In 2016 Ilona Kickbusch highlighted a shift in the distribution of power away from the United States, termed as “the rise of the rest”, whereby a wider array of countries are able to participate in global governance as a result of increased resources, transnational connectivity and shifts in geopolitical status (Kickbusch, 2016). Now, in 2020, Kickbusch argues that the future of global health will be dominated by geopolitics over the coming decade (Kickbusch, 2020). COVID-19 has acted as a political accelerator and made apparent a proxy war between the United States and China concerning the power each country has over the World Health Organisation (WHO). In this context, Kickbusch (2020) identifies three key areas of reform in global governance that are fundamental to empower the WHO to continue to “act as the directing and co-ordinating authority on international health work” (Who.int, 2006). These are: 1) re-define the WHO’s financing model to dissipate the undue influence from specific countries; 2) shift away from the sovereignty paradox to support a WHO model that promotes multilateral cooperation based on smart sovereignty; and 3) create change and strengthen the normative and standard-setting powers of the WHO by using the new power dynamics to balance the rulemaking powers of the WHO.

I agree that geopolitics will dominate global health for at least the next decade and that these dynamic shifts must be harnessed to address the most urgent global health issues as identified by Kickbusch: financing, authority and fragmentation (Kickbusch, 2020). If we are to be prepared for future pandemics and safeguard human health whilst working towards establishing Universal Health Coverage (UHC), I believe we must balance geopolitical powers and resources and empower the WHO to democratically pursue common interests. Kickbusch (2020) suggests that the future of geopolitics will be more closely aligned to a realist view, as opposed to a liberal internationalist view, whereby countries will seek to secure zones of influence. Whilst I agree that current policy attention on geopolitics supports a realist view, I will demonstrate the need to reshape multilateralism to balance geopolitical powers with the goal of strengthening national health systems. This essay will demonstrate this stance through a literature review and discussion of the current policy attention given to geopolitics, the place of the WHO and other global institutions in global health, the current competing paradigms and priorities in global health, and the power and strength of global institutions.

Current policy attention on geopolitics

It is no new phenomenon that those with power are able to control the narrative. If we look at how COVID-19 has been portrayed in Africa, international news coverage has automatically presumed that Africa’s response to the pandemic will not be successful due to a lack of resources, where the lack of resources is caused by colonialism and imperialism (Büyüm et al., 2020). What we don’t hear about is the successful pandemic response strategy from Senegal who used innovative technologies to create affordable virus tests that are widely accessible across the country. This controlled and biased news narrative is a prime example of the imbalance in geopolitical powers. WHO Director General Tedros Adhanom Ghebreyesus has used the term ‘colonial hangover’ to describe the disproportionate representation of the ‘Global North’ in global health institutions (Büyüm et al., 2020), effectively perpetuating a Eurocentric stance in global health governance that doesn’t reflect the needs of the rest of the world. The ‘colonial hangover’ arises from multilateral frameworks that are shaped through the historical and existing political, financial, and knowledge frameworks apparent in today’s neoliberal capitalist market, whereby capitalist enterprises are more concerned with accumulating capital than promoting global health for the sake of all. For example, the 2008 Global Financial Crisis threatened global capitalism and the response to this blatantly exposed the priorities of the current system of global health governance. Tremendous bailout sums were provided to capitalist enterprises, squandering the amounts of money dedicated to foreign aid and the Millennium Development Goals (MDGs) in comparison (Gill and Benatar, 2017). Even financial capitalist George Soros has been quoted explaining that continued use of current monetary policies will only “increase inequality between rich and poor both in regards of the countries and people” (Miller, 2015).

If we turn our attention to the 2000 – 2016 Golden Era of health, new global health financing mechanisms, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, were established to help achieve the three health MDG’s (Kickbusch, 2016). However, the efficacy of global health financial mechanisms to support Health Systems Strengthening (HSS) is undermined by the health workforce crisis, as the ability to absorb, deploy and efficiently use global health financing depends on the human capacity available in those countries (World Health Organisation, 2006). HSS is also considered a prerequisite to achieving the Sustainable Development Goals (SDGs) and UHC (Herrick, 2017). In addressing LMIC’s protracted deficit in health workers, UK Global Health Partnerships (GHPs) have emerged as a ‘lever of change’ to promote more sustained and holistic global health funding. Whilst GHPs operate with the philosophy of south to north flows of knowledge and skills, they are inherently geopolitical in that their HSS remit spans the determinants of health that are frequently omitted in global health activity (McCoy and Singh, 2014), and are used as an instrument for the UK to extend its influence and soft power (All-Party Parliamentary Group on Global Health, 2015).

