, acting at national and international
levels that seek to control, regulate or ameliorate this global system of disease. For us, global
health governance (GHG) is an umbrella concept encompassing a gamut of activities from
the treatment of individual patients through to the social regulation of the structural economic
drivers of ill health to the emergence of global health care businesses.
2
The defining mood of contemporary analyses of GHG is one of failure (e.g. Cooper et al
2007; Labonte et al 2004; Lee et al 200; Beaglehole and Yach 2003). Current diagnosis of
that failure is almost always expressed in terms of a lack of political will; an inchoate health
governing institutional architecture; organisational failure and resource deficiency. We
accept the premise of GHG failure but reject this diagnosis. Rather our IPE-guided
perspective gives centrality to economic processes and policies to help explain the
disjuncture between the scale of the challenge of the global system of disease and the limited
nature of the governance response. In our analysis, both the global system of disease and the
development of contemporary global health governance are increasingly driven and
structured by processes of liberalisation and commodification. These key processes of
economic globalisation have concrete institutional and policy manifestations with regard to
health, and interact with an ideational alliance of neoliberalism and the biomedical model’s
individualisation of health risk to intensify the scope and scale of the global system of
disease whilst simultaneously emasculating the capacity of health governance actors to
respond effectively. We argue that globalisation creates problems for health and as well as
acting to make the solutions harder to achieve.
This paper adumbrates the key tensions, faultlines and competing world views of health in
GHG, but presents the argument that the salient tendency in this contested policy space is
pressure for and momentum toward the liberalisation of health sectors globally. This broad
tendency co-evolves with and adapts to other priorities, goals and policies; sometimes in
tension or often in alliance. It is clear that important socio-political projects such as
welfarism, where individual access to health care or insurance is governed by social rights, or
public health, where poverty and inequality are the key structural determinants of health
status, remain powerful alongside liberalisation efforts. Likewise, concepts of sovereignty
over public health and national security also constitute elements of GHG and expose the
rhetorical nature of claims of a borderless free-market world. The evident power of these
alternative ideas of global health continues to motivate of a range of actors and institutions
involved in global health governance (including unions, academics, philanthropic
organisations, NGOs, and even many state governments), and are evident in policy and
governance responses over a range of health issues and crises.
This paper is the basis for an introductory chapter to an edited volume in which contributors
interrogate tendencies to liberalisation its main alternatives in the GHG system. Security
3
(especially national security) is now both a dominant discourse and policy driver over a range
of infectious diseases most notably HIV/AIDS as it relates to fragile states, armed services
personnel and regional instability. Both the SARS outbreak of 2002-2003 and recurrent
outbreaks of avian influenza such as H5N1 have pitied considerations of state sovereignty
over public health against efforts by WHO to execute its disease monitoring and surveillance
mandate. The rationales of sovereignty and national security were both employed by states
such as China and the US to stymie efforts to create a truly effective system of international
health regulations in 2005 with governance teeth. Notwithstanding this, the much maligned
and often politically neutered WHO remains the most important international institution
dedicated to disease monitoring, performing a key and arguably legitimate function as the
technocratic arbiter of global health governance. Likewise, state development aid
programmes in health such as US’s PEPFAR have been understood as vehicles of foreign
policy rather than as health investments of an altruistic and cosmopolitan nature. This paper
pays greatest attention to the most obvious and compelling countertendency to the
liberalisation and commodification in health: the persistence of the welfare state as a model
of health care provision and continued public and union support for such systems in the face
of liberalising pressures (e.g. Giaimo 2002; Moran 1999; also Hacker 2004; Holden 2005).
Notwithstanding these important alternative and counter tendencies, we view the balance as
shifting to a new IPE of global health which is increasingly market orientated. In essence, we
argue that health is being steadily commodified and redefined a tradeable good which can be
‘demanded’ by consumers and ‘produced’ by firms in a global market, and that this major
transformation represents both an ideational and material shift that is steadily eroding the
ideas and practices of health and healthcare that are couched in terms of public welfare,
public health, and health as a public good.
Why have liberalisation and commodification emerged as the dominant tendencies in the
health sector? Both processes have historical roots in the wider project of neoliberalism of
the last three decades. Whilst the term neoliberalism is often used to refer to a historical
period, marked by the metastasis of free-market capitalism and a monopoly of economisminspired
policy ideas among elite policy-makers creating new kind of common sense and
subjectivity, analysis of neo-liberalism in practice requires stress on the interaction between
the phenomenon-in-general and its particular instantiations (Harvey 2005; Hay 2000; Held et
al 1999). Neoliberalism has always interacted with other political projects to produce
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multitudinous and hybrid forms. In many places, health has been a laggard sector in the
process of neo-liberalisation, outside of the policy mainstream in the 1980s and 1990s and, in
particular, spared from some of the exigencies of competitiveness. The idea of health as a
commodity that is subject to market principles has had an uneven trajectory and is effects are
not territorially uniform. It is clear that neoliberalism has not affected all health sectors and
all countries at a single moment, and only some countries (mainly LDC and developing
countries) and some health sectors felt the effects of the early processes of liberalisation and
commodification from the mid 1970s onwards. It is also notable that these changes largely
occurred as a result of measures revolving around debt restructuring instigated by the IMF,
and to a lesser extent the World Bank. In retrospect, these tendencies were the critical
precursors of a more globalised shift toward neoliberalised health which has become
entrenched as the dominant tendency via a combination of global health policy emerging
from a range of IOs alongside the rapid growth in medical technology, transnational clinical
services, global health management and insurance businesses and nascent global markets for
health care. It is also reflected in the changing discourses of health emergent from networks
of global policy makers and in global health policies.
