Inside the Issues 3.4 | Global Health Governance



today on inside the issues I speak with James or Vince key on global health governance hello and welcome to this week's edition of inside the issues a CG online podcast I'm David Welsh CGT chair of global security at the ball Slee school of international affairs and professor of political science at the University of Waterloo every week I'm pleased to welcome here into the studio at the center for international governance innovation a noted expert on some aspect of international public policy or global governance this week I'm very happy to welcome James or Vince key thankee bowls Lee schools the CG chair of global health also / F professor of in the school of international policy and governance at Wilfrid Laurier University and director of the Africa initiatives here at CG so come in with many titles it's quite a mouthful that's right so we have a lot to talk about but to get right to it global health governance you you're a person who has experience in the field providing health in parts of the world that don't tend to have adequate provision for for health services so you've seen it from the micro and you've been at least for a significant period of time President of Medicine Australia major NGO attempting to provide health services in in stricken crisis stricken areas and now you have a chance to study it how do you characterize and how do you currently understand this thing we call a global health governance and and where would you like to push the frontiers of our understanding of that here at the balsley school well its first of all it's it's the idea of global health governance is it's a relatively new idea and it's an emerging field and emerging discipline and an emerging practice and it's driven by many many factors primarily the growing interdependence of the world both economically and politically but also shared problems or shared problems of the Commons if you will so for example challenges like climate change challenges that affect all people in slightly different ways depending on where they are but that affect all people and that require all people and all nations to engage in a meaningful response if there is going to be a meaningful response other issues like emerging re-emerging infectious diseases are problems if you will of the global Commons and they require again the same a similar kind of approach so today in our vastly more interdependent world than it was even 50 years ago the issues that require attention are certainly scientific there's certainly technical at some level but they're also deeply political and the way in which we approach a problem the way in which we define a problem the political architecture if you will that we use to approach a problem and to define a problem really defines the range of possible solutions that can emerge so attention to that process is really front and center in terms of importance when trying to achieve a viable a meaningful and an effective policy outcome so from my perspective I've certainly been engaged and continue to be engaged very practically with the provision of health care and health care services and so for example now I'm deeply involved with Dignitas International which is a Canadian based non-government organization that I was involved in starting and it's focused on health systems in Malawi and health systems that attempt to a deal with the HIV epidemic and also deal with concomitant or related epidemics like tuberculosis and other primary health care issues and that is a that opportunity and that experience really gives me a kind of a solid basis if you will from which to look at the importance of governance and so through that experience and working primarily in while in in Malawi one of the things that's absolutely clear in terms of dealing with the HIV epidemic is that this is a global governance issue and it requires it requires a political approach to what traditionally has been seen as a technical medical public health problem and so governance and how we think about governance how we define it how we structure it is really central to to achieving better health and globally the other thing that I would say is that it's quite important to recognize that governance is a broader term than for example government and and and it is attractive to me and I'm one of the main reasons that I've decided to really focus on this is big is because it incorporates a recognition of both formal actors and informal actors so States for example and in the various ministries and departments within States whether it's a Ministry of Health – Foreign Affairs or whatever so formal actors and also informal actors like non-government organizations faith-based organizations the private sector foundations and so on all of which are in varying configurations deeply deeply important in terms of actually defining viable approaches to problems of the comments and particularly those that relate to health very good great start to our discussion and we'll be back in just a minute with James or Vince key listening to inside the issues the CGT online podcast look for us at cg online dot o-r-g on facebook on twitter and on youtube welcome back so James you mentioned the contrast between health governance 50 years ago and health governance today and there's at least two things you flagged already one is now there's a wider variety of actors yeah we've had just a few more states today there are a few more states today than were 50 years ago but not that many more a whole lot more informal organizations non-governmental organizations and other kinds of moves the other thing you flagged was it's now more of a political enterprise than a technical medical enterprise those both strike me is very important when people talk about the effectiveness of global governance they often immediately think about with the role of the UN and then people often very quickly decide well among the great success stories of the UN is the w-h-o of the World Health Organization so would you say that the UN system and the w-h-o as the functional agency remains at the center of global health governance is it some kind of pivot around which much of the rest of it operates yeah I mean I think in a contemporary context it's important to recognize that there are huge challenges huge challenges that as a global community we've never faced before and the variety of actors is certainly much more diverse and the skill level of the each of those actors is variable but generally much higher than it was even 50 years ago the nature of relationship for example between civil society and government and the state if you will has fundamentally changed the provision of services the levels of expertise where are the repositories of knowledge for example traditionally over the last hundred years and just speaking very broadly much of sort of deep science knowledge has been largely stayed based now that has shifted into the public domain if you will so we into the private sector and into civil society organizations and with that so too has competence and capacity to actually define a problem and deliver a problem but one thing that hasn't changed and and it's very important to recognize is is the centrality of formal legitimacy so states are the final if you will imprimatur of legitimacy to a particular policy law or practice only states can define formally and make formal a particular policy and can make formal or embody in law and practice for example a particular policy perspective so states are vital and their institutions are vital so the the World Health