The current ‘colonial hangover’ and priorities of global health monetary policies bring to light the realist view of geopolitics that Kickbusch (2020) foreshadows dominating global health governance in the coming decade. However, current geopolitical patterns indicate that power is the end goal. To reshape multilateralism to include subnational and non-state actors will balance geopolitical powers and support advancing global health governance as a system that benefits all (Global Solutions Initiative, 2020).

The place of WHO and other global institutions in global health

The WHO constitution defines the objective of WHO to “be the attainment by all peoples of the highest possible level of health”, with its first function being “to act as the directing and co-ordinating authority on international health work” (Who.int, 2006). However, the ability of the WHO to fulfil its objective relies on generous financial contributions from member states. As Kickbusch (2020) highlighted, only 20% of the WHO’s budget comes from assessed contributions (AC), whereas an estimated 75% of the WHO’s budget comes from voluntary contributions (VC) comprised of only 20 out of the 194 member states. A mere 3.9% of the WHO’s budget is in the form of core voluntary contributions (VCC) (World Health Organisation, 2020a). This financing model undermines the WHO’s ability to act as a coordinating authority in global health, as less than a quarter of its total budget can be used at the full discretion of the WHO. With the United States currently being the largest contributor of VC (World Health Organisation, 2020b), they are privy to extend undue influence on the WHO’s priorities. Although the United States is likely to remain a member of the WHO under the Biden administration, member states have increasingly shifted their funds to alternative multilateral health initiatives. Consequently, without a reassessment of the WHO’s financing model, its authority to act independently in the pursuit of common goods for all will continue to dissipate and global health governance will become increasingly fragmented.

Some of the most powerful member states of the WHO, including the United States, were disgruntled by The Global Strategy for Health for All by the Year 2000 and turned to the World Bank (WB) to influence global health governance as a result of its greater funding power (Brown, Cueto and Fee, 2011). The WB helps “countries share and apply innovative knowledge and solutions to the challenges they face” and “works in every major area of development” (World Bank, 2020). However, the flaws of the World Bank’s structural adjustment conditions in its health sector strategy were all too apparent by the late 1990’s, whereby problems in LMIC health security and equitable access to health care were emerging (Ooms and Hammonds, 2016).

At the turn of the 21^st century, we experienced a proliferation of public-private partnerships (PPPs) such as the Global Fund to Fight AIDS, Tuberculosis and Malaria. The Global Fund was created to mobilise and invest in national level financial interventions and programs designed to advance the end of the AIDS, Tuberculosis and Malaria epidemics (The Global Fund, 2020). Continuing the assumption that greater funding power implies a greater influence in global health policy, then The Global Fund is just one PPP that has surpassed both the WHO and WB (Ooms and Hammonds, 2016).

Recently there has been a stagnation in Western countries global health development donations, supporting Kickbusch’s (2016) claim that the “rise of the rest” will be a defining feature in the future of global health. As alluded to above, the fragmentation of global health financing significantly weakens the opportunity to coordinate effective global health policies as a result of dispersed authority. This signifies that financing, authority and fragmentation are indeed the most pressing global health governance issues today that geopolitics would do well to collectively harness.

Current competing paradigms and priorities in global health

According to Kickbusch (2020), the WHO is subject to the sovereignty paradox which theorises that weak agreements are made between countries due to a desire to protect their sovereignty. COVID-19 has illustrated that the cost of weak agreements made under the sovereignty paradox is a lack of policymaking sovereignty resulting from inadequate coordination (Kickbusch, 2020). If we were to take advantage of the currently shifting geopolitical power dynamics, there would be an opportunity to re-establish the WHO as an effective, transparent and fair global health institution where countries cooperate based on the principle of ‘smart sovereignty’. Smart sovereignty adds an extra layer to territorial sovereignty by defining a responsibility to protect, as well as a right to use (Bosselmann, 2017). Furthermore, Australian Prime Minister Scott Morrison has openly advocated the need to overcome the sovereignty paradox by allowing the WHO to “forcibly enter any country” as a new element of the WHO’s re-established mandate and in alignment with the smart sovereignty paradigm (Kickbusch, 2020).

These called upon changes to the WHO reflect a wider consensus that argues there needs to be a shift away from specific reactional paradigms in global health governance, to a systemic, holistic and preventative paradigm (Paul, Brown and Ridde, 2020). Current COVID-19 emergency responses have been based on the ‘Pasteurian paradigm’ that stipulates one pathogen causes one disease, and thus, each disease has one cure (Paul, Brown and Ridde, 2020). However, evidence of biosocial contagion means the current globalised world is experiencing a syndemic, or a synergy of epidemics, nullifying the use of the Pasteurian paradigm. The global level of unpreparedness to the COVID-19 epidemic also emphasises one of the key failures resulting from the present fragmentation of global health policy. Specifically, global health policy has persistently relied on reactionary paradigms, symptoms-based denominations and access to vaccines, alongside continued failures in addressing the upstream determinants of health (Paul, Brown and Ridde, 2020). Given the global economic cost of COVID-19, not to mention the social cost, preparing populations against future epidemics and strengthening local health systems should be the main priority of global health, and would only represent a fraction of the cost comparatively. Shifting to a systemic, holistic and preventative global health paradigm, reflecting security and health development approaches, would represent the broader picture of the global burden of disease and promote equity and efficiency through adaptations to local contexts and strengthened national health systems.