We see global health policies as the crucible of the contestation between the neoliberalisation
of health and its alternatives. Global health policies consist of specific policy
prescriptions for national health systems articulated by IOs as well as a tier of supranational
health policies involving the global governance of health including global trade in health
services, international health regulations and collaborative regulatory measures such as the
Framework Convention on Tobacco Control. Whilst we recognise that global health policies
include mechanisms and interventions channelled towards international public health goals
such as improved coordination and surveillance, it is the entry of new and powerful actors
that is a key facet of the ascendancy of neo-liberalism in global health policy. Global health
policies are increasingly the province of a number of key global economic supranational
institutions, most importantly the World Bank, IMF, and WTO (the Bretton Woods
organisations), whose policy instruments and world views of health are cross-pollinating and
coalescing to promote health sector liberalisation. Global health policies are also actively
framing national health policy-makers’ strategies, and also capping state investments and
public funding for national health systems (NHS). The Bretton Woods institutions are acting
together to generate a policy template under which what is possible in terms of GHG and
NHS is increasingly narrowed and circumscribed.
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There are several reasons why the processes of liberalisation and commodification of health
are ascendant. First and foremost, neoliberalism is both pervasive and powerful as policy
template in global governance in general, and global health policy has been developed by
analogy with and extension from other sectors. Neoliberalism also encompasses a range of
legitimatising ideologies that promote and justify commodification and liberalisation,
including appeals to the imperatives of competitiveness, efficiency and consumerism and
choice that normalise health as tradeable commodity. In short as an ideology, neoliberalism
has a powerful and simple appeal which opposing coalitions have had difficulty with. In
material terms, health remains the largest service sector worldwide that remains largely unprivatised
and it is clear from almost three decades in which neoliberal policies have pursued
exactly this goal across a range of industrial and service sectors that health would be difficult
to maintain as exceptional. Let us not forget that health services are already the largest
industry in employment terms in the US (Bureau of Labor Statistics 2007) and a world of
general economic growth demand for health is price inelastic but income elastic. This is truly
an important and lucrative frontier for a range of organisations and actors at the heart of the
neo-liberal project.
Finally, neoliberalism in national and global health policies is not simply defined by a crude,
binary opposition of state and markets. Rather its logic often colonises certain health sectors
and synthesises with welfarist models of national health as seen in quasi-markets, PFI,
budget allocation formulae and a plethora of often seemingly incidental areas of health care
and policy. It also resonates with debates about the causes of ill-health, in particular with the
biomedical model’s stress on health risk being located at the individual rather than at the
level of economic conditions, the state or public health infrastructure.
The paper proceeds in three sections. The first critiques the existing GHG literature and
reveals how a reliance on a public health-inspired notion of global health leads to analyses of
GHG as something which sits apart from globalisation. We argue that such an approach
misses the core political and ideational struggles between neoliberalism and its alternatives in
health that constitute contemporary GHG. Section two describes how global health policies
act as a crucible for these contests and the role certain international organisations play in the
ascendancy of liberalisation and commodification in health care. In the final part, we return
6
to the macro-scale of IPE analysis to delineate the on-going fault lines between neoliberalism
and its alternatives in the development of GHG.
IPE AND THE ANALYSIS OF GLOBAL HEALTH GOVERNANCE
The concept of global health
In the literature that has emerged over the last decade or so, the concept of global
health is used as the evaluative standard or benchmark against which GHG in various
respects fails or disappoints. The current GHG literature constructs global health as
an objective and measurable category of health status connected to risk factors that
are variously cross-border, transnational and/or global in nature. These risk factors are
grouped under the heading, globalisation and in such terms, globalisation causes
global health. Importantly, this conception is conjoined with the assumption that GHG
is something which sits outside globalisation processes, with the purpose of regulating
or ameliorating the adverse consequences of globalisation for the distribution of
health risk factors. Reflecting the positivism typical of public health scholarship,
globalisation is conceived as a natural process whose locus is beyond the space of
GHG, which is seen as part of the political sphere where responses to globalisation
are developed (e.g. Huynen 2005).
