[MUSIC] We will now look at global health governance, an area that has become an important field of study in the context of global health. Because, if we want to manage interdependence, if we need to bring together the national, the global, and the local interests in health, then we need to have a form of governance that does so. How do people define governance? If we look what global governance does, then it's the question of managing interdependence. Obviously, we don't have a global state that rules the world. We have many different actors, states, nongovernmental organizations, regional organizations, private business, and they need to come together to manage global affairs. So this is what we have called global governance. And global governance usually has a purpose. So if we speak about global governance, it's a purposive order. That is, that there are rules, there are processes, and there are institutions that work towards a specific goal. Be it the environment, be it global finance, be it global trade. Be it, as we will look at more carefully, global health. So the word that has been used a lot in global health is the term global health governance. Global health governance obviously has a goal. And its goal is the pursuit of health and health equity as a collective goal. That is, global health governance wants to improve the health of the totality of nations and people. So there are a number of definitions, of course, of global health governance. But the one I like using very much, refers to both formal and informal institutions, rules and processes by these many actors, that then come together to undertake cross-border collective action to address health. So the notion of globalization of cross-border action is absolutely central to global health governance. So, again, I'm repeating a picture you might have seen in other presentations as well, that there are many, many different actors in global health. And this multitude of public and private actors, and their many competing interests, come together in global health governance. But we have found that the term, global health governance actually isn't sufficient, it doesn't allow us to describe its complex nature. That is why we have suggested that we should actually make a differentiation between three types of governance. One is global health governance. Which is the governance of the international health organizations and their interface. So organizations that are focused on health, like the World Health Organization, UNAIDS, The Global Fund for AIDS, Tuberculosis and Malaria, for example. But increasingly important is global governance for health. That is where health is the subject of other areas of global governance, such as, I have already mentioned, for example, if you have negotiations on intellectual property in the World Trade Organization. That is governance for health, because those negotiations significantly influence the determinants of health. And finally, we have governance for global health. That refers to the kind of infrastructure, the kind of cooperation you need at the national or the regional level to actually prepare for governance processes at the global level. So if we look more carefully at the governance of the dedicated health organizations, the starting point, of course, is their key goal, health equity and disease control. And in the center of that governance is a unique actor, the World Health Organization that was founded in 1948. In its constitution, it's given the role to act as the directing and coordinating authority on international health work. And that is an initiative that it is very engaged in, but a job that has become more and more complex as there are more and more health actors. What's important to remember is that WHO is a intergovernmental organization, that means its members are states, nation states. But not only that, WHO is unique because it has treaty making power. WHO can adopt treaties that then apply to all countries. And two such important treaties are the Framework Convention on Tobacco Control and the International Health Regulations. No other health organization has such treaty making power. And many people want WHO to use that treaty making power even more than it does at present. Next to the treaties, WHO also provides norms, standards, rules, codes of practice, many different things that countries and professional organizations use day to day. Now, in the 1990s, it was felt that there needed to be other forms of global health governance, that an intergovernmental organization like WHO was not sufficient for the many, many challenges that we had to face in global health. So, therefore, a whole range of innovations in governance, in global governance, for health and global health governance were introduced. I've mentioned the new legal frameworks, the treaties that were adopted in 2003 and 2005. But also new types of organizations were created, we called them hybrid organizations. Because they don't just have states as members, but also others like foundations, like NGOs, like the private sector. And examples are the Global Fund for AIDS, Tuberculosis, and Malaria. There are new public-private partnerships that work together for health. There are new innovative financing mechanisms. There's increasing engagement by a whole range of non state and non health actors, and there is more national action for global health. That is why, for innovation, we speak of a constituency model of governance. And here on this slide, you can see which constituencies are important in global health governance. There are the governments, of course, but there are bilateral donors, there's the private sector, there's private foundations, civil society. In some cases, people affected by the issue, like people living with HIV AIDS. And multilateral organizations, for example, like WHO or the World Bank. And next to the model, you can see that this is, for example, applied in the Global Alliance for Vaccines, GAVI. But there are many other alliances. I've just shown some here, an alliance to fight non-communicable disease, an alliance to end Polio, an alliance to support the health of women. There's practically no health issue that does not have an alliance now, and where many, many of the actors work together. So those were some of the key elements of global health governance. If we now look very quickly at global governance for health, that means our starting point are the social, economic, and political determinants of health. And those are dealt with and negotiated in the context of global organizations in other sectors. One of the big, big changes, in terms of health in the global arena, has been that health is now discussed much more in the context of the United Nations. HIV AIDS was actually discussed at the UN Security Council in the year 2000. We have Millennium Development Goals, three of which are related to health. We have discussed, at the United Nations General Assembly, global health and foreign policy. Of course, also HIV AIDS, universal health coverage, but also non-communicable diseases. And right now at the UN, countries are negotiating what kind of health goals we should have after 2015. In other sectors, health is also being negotiated at the FAO, the organization for food and agriculture. At the ILO, the organization for labor. At the World Bank, who finances many global health projects. At WIPO, which is the World Intellectual Property Organization. In the European Union, one of the most critical regional bodies for health. And what do they discuss? They discuss food security, which is critical for health. Environment and climate change, which has great impact on health. Development and poverty reduction, particularly the World Bank. And, of course, again and again, trade security and issues that are important to foreign policy. But working conditions for people worldwide, their income levels worldwide, all those are critical factors for health. And they are frequently determined politically with great economic and social consequences. Finally, I have mentioned governance for global health. That means that global health is an issue at home. We say global health begins at home. That means that countries are aware how global health issues affect them, and how they impact on global health issues. For example, if a country is a producer of pharmaceuticals, will it only protect its pharmaceutical industry? Or, will it contributes to global health by allowing a new approach in the context of intellectual property? So governance for global health, the creation of the basis for the decisions in global health governance is absolutely critical. I'd like to end with six governance challenges that you will be dealing with as you continue this course. One is that there are many competing interests in global health and that there is great fragmentation. There are a number of suggestions how that can be overcome. How can also, we get a greater commitment of countries to global health issues? And that doesn't only mean that the rich countries give money to poor countries. It means an agreement to have treaties, to have global agreements, how we act, and how we take responsibility. Everyone is grappling with the role of corporations, the private sector, and private sector foundations in global health. They're very rich, how influential can they be? How can they set agendas, how accountable should they be? A very, very critical issue, particularly in relation to non-communicable diseases. We've experienced this with big tobacco, but what about big food, or big alcohol, or big soda? So those are issues that we really need to take up. How can we get reliable funding in global health and should that only be government funding, or must we find a way that the other global health actors must contribute but cannot set the agenda through financial pressure? And finally, how can we get more political support so that in global governance for health, the decisions taken in other organizations that impact the political, social, and commercial determinants of global health, that those decisions are taken in the interest of health and in the interest of equity? And finally, and a really, really important dimension, how can the voice of civil society, of the people of the world, be ensured in global health governance? We have a wonderful example right now in the negotiation of the post-2015 Millennium Goals, the world we want, where people from all over the world can raise their voice and contribute. And we would like to see more of that interface, that people's voice, in global health and in global health governance. So if you are active in global health, be active and contribute and give your voice in the context of global health governance. It's important. [MUSIC]