The power and strength of global institutions

The WHO is the only global health institution with a formal mandate to prepare and promulgate international law under Article 19 of its Constitution (Ooms and Hammonds, 2016), demonstrating its institutional power as a decision-making body. Prior to the shift of WHO member states to the greater funding body of the WB during the 1990’s, the WHO’s institutional power was reflected in its ability to reconcile the views of multiple health experts, its financial assets, and its global representation (Patterson and Clark, 2020). However, the WHO’s institutional power is at the mercy of geopolitical dynamics, as it requires member states to formally recognise its institutional power and it is up to individual member states to determine whether they will ratify WHO conventions and treaties or not. The WHO also possesses normative power, which is gained legitimacy and influence resulting from claims of the promotion of ethical principles (Patterson and Clark, 2020).The WHO’s normative power is evident through its advocacy for the ‘right to health for all’, although it is limited at the global scale as legitimacy relies on social contracts formed in consultation with affected people. In alignment with Kickbusch’s (2020) statement that there is a strong appetite for the WHO to marshal the changing geopolitical dynamics and establish an alternative balance of power within the WHO that pays no attention to the US-China proxy war. Furthermore, the WHO could strengthen its normative power through dissipating the Eurocentric view of health that has resulted from the ‘colonial hangover’.

Whilst the WB does not have a formal mandate to prepare or promulgate international law, it does however possess the financial resources to support its recommendations (Patterson and Clark, 2020). Thus, as the primary financial institution responsible for the economic growth of developing nations, the WB occupies considerable resource-based power. As the chair of various bilateral donor organisations who negotiate the with recipient governments of WB funds, the WB holds negotiation leverage over these national governments stemming from its control in the flow of donations (Clemens & Kremer, 2016). Essentially, the WBs resource-based power enables it to influence global health policy priorities on a global scale. This influence also illuminates the WBs soft, discursive power. As a platform for independent policy conversations, the WB practices discursive power through its ability to frame and shape different actors’ discourses, and soft power through its ability to attract actors to its way of thinking (Thow, 2020).

The Global Fund created its own policy when it was explicitly created to finance interventions and programs aimed at targeting three infectious diseases at the national level (Ooms and Hammonds, 2016). Thus, The Global Fund possesses significant decision-making power demonstrated through its ability to be involved in decision-making and in formal norm-setting to achieve its purpose as a global health institution and determine financial allocations as it sees fit (Thow, 2020). However, the limitations of this model are evident through the discretionary choice of states to contribute to The Global Fund, potentially hindering its progress.

The WHO’s regulated institutional power, the WB’s individual resource-based power, and The Global Funds reliance on discretionary spending supports Kickbusch’s (2020) claim that the future of global health governance will be dominated by geopolitics in a realist world view. Realists claim that power is centred in sovereign states and that they act rationally in accordance with their own interests (Thow, 2020). Therefore, without international monetary financing reforms and a shift to smart sovereignty within the WHO, there will continue to be a fragmentation in global health policy coordination and undermining in the achievement of UHC.  

What is the future of global health governance?

Throughout this essay I have demonstrated my agreement with Kickbusch (2020) in foreshadowing the dominance of geopolitics in the future of global health governance. The current policy attention on geopolitical dynamics revealed a ‘colonial hangover’ in which our neoliberal capitalist market perpetuates realist multilateral frameworks, and GHPs are used as a mechanism to increase influence and soft power. The inclusion of subnational and non-state actors in multilateral spheres could help to reframe geopolitical patterns as a means to achieving UHC. An analysis of the place of the WHO and other global institutions in global health exposed fragmentation in global health financing, ultimately dispersing authority and undermining the opportunity to coordinate global health policies. A call for the introduction of smart sovereignty and a shift to systemic, holist and preventative paradigms in global health governance emphasises the opportunity we have to harness shifting geopolitical power dynamics to recreate an effective, fair and transparent WHO that represents the true burden of disease and strengthens national health systems. Finally, a critique of the power and strength of global health institutions highlighted the undue influence that sovereign states hold over global health financing mechanisms. Thus, to address financing, authority and fragmentation as the most pressing global health governance issues in today’s world, multilateralism must be reshaped to balance geopolitical powers with the goal of strengthening national health systems. 

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