In contrast, we develop two alternative IPE insights. First, GHG is a contested space
where the political project of neoliberalism confronts, acts upon and is acted upon by
other political projects such as security, public health, and the welfare state. For us,
GHG is mutually implicated with processes of globalisation in a global system of
disease. Secondly, it is only by apprehending the latter that we can make progress
understanding the causes of the causes of global health. Whilst the current literature is
making great strides towards connecting changes in the contemporary distribution and
intensity of health risks with measures of health outcomes (e.g. Lee et al 2001;
Cooper et al 2007; Taylor 2004); what remains markedly underspecified is how these
socio-economic variables qua health risks relate to the wider international political
economy and the neoliberal project.
The notion of global health is problematic for public health scholarship both as a dimension
to be measured and its connection to social and economic structures. In terms of the former,
statistics which show rising global life expectancy correlated with sustained growth in the
7
world economy over the last several decades sometimes obscure as much as they reveal.
Even accepting life expectancy as a useful, if simple, proxy for global health, such macro
scale trends do not show that new infectious diseases continue to emerge in populations
throughout the world; or that more than 30 agents have been found during the past two
decades and infectious diseases may also re-emerge after relatively long periods of being
dormant or appear in new localities. Nor does such macroscale analysis tell us that in several
states in sub-Saharan Africa with a high prevalence of HIV/AIDS life expectancy has
actually fallen in the last decade.
The international public health tradition has, for over 100 years, investigated the link
between disease and economic development (Lee and Collin 2005; Taylor 2004). The
problem is that this tradition sees capitalist development as happening in stages and primarily
at the national level. Consider Abdel Omran’s famous theory of epidemiologic transition
(Omran 1971). He argued that economic development leads to a fall in infectious diseases
over three distinct historical phases, involving a commensurate increase in life expectancy
and an ageing of the population. As development increases, mortality is more greatly affected
by the emergence of degenerative, man-made non communicable diseases. However, under
globalisation we observe the persistence and sometimes re-emergence of highly infectious
diseases as significant health risks in high income countries. Also in contradiction of the
stages of development thesis, we are currently witnessing the prevalence of noncommunicable
diseases in middle and low income countries well-ahead of their stage of
development.
Oman’s causal economic explanation for improvements lacks sensitivity to essential
variations and differences in health outcomes across economic space under globalisation and
the persistence of old and new diseases. It also suffers from an absolutist and teleological
sense of progression which sees the eradication of diseases of poverty (infectious diseases)
and their replacement by diseases of prosperity. Instead, we require accounts for variations
and differences across the global system of disease that are related to key characteristics of
globalisation, nor can his model explain continued structural inequalities in health outcomes,
despite a prolonged period of overall global economic growth. Our problematique is the scale
and differences within and across the global system of diseases and their relationship with a
single and all encompassing economic system that is also characterised by difference and
inequality.
8
Any IPE approach to global health problems must therefore account for a central essential
characteristic of globalisation: the simultaneous interconnectedness of countries at very
different levels of economic development, within a single global economic space. Hardt and
Negri (2000) develop the notion of ‘simultaneity’ to capture this aspect of globalisation. The
concept helps us understand contemporary trends in global health where we observe secular
increases in world life expectancy, significant growth in degenerative, man-made noncommunicable
diseases in middle and some low income countries alongside the emergence
and re-emergence of acute infectious diseases. In our IPE analysis, there is in fact one global
capitalist system that has internal variations, rather than multiple systems with their own
relationship between development and disease. Health is a good example of the oft-repeated
claim that ‘there is no more outside.’ There is now a global system of diseases in which
spatial differences in the global distribution of the burden of disease are of global import. The
global system of diseases is connected by a network of capital, labour and product flows;
different diseases have a similar medical geography as they cluster around common causes
e.g. poverty or trade flows: and these structural socio-economic causes are global in reach,
they function as elements in an international political economy of health.
Our main critique of the current GHG literature is that it does not advance our understanding
of globalisation in health beyond its role as catch-all causal variable, where it stands as
shorthand for a disparate and complex array of health risks. The links between globalisation
as a broad political project and the risk factors are underdeveloped. Our IPE insists on
interrogating globalisation as a cause of causes of global health; health, rather than something
affected as an unintended and collateral consequence of globalisation, is actually central to
globalisation’s on-going momentum.
The study of GHG as a phenomenon
Dodgson et al (2002) present a comprehensive literature review of the study of global health
governance. In common with this literature, they adopt a public health perspective (their
research was funded by the WHO) to advance their starting and familiar premise that the
relative capacity of national governments to protect and promote the health of their
populations has been eroded under globalisation pressures. In particular, they aver that in a
liberalised system of world trade in goods, services and capital diseases can cross borders
easily and further, the prevalence of such diseases is compounded by global economic
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development exacerbating some of the underlying socio-economic causes of infectious
diseases such as rapid urbanisation, poor housing and sanitary conditions, environmental
degradation.
