Gridlock, Innovation and Resilience in Global Health Governance
| Author | Dario Piselli,David Held,Ilona Kickbusch,Kyle McNally,Michaela Told |
| DOI | http://doi.org/10.1111/1758-5899.12654 |
| Date | 01 May 2019 |
| Published date | 01 May 2019 |
Gridlock, Innovation and Resilience in Global
Health Governance
David Held
Durham University
Ilona Kickbusch
Graduate Institute of International and Development Studies, Geneva
Kyle McNally
M
edecins Sans Fronti
eres, Tashkent, Uzbekistan
Dario Piselli
Graduate Institute of International and Development Studies, Geneva
Michaela Told
Graduate Institute of International and Development Studies, Geneva
Abstract
Global health governance is in many ways proving more innovative and resilient than other sectors in global governance. In order
to understand the mechanisms that have made these developments possible, this article draws on the concept of gridlock, as well
as on the additional theoretical strands of metagovernance and adaptive governance, to conceptualize how global health gover-
nance has been able to adapt despite increasingly difficult conditions in the multilateral order. The remarkable degree of innova-
tion that characterizes global health governance is the result of two interrelated conditions. First, developments that are normally
associated with gridlock in multilateral cooperation, such as institutional fragmentation and growing multipolarity, have trans-
formed, rather than gridlocked, global health governance. Second, global health actors have often been able to harness the oppor-
tunities offered by three important pathways of change, namely: (1) a significant degree of organizational learning and active
feedback loops between epistemic and practice communities; (2) a highly polycentric system of governance; and (3) the increased
role of political leadership as a catalyst for governance innovation. These trends are discussed in the context of three case studies
of significant political, social and health relevance, namely HIV/AIDS, the 2014 Ebola outbreak and antimicrobial resistance.
Policy Implications
•The WHO should not seek to separate its normative and technical function from its convening and leadership function in
order to re-assert its authority as the core institution of global health governance.
•The use of effective interorganizational coordination mechanisms need to be expanded, with emphasis on areas such as
environmental health and non-communicable diseases, or strengthened when already in place (such as in AMR), given
that most current and emerging health challenges now require action beyond the health sector.
•Raising the political profile of health challenges requires the consideration of the conditions under which doing so might
foster significant progress. It is necessary to form inclusive alliances which coalesce around common goals and norms and
bring together different types of actors.
•The funding strategies of actors including multilateral development banks and private foundations must increasingly shift
from vertical disease programmes to health system strengthening objectives, including universal health coverage and
greater attention to the determinants of health.
•International efforts aimed at generating buy-in by developing country actors on global health initiatives will have to be
complemented by a stronger emphasis on using political leadership to create ownership at the domestic level, filling the
persistent implementation and capacity gap that many countries still face.
The complex interdependence and interconnected crises
that characterize the current stage of globalization are often
perceived to have outgrown the capacity of the
international community to further engage in multilateral
cooperation to supply global public goods including finan-
cial stability, climate change mitigation, security and the
Global Policy (2019) 10:2 doi: 10.1111/1758-5899.12654 ©2019 The Authors. Global Policy published by Durham University and John Wiley & Sons Ltd.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, whic h permits use and
distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
Global Policy Volume 10 . Issue 2 . May 2019 161
Research Article
integrity of the biosphere (Goldin, 2013; Hale et al., 2013a;
Lamy and Goldin, 2014). Not only do the multilateral institu-
tions established after World War II seem increasingly
unable to address problems of collective action that cross
national boundaries, this deficit is reinforced by a more sys-
temic crisis (if not outright decline) of the international lib-
eral order, punctuated by the parallel rise of nationalistic
and protectionist tendencies in many countries (Ikenberry,
2018).
As recently discussed by Hale et al. (2017), however, the
effectiveness of global governance presents stark variations
across sectors and even at the level of single institutions
or regimes within them. Global health governance, in par-
ticular, has undergone a radical transformation over the
last three decades (Hoffman et al., 2015; Schaferhoff et al.,
2015), while during the same period some other areas of
global governance were suffering from severe instances of
stalemate and inaction (Hale et al., 2013b).
1
Beginning in
the 1990s, available funding for global health (IHME, 2018)
and the number of global health actors (Hoffman et al.,
2015) both started to increase exponentially, resulting in
major shifts in the approach to global health, in the archi-
tecture of the global health system (Hoffman et al., 2015;
Youde 2014) and in its mechanisms and objectives
(Schaferhoff et al., 2015). One consequence was significant
achievements across several regions and issue areas, such
as the global fall of maternal and child mortality (UN,
2015), increased access to anti-retroviral therapy, scaled-up
malaria interventions in Africa (UN, 2015) and continued
progress towards the eradication of polyomielitis (WHO,
2015).
