The Rise of Global Health: How Did Health Become a Matter of Global Concern?
While the rise of these non-state actors has been welcomed by many, as indeed they are often able to promote positive and equitable health outcomes when government action is inadequate, they raise difficult questions of accountability and responsibility (Harman 2012: 141). Moreover, like IGOs, they also face challenges in terms of funding, often leading to a similar focus on vertical initiatives that can provide easily measurable outcomes in a short period of time in order to satisfy investors, and the devotion of resources to health issues that mainly affect the developed parts of the globe, in pursuit of higher profit margins (Orbinski, 2007: 34). An examination of the importance of non-state actors in shaping the global health agenda should therefore be accompanied by a parallel awareness of the political and economic contexts in which they are situated.
Furthermore, the role of non-state actors should not be overstated. States retain their importance as sources of funding, architects of legal frameworks for domestic and international action, and providers of the health systems and infrastructure that can determine the success or failure of health interventions (Davies, 2009: 55, 60). The sustained power of states in affecting processes of global health governance was demonstrated when Indonesia refused to share its H5N1 virus samples, due to concerns that those samples would be used by pharmaceutical companies to develop vaccines priced beyond the reach of developing countries most in need of such products (Irwin, 2010). What non-state actors seek to do, in this double context of the persistence of the importance of states in addressing health issues coupled with new challenges and opportunities due to the increased globalization of the determinants of health, is to assert their influence by inserting themselves into the dynamics of political contestation that underlie the processes by which global health issues are defined, identified, classified and prioritized.The way in which issues are framed influences how problems are conceptualized, what possible responses are seen as effective and desirable, and thus to which ends political and economic resources should be devoted, an insight of immense importance not only to questions of global health, but also global governance more generally (Mintz & Redd, 2003). The mobilization of resources towards addressing health issues often depends on the extent to which these issues are framed in terms of the interests of the most powerful actors in the global health governance arena, usually Western sovereign states. Thus health issues successfully framed as a threat to the national security of developed countries, or as having a direct effect on their economies, have evoked the most effective, coordinated and rapid responses from the global health governance regime (Feldbaum & Michaud, 2010: 2-4).
In fact, developing countries have begun contesting securitized conceptions of health due to concerns of a skewed focus on issues that directly affect the industrialized world, rather than on a comprehensive approach to health governance that seeks to address the broader determinants of health globally, which often goes against the immediate economic interests of developed countries (Aldis, 2008). As successful framing can induce mass mobilization of economic and political resources across the world, the arenas in which certain health issues are constructed as global matters of concern become important sites of political contestation for both state and non-state actors (Abeysinghe, 2013). An awareness of this political dimension of global health governance illuminates the dynamics by which the interests of the economically and politically powerful often prevail, which explains persistent inequalities in health outcomes both within states and across the globe.
Horizontal approaches to strengthening global health systems and addressing the underlying social and economic inequalities that act as permissive or causative factors producing various health issues are often overlooked, although such an approach can promote environmentally, economically and socially sustainable long-term development (Lee, 2004: 198-200; Sanders & Chopra, 2003: 108). Instead, resources are devoted to vertical initiatives aiming to tackle specific health issues that present a direct security or economic threat to powerful states, produce immediately measurable outcomes and are thus more easily justified to financial backers of NGOs, or provide high-profit opportunities for private corporations. This balancing act between the interests, capabilities and responsibilities of state and non-state actors, in the face of increasingly globalized determinants of health, goes to the very heart of global health governance.
It becomes clear, then, that instead of being an entirely natural and apolitical development, the globalization of health governance is deeply political. This essay has shown that while the structural forces of accelerated globalization have given rise to new challenges and opportunities for global health, the way in which they are prioritized and addressed is the product of complex political contestation between countless state and non-state actors. An understanding of the centrality of these economic and political relationships of power can explain the skewed nature of the global health agenda, and thus the persistence of inequalities in terms of health outcomes both within states and between them.
Such an understanding is crucial in order to highlight the opportunities for new arenas of political contestation and collaboration in order to address these inequalities. Indeed, popular mobilization within the current institutions of global health governance and a cognitive transformation towards a global, rather than a national or regional, conceptualization of health, have already resulted in incremental, yet significant progress in this direction (Garner & McKee, 2001). Although by no means an easy endeavour, due to the complexity of the political dynamics and the power of the myriad actors involved in global health governance, a more equitable, healthy world is possible.
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