Moreover, they argue that globalisation reveals ‘even more poignantly’ than nationally
organised capitalism the need for health policy to address the basic determinants of health
rather than exclusively focus on the symptoms of ill health. In framing the global health
problem in these terms, many GHG scholars are reviving debates that were seemingly lost at
the national level in advanced industrialised countries during the 20C as health insurance
schemes and hospitals became the political, technological and financial foci of health policy.
For much of the existing analysis of GHG, it is the shift in territorial scale of health that gives
impetus to the long standing and well developed public health critique of biomedical and
welfare state approaches to health. The public health insight into the deeper structural
determinants of health has always found an institutional voice in the WHO, whose
constitution expresses health as being ‘a state of complete physical, mental and social well
being and not merely the absence of disease or infirmity’ and most GHG scholars looks to
the WHO for responses to global health problems.
It is also through the public health lens that we get global health as a concept; as Dodgson et
al (2002, p.13) put it: ‘The distinction between global health and international health…is that
the former entails a broadening of our understanding of, and policy responses to, the basic
determinants of health to include forces that transcend the territorial boundaries of the state.’
However, what this distinction hints at is that the GHG literature is characterised by a
naturalisation of globalisation; this is the providential force beyond existing national and
international governance structures that demands a public-health inspired response.
However, the challenge of global health cannot be viewed simply as a discrete and in situ
area of public health governance which could solve the problems of global health if only the
resources or political will were present. Neither is it simply an issue of territorial scale, in
which the national and international public health traditions acquire contemporary policy
relevance under globalisation. Whilst GHG encompasses biomedical and international
public health goals and policies for sure, it crucially also incorporates forms of governance of
global health which are orientated to global health markets, control of state spending on
NHS, trade in health services, and policies or templates for best practice in a range of areas
10
(such as payment systems) in health service provision. These are areas which are pivotal in
GHG and in the global system of disease. Indeed it is here that we see the contests between
neo-liberalisation and public health, welfarist and biomedical views. For example, markets
for food retailing and particularly processed food have been opened by virtue of the WTO
and the reorientation of many previously closed economies to the global economy (see
China, India). The FAO has failed to regulate both fat and sugar content of foods due to a
combination of corporate lobbying and pressure from key states with large food processing
sectors (see EU and US).
GHG is a notion which is difficult to use analytically or critically because it is almost
impossible to identify factors and features of the global economic system which are not part
of global health governance. Dodgson et al (2002, p.18) respond with the plea that: ‘defining
the scope of GHG…remains a balance between recognising the interconnectedness of health
with a varied range of globalising forces, and the need to define clear boundaries of
knowledge and action’. Their answer is an IR-inspired definition (in particular Held et al
1999) of global governance as the formal institutions and organisations through the which
rules that govern the world order are made and sustained as well as the organisations and
pressure groups such as TNCs, NGOs, and transnational social movements who have an
impact on global rules and authority systems. This understanding of governance stresses not
only the impact of these agents on the formulation and design of the rules, but also their
impact on the implementation, delivery, and evaluation of policy; for example through
strategic alliances and various types of collaborative partnerships.
In our terms, this is a useful starting point for refining the notion of global health governance
as it distinguishes a clear approach within the broad family of possible IPE approaches to
governance. In particular, despite the stress on the range of actors involved in the broader
governance space, it still centred on formal political authority (see Dodgson 2002, fig
1).This, of course, is a potential area of criticism from alternative IPE approaches; those
which draw on the intellectual legacies of Gramsci, in terms of hegemony, and Foucault, in
terms of governmentality, to decenter formal political authority from social analysis. For
example, Foucault defines governmentality as the ‘art of government’ in a wide sense, with
an idea of ‘government’ that is not limited to state politics alone. Instead, governing health
includes a wide range of control techniques that apply to a wide variety of objects, from one's
control of the self to the ‘biopolitical’ control of populations. The notion of governmentality
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refers to societies where power is de-centered and its members play an active role in their
own self-government (the liberal part of neo-liberalism) and any social regulation must come
from 'inside'. Whilst there is great potential for an insightful and important literature in terms
of an IPE of global health associated with neoliberal governmentality, we accept the starting
point provided for us in Dodgson et al (2002) for conceptualising global health governance as
a system which is centred on but not dominated by intergovernmental organisations (IO).
However, this still leaves us with the previous problem that global health governance is
conceptually broad to the point of obscuring the potential for a distinct unit of critical and
analytical analysis of different governing modes. It also fails to grasp how the range of actors
associated with governance reflects interests, and how competing interests mean that health
governance is an essential contested space. Second, the failure to describe power in that
system also means that the understanding of global health outcomes and policies is divorced
from the dominant (or hegemonic) processes, discourses actors and interests apparent in the
global political economy.