Moreover, this expansion of global health governance
occurred at a time of significant changes in the global
political landscape, effectively spelling a new age of global
health. At present, we can see several trends at work. First,
high-income countries remain the principal funders of the
major global health organizations and initiatives (Dieleman
et al., 2016), but political trends against foreign aid in
many of these countries, and particularly in the United
States, have resulted in a growing uncertainty about the
future of global health financing (Donor Tracker, 2018;
Kates et al., 2018; Van Hise, 2017). Second and in parallel,
the political influence and global health expenditure of ris-
ing middle income powers including China, India, Brazil,
South Africa and Russia have progressively grown (Gautier
et al., 2014; Harmer and Buse, 2014; Jakovljevic et al.,
2017), highlighting a gradual but steady shift in the distri-
bution of powers in global health governance. Third, the
adoption, in September 2015, of the Sustainable Develop-
ment Goals (SDGs) has ushered in a vision of global health
governance which moves away from a vertical focus on
specific diseases and towards a broader emphasis on
health systems and a more holistic vision of health and
well-being (Buse and Hawkes, 2015). Lastly, the 2017 elec-
tion of Tedros Adhanom Ghebreyesus as the World Health
Organization’s (WHO) new Director-General demonstrated a
stronger emphasis, on the part of the organization, on the
exercise of political leadership as a means of maintaining
global health high on the political agenda of countries
(Kickbusch, 2017).
The expansion and politicization of global health gover-
nance suggest that this sector has been more innovative
and resilient than usually assumed for global governance as
a whole. However, we still have an insufficient understand-
ing of the specific features and causal mechanisms that
have made it possible for the global health system to adapt,
learn and respond to the changing conditions of the multi-
lateral order. Improving such understanding would not only
facilitate mutual learning and comparison of promising
pathways of change across sectors, but also, prospectively,
help identify the means through which global health gover-
nance can remain fit for purpose in an era of rapid
economic, social, technological and environmental transfor-
mations. Doing so, in turn, would require situating global
health governance debates in a broader historical and insti-
tutional context and particularly applying more solid foun-
dations drawn from international relations theory to its
study. As noted by Lee and Kamradt-Scott (2014), the extent
to which theory and practice have been able to inform each
other in global health governance literature has generally
been limited. More recently, this has resulted in either: (1) a
narrow focus on specific institutional arrangements, issue
areas, population groups and geographic regions (Clinton
and Sridhar, 2017; Crawford et al., 2017; Gostin et al., 2015;
Nikogosian and Kickbusch, 2016); or (2) discussions with a
strong conceptual and sometimes prescriptive focus (Ben-
nett et al., 2017; Frenk and Moon, 2013; Mackey, 2016;
Smith and Lee, 2017).
To bridge this gap, this article conducts a theoretically
grounded analysis of the pathways to increasingly difficult
cooperation and change that have characterized global
health governance in the past three decades, as well as the
interactions between them. First, the article draws on the
concept of gridlock (Hale et al., 2013a, 2017) and investi-
gates the dynamics of global health governance in order to
understand how pathways to gridlock apply in this field.
Second, the article considers additional strands of theory,
particularly those of metagovernance (Holzscheiter, 2014;
Meuleman, 2008) and adaptive governance (Dietz et al.,
2003; : Chaffin et al., 2014) and evaluates how this sector of
global governance has confronted underlying conditions of
gridlock in the multilateral order. In order to do so, the arti-
cle relies on three case studies of significant political, social
and health relevance which also exemplify different types of
health threats, namely HIV/AIDS, the 2014 Ebola outbreak in
Guinea, Liberia and Sierra Leone and antimicrobial resistance
(AMR).
The article is structured as follows: Section 1 describes the
research approach and methodology, Sections 2 and 3 pre-
sent and discuss the main findings, focusing on the main
pathways to cooperation that we have uncovered in the
recent evolution of global health governance (section 2) as
well as on governance innovations and pathways of change
(section 3).
2
Finally, section 4 concludes by highlighting the
implications of our analysis for the future development of
global health governance.
©2019 The Authors. Global Policy published by Durham University and John Wiley & Sons Ltd. Global Policy (2019) 10:2
David Held et al.
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