January 2005, Vol 95, No. 1 | American Journal of Public Health 8
© 2005 American Public Health Association
Global Health and National Governance
Daniel Tarantola, MD
International Associate Editor
The term global as applied to human development emerged in the 1960s at the time of the green revolution, when the World Bank advocated the need to "think globally, act locally." The terms global, international, and intergovernmental have different roots and translate differently in policy; institutional functions; and level of analysis, action, and accountability. They are not mutually exclusive. While the term international has framed much of the work in health across countries over the past decades, the term global has become more politically viable in that it elevates the vision of health to the whole planet, moving beyond geopolitical boundaries and including not only governments but nongovernmental stakeholders and actors.
The World Health Organization (WHO), created shortly after World War II as a specialized, intergovernmental agency, is intended to lead and coordinate the health actions of governments worldwide. The work of WHO is facilitated when consensus is reached among countries on global priorities, as was the case for malaria and smallpox eradication in the 1960s, primary health care and immunization in the 1970s, and the Global Program on HIV/AIDS in the 1980s. It is hampered when a few influential countries disagree with the majority, as illustrated by current controversies surrounding access to essential medicines in developing countries. Differing emphases on equitable access to life-saving products versus protection of the global pharmaceutical market impede consensus on the interpretation of the agreement on Trade-Related Intellectual Property Rights. WHO’s work is also hampered when controversy is fueled by cultural and religious differences, as in the area of reproductive health.
Today, health is heralded as both a source and a product of economic development that necessitates the coalition of governmental and nongovernmental actors. Accordingly, an impressive and growing number of global health initiatives intended to move beyond the confines of intergovernmental efforts have been launched over the last decade. To cite only some, the Global Alliance for Vaccines and Immunization; the Global Tuberculosis Partnership; and the Global Fund on HIV/AIDS, Tuberculosis and Malaria all represent coalitions of a range of concerned actors. These global ventures offer structured responses to the most significant causes of mortality and morbidity in low- and medium-income countries. They stimulate the transfer of unprecedented amounts of financial resources by bringing together governmental and nongovernmental stakeholders, including the private commercial sector, under what are now commonly referred to as public–private partnerships. Yet these global initiatives raise important issues for the autonomy of recipient countries, in relation to both investment priorities and governance. While laudable in their goals, they carry with them the risk of further distancing poor countries from choices made by donors on their behalf. Indeed, both the magnitude and strategic priorities of these initiatives are strongly influenced by external funding, be it from donor governments or foundations, and they are often placed under the oversight of makeshift governing bodies with unquestioned legitimacy and accountability.
The short-term gains offered to countries through these sorts of efforts must be balanced against the long-term benefits to be derived from stronger national self-reliance. The success and sustainability of these initiatives will depend on the capacity of states—all states—to determine the course of their future health within and beyond negotiated international agreements, treaties, and programs of action that bring into focus the obligations of states to improve the health of all people, and thereby global health.
Copyright © 2005 by the American Public Health Association