In fact we can take forward these facets of health governance by focusing on a level which
forms the tacit underbelly, or does the real work in Dodgson et al (2002, p.22). They mention
the ‘nitty gritty’ of global health governance. We understand and explain this nitty gritty as
global health policy. Global health policies have two dimensions that are comnected and
simultaneous; they involve a tier of specific policy prescriptions for national health systems,
as well as a further tier of supranational health policies that incorporate the global
governance of health, including global trade in health services, international health
regulations, and a globalised institutional economic rationale for health policy. The system of
global health governance is therefore viewed as the locus and generator of global health
policy which is increasingly also having significant national effects. Global health
governance is in fact constituted and delineated by such policies. Global health policies are
therefore exactly the space where we can observe in a detailed empirical manner an
international political economy of global health governance.
GLOBAL HEALTH POLICY-MAKING: THE CRUCIBLE OF GHG
The activities of international organisations are shifting the landscape of contemporary health
governance in advanced industrial as well as in middle and low income countries. Global
health policy consists of prescriptions for national health systems as well as policies
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concerning global trade in health-related products and services, global regulation of health
care systems, and the promulgation of global rights to health. The emergence of global health
policy is eroding the autonomy of national health care systems, challenging the implicit
notion in much work on the comparative political economy of health policy that sees national
health systems as ‘closed’ and capable of being subjected to national control (Hacker 2004;
Giaimo 2002; Moran 1999). Instead, global health policy is a crucial factor in rising health
care costs, rapid but uneven advances in health care technology, and influential ideas about
public-private mixes in financing and delivery all regularly identified as key drivers of
national health care reforms.
We can see the neo-liberalising process in the health sector clearly in global health policymaking.
The World Bank (WB), World Trade Organisation (WTO) and International
Monetary Fund (IMF) (collectively the Bretton Woods (BW) institutions) are creating a new
global health policy geared toward the liberalisation of national health care systems and the
exigencies of a rapidly expanding global marketplace for healthcare related services.
Crucially, the BW institutions are contesting the long-standing role of the WHO, which with
its public health focus sits at the centre of GHG for many scholars. There is only a limited
(but influential) literature interrogating this important shift; highlights include Woodward et
al (2001), Schrecker and Labonte (2006), Labonte and Schrecker (2004), Sen (2003), Buse
and Walt (2000), Holden (2005), and Deacon (2007). However, it is through this nascent
literature that the IPE approach to the analysis of GHG will become fully developed as we
gain more cases of the struggle between neoliberalism and alternative health projects.
Whilst each BW institution has generated a unique set of policies and institutional
mechanisms for reshaping global health, we can see a policy convergence with regard to: (i)
the rolling back of state authority over national health services (NHS) (largely but not
exclusively by means of limits on public financing); and (ii) the drive toward health sector
liberalisation (largely via the introduction of competition). Importantly, these policy are
crucial components of the liberalisation and commodification of health care, manifest in the
emergence of a global health care industry, transnational patterns of investment and
international markets in many health care services, that is actively changing the policy
context for national systems of health care financing and service provision. Global health
policy is both affected by and acts upon the process liberalisation of health care provision.
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In addition to pressures on the twentieth century welfare-inspired health care state, the
international public health policy frame with its clear focus on the links between poverty and
ill-health is also being contested by the emergence of a global health industry and its interest
in liberalised trade in health care (Leon and Walt 2000), by demands to restrict public
expenditure in some middle- and low-income countries in the interests of ‘good’ governance,
as well as economic analysis that frames population health improvements in terms of
increased worker productivity and an elevated rate of FDI inflows (Alsan, Bloom and
Canning 2006).
The study of global governance as a general phenomemon tends to focus on often
unspecified demand by states for international institutions as solutions to transnational policy
problems. However, in global health policy there is now the key supply side factor of
existing IOs and their autonomous agenda setting activities. This soft power alongside
concrete legal and disciplinary powers backing global health policies are key mechanisms of
neoliberalisation. For many scholars of IOs, compliance is no longer just a matter of carrots
and sticks, or the instrumental use of organisations by key states. Instead IOs ‘socialize’
states and other actors into compliance, including through benchmarking and other ‘groundup’
managerial methods touted by experimentalists in democratic international governance.
On matters both mundane and consequential – from the classification of fat-free food
products to whether tourists will be warned away from their shores because of SARs, to the
public procurement of hospital services – those who exercise national authority face severe
policy constraints not merely because of globalization, but also because of globalisation’s
agents – including the rules and processes promulgated by IOs and other agents of global
administrative law. The domestic politics of health policy is generally seen ‘low’ politics of
distribution and allocation; however it is important to note that IO-generated rules do not stay
away from subjects that might be characterised as of ‘high politics.’ The UN proclaims what
rights governments need to respect for their citizens. Despite article 2(7) of the UN Charter,
there is little left of an untouchable, sacred ‘domestic jurisdiction.’