Organization is an intergovernmental organization it's an intergovernmental institution and I think historically one can look at the WHL and say yes it has been enormous ly successful in its political context of states although it has achieved great things and today in my view it's absolutely central of central importance that the w-h-o remain the final imprimatur if you will of legitimacy to a particular policy or practice the way it does that the way it achieves the designation of people of legitimacy around a particular policy or practice that is changing and must continue to change and that must adopt new governance processes and newest new approaches to defining new knowledge to defining particular practices and so on but how is it changing is it opening itself up to non state absolutely yeah absolutely to non-government organizations to foundations so in the domain of health global health one of the one of the the most important found institutions or actors that's call it in the world is the Gates Foundation now that's a new phenomenon in relative terms excuse me its resources are enormous and where it chooses to focus by definition that focus becomes a focal point for activity whether it's science or implementation or whatever around around health so it's extremely important that that institution that organization is properly engaged and that it is part of a broader dialogue and part of a process that recognizes priority needs that also acts in relationship to other actors and that achieves outcomes that are both obviously effective but but that are also in line with other activities with other policy initiatives with other outcomes through other actors so that you can actually synergize if you will activities and outcomes so this is this is a this is process this is all about process and it's all about the politics of that process and tied in with with with with that process our interests around better health obviously also interests around massive economic interests around health systems who buys who pays and who gets access to health care issues around intellectual property rights for example when we talk about drugs Diagnostics vaccines the development of healthcare technologies much of that development is driven by private sector activity that is rewarded through intellectual property rights and that's good that's a very very powerful and important driver of innovation in terms of new knowledge and applications and so on but there are there there's a whole range of other needs that are outside of the market the markets not interested in for example the diseases of poor people who don't have by definition means to pay for goods or services and therefore does not necessarily engage in appropriate R&D for to address those needs so some other response other than a private sector response is required and so finding the right relationship between the actors the interests and the drivers of their activity these are core governance challenges and and require more than a more than a let's just see how it goes kind of attitude they require attention they require a careful study they require experimentation they require evaluation and and that's the kind of activity that we are engaging here at the bacilli school very good we'll be back again in a minute with James Urbanski you're watching or listening to inside the issues the CG online podcast look for us at CG online dot o-r-g on Facebook on Twitter and on YouTube welcome back so you've already indirectly referred to a third change in the last 50 years which is health care provision now is not just about treating disease it's about a lot of prevention it's a whole a whole lot of providing basic yeah services such as clean water and adequate food and so forth so the people don't get sick in the first place when you add sort of the broadening of the agenda to the increased number of actors is there a danger of people working at cross-purposes and sort of defeating each other in the course of of doing their own thing or absolutely she does it tend to work out pretty well on balance that that more or less these efforts pull in the same direction the synergies tend to wash out the classes it's a very good question I mentioned the Gates Foundation a moment ago the overall I would have to say that that given a balance if you can ensure balance in terms of power and in turn power is not just military economic or materials also ideas and particularly science science-based ideas very very powerful very important but if you can if you can ensure a relative balance in your among your among the players then generally things do at least in my view kind of work out you there are appropriate checks and balances but if there is a imbalance in power then the question of equity the the question of fairness the question of respect for people's basic dignity all people's basic dignity the question of can we achieve a viable planetary future that becomes less certain and this again is why attention to governance is so important so if you have for example a foundation like gates that has such huge power if it is not related and and interdigitated if you will appropriately with other actors then it can get its agenda wrong and I think actually Gates Foundation is a good example a very good example of how an actor with a significant power has in my view appropriately interacted and continues to appropriately interact with other actors in this broader landscape of actors that are engaged in in global health how would you characterize the role and how would you characterize the power of the recipients the beneficiaries well you see this is this is another this is a very very important shift that's taking place the idea that there is a beneficiary that one receives one gives and another receives this is fundamentally changing this is really at some level this is a very sort of charity based conception tradition of health and global health even you know 10 years ago that was very much the kind of base underlying assumption behind much international engagement around global health issues but that has changed even in ten years and the idea that there's a there's a giver recipient relationship and that that's the way to go has very much it is shifting is not complete but it's starting to shift so that there is an interdependence a recognition of interdependence and a recognition of mutuality and also a recognition that in fact my future really does depend on your well-being and my well being is married to your future so that it is even with disproportionality is in power that underlying assumption is is is very much starting to percolate into the discourse and into the way in which we think about about governance how does that change play out on the ground at a fairly local level how would you see things done differently now as opposed to 10 years ago based on this kind of chair yeah so I think I'll give you two examples one very very concrete in terms of bench science when you're developing a vaccine to for example h1n1 a global pandemic organism or an organism with global pandemic potential let's call it if you're going to develop a vaccine to that organism you need you need all of the genome you need all of the the particulate components to that vaccine you can't just have some so you need to to have the antigen for example from Thailand just as much as you need the antigen from the United States or from somewhere in constant to Europe if you couldn't develop a viable vaccine if the Thai community Thai government does not want to give you access to that antigen well you can have