The development of new global health policy is a key catalyst in an increasingly liberalised
IPE of health care. While political economy perspectives dominate approaches to welfare
state analysis at the national level (Moran 2000), the GHG literatyure lacks a sustained
engagement with the critical issues raised by the IPE approach to the analysis of GHG
outlined here. Work on global health policy has so far been confined to looking at the
14
impacts of policy from one of the BW institutions in a national health context (e.g. Pollock
and Price 2003). This gap in our understanding of global health policy is crucial: we miss the
sources of the strong market orientated liberalising thrust (linked with economic
globalisation), which is both incrementally changing the landscape of global health
governance and substantially re-orientating national systems of public health and national
health services.
For ease of exposition of the links between global and national health policy, we can break
down the notion of ‘global health policy’ into three areas. These areas are where we can
mostly clearly see a contested global health policy arena between the established WHO and
its public health remit, medical expertise and institutional tradition and the BW institutions as
agents of economic globalisation taking an interest in health. The three policy areas are:
1. The World Bank Country Health Portfolios (WBCHPs) are packages of health care
financing and health policy reforms for developing countries. The WB is the single largest
source of health care funding for developing countries, offering in excess of US$16 billion in
loans between 1970 and 2000. It is able to package policy ideas and money together in a
sector and country portfolio ‘which would otherwise be unavailable to the Bank’s low- and
middle-income client countries’ (Gilbert et al 2000: 51). For some, this represents the
assertion of a liberalised IPE of health care where developing countries become markets for
primary and secondary health care providers from the prosperous North (Sen 2003, Buse and
Walt 2000).
2. Poverty Reduction Strategy Papers (PRSPs) are documents required by the IMF and WB
before a country can be considered for debt relief within the Heavily Indebted Poor Country
(HIPC) program. They are prepared by the member countries through a participatory process
involving domestic stakeholders as well as WB and IMF officials. They are seen by critics as
imposing a liberalised IPE in areas such as health; for example by limiting public expenditure
on health care (Gould 2005; Labonte and Schrecker 2004; Schrecker and Labonte 2006).
1999 saw the joint IMF and World Bank launch of the PRSP mechanism as the successor to
the popularly maligned Structural Adjustment Programmes. Despite their evident and well
documented importance both to debt and loan conditions, and thereby to state spending on
services and liberalisation measures, PRSPs have received little or no systematic examination
with regard to their impact on NHS and health policies (Gould 2005).
15
3. The General Agreement on Trade in Services (GATS) is a treaty of the WTO that entered
into force in January 1995 as a result of the Uruguay Round negotiations. The treaty was
created to extend the multilateral trading system for manufactured goods under the previous
General Agreement on Tariffs and Trade (GATT) to all services including publicly financed
and provided health care services i.e. once a country has agreed to sign up to GATS for a
specific service it must treat equally firms from all nations in terms of market access.
The global-national health policy nexus
We have described global health policy-making as being the crucible of GHG; it is here that
we observe the role of the BW institutions in creating a new global health policy that is both
responding to as well as catalysing processes of liberalisation and commodification in health
care. Whilst the GHG literature has generally treated global health governance and global
health as separate from national health policy; this heuristic separation is no longer tenable.
The new global health policy is a key institutional mechanism linking national health policy
reforms in both the OECD and, perhaps more directly, in many developing countries to the
broader processes of liberalisation and commodification.
There is no single, universal type of NHS that might provide us with a critical case to study
the global-national policy nexus in the context of liberalisation; at least 30 years of scholarly
effort spent on creating a typology of NHS for the purposes of comparison is testimony to the
essential variations and differences involved. Therefore the global-national policy interaction
is inevitably complex as well as temporally and spatially contingent. Nevertheless, in terms
of the macro-scale of IPE, we can group common demand and supply side pressures on NHS
which provide the context of global health policy making, and in turn delineate the
connections from global health policy to national health policy making.
NHS are all experiencing problems and strains in the manner in which health is supplied,
particularly in terms of the introduction of competition, burgeoning costs of (now
internationally competitive) health professional salaries and medicines, the introduction or
availability of new medical technologies, and in the manner in which healthcare is payed for.
In both the developed and developing worlds NHSs are therefore experiencing similar strains
which are the result of political-economic choices in an era of globalisation: rising costs of
health care; questions of access to health care; the requirements of rationing; with many
16
financing systems under severe pressure. Certainly different states are relatively more
equipped to deal with these problems of supply than others, at least in the simple terms of the
economic resources available to them. Indeed, many developing countries have the additional
problem of low existing levels basic public health infrastructure and sanitation. These
structural problems create additional disease burdens, and compete with NHS for the limited
resources available. However, in OECD countries public expenditure on health in increasing
in excess of the rate of growth of the economy even as competition and privatisation is being
introduced to the system of supply, and begs fundamental questions about the role of the state
in the new IPE of health. The state is certainly not disappearing as an actor in the supply of
health care, but its role is altering incrementally nonetheless. In effect, many states (and the
public) are underwriting and directly subsidising an increasingly liberalised and privately
provided NHS, a transition which is often legitimised by the fact that privatisation ostensibly
solves many of the problems of supplying health identified above.
NHS are also experiencing pressures resulting from both global and local systems of demand
for health. At the level of states, demand problems are witnessed in terms of user
expectations and the income elastic demand for healthcare in an era of a booming world
economy. In the latter case, wealth simply produces new sets of diseases, or even the
perception that new types of health products and treatments are vital and necessary. Indeed,
the health economists’ foundational assumption of an unlimited demand for health care
seems to be robust across time and space. The system of demand for health is now also
globalised, particularly when one considers specific health markets such as dentistry and
cosmetic surgery, and, more obviously and widely, in the area of pharmaceuticals for which
there are often no local alternatives. These globalised markets for healthcare services and
products are thereby reorientating certain sectors of NHS toward a globalising system of
demand for health. The globalising structure of demand for health also features in the
mobility of health sector professionals, where problems associated with the supply of
necessary human resources (arising from training costs etc) interact with demand (in the form
of international differences in wages) to create crises in the many NHS that are being
effectively hollowed out of indigenous personnel. The global demand for health also sits
uncomfortably with the fact that the poor are less able to pay for, and often need more, a
supply of basic healthcare and state funded NHS. This in turn tiers outcomes in the global
system of disease, and means that changes in NHS are now more often than not responding
to a demand structure that is economically driven rather than by basic health needs.
17
Importantly, health care services have become a major export revenue source for many
OECD countries. The consequences of health care services, medical technology and medical
devices becoming accepted as tradable commodities, and as part of the market rather than as
public goods, are that generalised pressures for increasingly liberalised world trade impact
directly on the national organisation of health care delivery. There is an inchoate literature
developing the themes of health sector liberalisation and the degree of national sovereignty
that can be retained over NHS (Ollila and Koivusalo 2002; Sen 2003; Pollock and Price
2003; Collins 2003).
The demand and supply side factors noted above provide the context for the transformation
of global health governance itself. Global health policies emergent from this system are
exacerbating the problems associated with the system of supply, and in many instances in
developing countries, actually limiting the policy responses to health crises and directly
determining the levels of funding that can be committed to NHS. Global health policies are
also introducing competition to NHS, often in specific sectors and in an incremental fashion,
and limiting the ability of states to regulate in areas of public health such as product and food
standards. Likewise, global health policies are interacting with global demand for health,
both in terms of liberalising the global health market and the selective movement of skilled
health personnel, and across specific sectors of individual country NHS. Moreover, the
WTO’s TRIPs has insured that the movement of key technologies and health products across
global markets iare protected in terms of pricing, and that monopolies over certain areas
fundamental to life can be retained, notwithstanding differentiation in terms of need and
ability to pay or the scale of market reach. More over the transfer of medical knowledge and
research lines can be stymied or actively blocked. In short, global health governance and
policies are, again, viewed as creating problems, and as central to the crises in the global
system of disease and NHS.
We reject geometric metaphor of a vertical layers of governance, in which economic activity
with profound health impacts takes place unregulated ‘above’ the nation state. In GHG there
are no clean lines of vertical encompassing authority; instead GHG is blurred and porous and
the edited volume contained accounts of actions by NGOs with international health care
companies, the agenda of CSR in health care, IOs activities and so on. This governance is
neither state nor non state; not global or local but both; and not really below the state or
18
above it. Instead this is a recognition of the transational nature of GHG. We have carefully
set out global health policy as at the crucible of this complex, messy GHG.
NEOLIBERALISM AND ITS ALTERNATIVES: FAULTLINES AND HYBRIDITY
IN THE DEVELOPMENT OF GHG
Throughout the paper we have discerned neoliberalisation as the key macro-trend in the IPE
of GHG. This leaves scholars with two key questions: in its own terms, does it work? Are
there limits to the market mode of governance in the distribution of health care provision?
Preliminary answers to these questions are ‘sometimes’ and ‘yes’. In terms of health care
provision in OECD countries as well as many middle income countries, liberalisation cannot
be interpreted as a simple process of market allocation substituting for public insurance as the
state rolls back. This basic dualism in neoliberalism has already been substantially critiqued
in discussion of the emergence of the regulatory state and contemporary IPE insists strongly
on the general point that markets require creating and then policing/enforcing and this
requires state enforcement. However, this phenomenon-in-general needs finessing for
application to the health care sectors of advanced industrial countries because marketisation
in health care typically involves quasi-monopolies or oligopolies in supply, particularly of
the very expensive, new medical technologies; and the government heavily involved as
purchaser, in single payer or multi-payer health care systems. The geography of neoliberalism
in health is uneven; in particular we posit a soft North version v a hard South
version. In the North, the political elites of medical profession and patient groups affect the
politics of business-government relations at the heart of marketisation in health care. The
politics here are local, contextual and often difficult to read.