the best science in the world but without that antigen you're not going to have a viable vaccine the Thai government for example may make it conditional and say look I will give you the antigen that I have but I need access to the vaccine at a fair and equitable price and so very very quickly the the the nature of relationship at the interdependence of relationship has fundamentally changed now the Thai government is capable government it's absolutely absent a lot of countries don't have functioning state that failed or failing states that aren't really in a position to enforce those kinds of deals what happens to people in those contexts to the neat champions do they require external champions step up and play that role yeah they do they also need support from within support to to actors within the state there's no I can't think of any country in the world where there isn't at least a very significant viable potential for good governance and for for good political leadership and when you're in a when you when you are when you have a situation like what you've described an external champion is extremely important but so too is engaging internal potential leadership and supporting that leadership and working a situation from with with both hands to achieve the kind of outcome that that sure that you're looking for very good we'll be back one more time with James or Vince key you're watching or listening to inside the issues the CG online podcast look for us at CG online dot o-r-g on Facebook on Twitter and on YouTube welcome back so in our last few minutes james i'd like to talk about some of your particular areas of expertise and some of your responsibilities to the organization here in new studio we're sitting a director of the Africa initiative and you also have a specific interest now in furthering the understanding of climate change induced health challenges yep what would you like to be doing on those two files as you go forward well I think probably that well not probably the most significant global health challenge today is climate change The Lancet table medical journal in the world has recognized it as such the implications of the actuality of climate change today and then the future implications of climate change are profound in terms of their effects on global health through the Africa initiative here at CG we are in the process of realigning our program focus around the effects of climate change on global health and we are looking at going to begin looking in detail under that rubric at the effects of climate change on for example emerging and re-emerging infectious diseases on the incidence and prevalence of natural disaster the impact of disaster natural disaster on population health the impact of climate change on migration and then the impact of climate change on conflict and this is a an area where there are already huge impacts and so for example in the southern region of of Africa were already seeing crop yields diminish as a function of climate change the expectations according to some of the best estimates in the world best models in the world which aren't by definition perfect suggests that crop yields could fall by 50% in the southern region of Africa and that water stress or issues around the decreased access to potable water could affect more than a billion people by twenty five twenty fifty so these are these are our significant issues today and they are growing in their magnitude and the way in which we approach health the way in which we approach mitigation strategies around around climate change and the way in which we approach resilience strategies for communities and for Nations will have a significant impact in terms of just what will the effects of climate change be on on health so this is the kind of issue that the kind of practical if you will issue that there where we're looking to to develop a capacity in is it safe to say that this single biggest effect of climate change on health will be through malnutrition through well it's actually not safe to say that the I just read a study this morning that looked that tried to model the effect of climate change on nutrition in Africa in the developing world and there are many limitations to the model but the point is that it's it their conclusion was vastly different from from the conclusions of others which would suggest exactly what you've said and their model is it's a very good model and it requires you know careful mythologic ratite but see that's a that's a very good example of what we do here and and a very good example of the necessity of good research and the necessity of highly skilled competent analysis these have the models have impacts they they affect how we see the world how we think about our responses and the way in which we define our response is deeply influenced by the systems that we use to project the future so being able to critically analyzed them being able to understand the limitations of particular methods and so on and being able to seek the best possible models and seek excellence in our in our research this this really has important kind of implications for for for what we actually do as a global community for our for our policy choices so it's you know that's a long answer but it's it's not 100% clear that the impact on morbidity mortality of climate change will be greatest in terms of food security or nutrition there will be an impact there's no question but we're not entirely sure I would not be prepared to say definitively yes to that at this point and what about the range of diseases that we tend to worry about when we think globally about health problems there's change yeah yeah so there's a right now globally there's a massive ship is called the the epidemiologic ship from communicable diseases to non communicable diseases so now currently the the largest proportion of morbidity and mortality globally is due to communicable or infectious diseases and that's changing to chronic diseases or non communicable diseases so diseases that are cardiovascular disease diabetes obesity osteoarthritis and so on that shift is is is taking place and that's a function of the political economy that we live in and it's a function of the change in our political economy and it's important to understand the nature of that shift these are quite quite a different health infrastructure to deal with right absolutely absolutely sure so when we think about non communicable diseases obviously the best way to deal with a non communicable disease is to prevent it because they are preventable and so our built environments for example have a huge impact on obesity our access to good food have a huge impact on our on our basic health on diabetes on obesity and osteoarthritis and so on our access to public transit has a huge impact our approach to clean air has a huge impact on cardiovascular disease on chronic obstructive pulmonary disease for example and so recognizing the shifts that are taking place and also recognizing the range of possible options in terms of actually mitigating disease or improving health these are also hugely important global health issues it's a very very full agenda well I hope you'll help me back then you can give us periodic updates on how things are going along the way thank you but welcome to the ball Slough school and thank you to our audience thank you for joining us and join us again next week for another episode of inside the issues the CGT online podcast look for us at cg online no RG on Facebook on Twitter and on YouTube

Maurice Vega

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