The pressure for the liberalisation of health care has not in any sense mean reduction in
public expenditure in health. Far from it: instead we have business-government relations in
health care production, this reveals the inherently political and corporate driven-aspects of
neo-liberalism. This is not blind faith in the market: we see hybrid forms of health care
governance in which the role of the public sector is adjusted as neo-liberalism interacts with
extant health care states whose initial construction was inspired by welfarist ideals or public
health movements.
19
At the IPE scale, we observe a change in the ideational shape of health care states rather than
their withering away. The process of commodification is central to this reshaping: economic
value is assigned to something not previously considered in economic terms. The ideational
creation of the commodity of health allows us to value things even if there is no market i.e. to
commodify is the ideational precursor to liberalisation. Thus in health policy terms, resources
may be allocated and rationed within state sector without recourse to a market or market-type
mechanisms but this is still commodification. Thus, the rise of financial cost per QALY
gained as a policy-making standard against which to judge the financing of medical
interventions is a perfect example of the changing ideational shape of health care states under
neoliberalism. Commodification allows health to be differentially valued and therefore
permits policy-makers to make trade-off in a policy analysis sense. For us, this is the key
ideational dynamic at work in the IPE of health: once we have the principle that health is
valued differently according to productive worth, the inevitable corollary is a widely unequal
distribution of global health care resources. Under such neoliberalising logic, health care
resources should be employed and developed for diseases of the more productive global
North.
A further corollary of commodification is the construction of the patient and citizen as health
care consumer, which underpins attitudinal shifts in the supply of health care in many
countries. Consumerism drives demands for new medical technology and services, as well as
quick access to health care services which include amenities and comforts up to the standards
contemporary society. Concurrently, the role of globalised health care businesses in national
health care states is often hotly contested area, which in many specific instances reveals
strong and enduring resistance to the general liberalising macro-trend that we have identified.
Although there have been primitive capital accumulation strategies by MNCs demanding
privatisation of health care services in middle and low income countries, the WTO has been
less successful in liberalising health care markets of advanced industrial countries relative to
other sectors; the field lacks detailed research on why this is the case, but one plausible
hypothesis is the effect sovereign risk; the fact that health care states may appropriate future
profits reduces attractiveness or feasibility of transnational investment. This political risk
arises for businesses in the context of the on-going power of the medical professions and
robust domestic politics that views health care as something outside from ‘normal’ market
transactions. In such cases, political movements can often elide public expenditure on health
20
and health company profits in the public mind and impose pressure for governments to take
action in cutting prices or renegotiating contracts.
The existing literatures from public health and IR tend to focus on demands for more GHG;
in the form of social regulation of transnational economic activity for the purpose of
improving public health. In assessing this point, it is important to recognise that it is the state
power of the global North (and clubs of states in IOs) allied with MNCs that are governing
globalisation: why should they change? One view is that just like nationally organised
capitalism, the demand for healthy labour will mean that nonmarket institutions will be
developed by states, IOs or NGOs to ameliorate the adverse health impacts of globalisation;
another might be that the national security implications of pandemics will drive different
shapes of GHG.
But any (re)assertion of state control or the autonomy of public health security systems runs
counter to marketization pressures that say that international health care markets should be
better regulated in order to increase trade in health care products and services. This is a
crucial fault line in the IPE of health, tensions along which have released dynamics of crises
at different points. We raise an open, profound and difficult question: an IPE of GHG helps
us apprehend liberalising thrusts and alternative tendencies and their on-going interaction;
but it does not give us a window to predict the outcome of tensions along faultlines. The
neoliberalisation of the health sector remains work in progress.
CONCLUSION
The neoliberalisation of the health sector is the central dynamic in contemporary GHG. We
have defined this in terms of the twin processes of liberalisation and commodification. The
current literature on GHG constructs a concept of global health that implicitly naturalises the
neoliberalisation process and pushes analysts to seek technocratic and political solutions to
adverse trends in population health across the globe. In contrast, in our IPE approach we
place the global system of disease and neoliberalisation of the health care sector at the heart
of GHG, viewing them as mutually reinforcing both the scale of the governance challenge
and attenuated nature of the response.
21
The neoliberalisation project has not swept all before it in the health sector. Indeed, the
persistence of other socio-political projects with longer traditions such as public health,
welfarism and state sovereignty have created faultlines that run through GHG. We have
begun to identify and describe in this paper; they give us dimensions and co-ordinates to try
and make some assessment of GHG. Indeed, it is our ability to set out the faultlines and
contradictions that will help provide the explanation for the liberalising tendency and its
countertendency/resistance that we observe. We have this complex and messy picture of old
and new governance forms in health care as the neo-liberalising logic interacts in local,
institutional specific, path dependent contexts in the health sector. But we are still confident
that the key macro-trend to articulate and theorise is that of neoliberalisation.
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