Governance seeks to clarify how different actors in a given system or organization operate and the reasons for the way they operate (Pyone, Smith, & van den Broek, 2017). International health governance is not something new. Following epidemics of plague and cholera, 10 international meetings were convened between 1851 and 1909 that led to international agreements for the control and treatment of disease. This cooperation expanded in the 20th century after the two world wars (Merson, Black, & Mills, 2012). However, it is in the last 15 years that we have seen a revolution in global health governance as a result of the entry of a multiplicity of new actors working in health. Global health governance is defined then as the set of rules, norms, and formal institutions that facilitate international interactions related to health (Brown, Yamey, & Wamala, 2014). This term was created to differentiate it from “international health governance,” describing the diversity of governance mechanisms that go beyond intergovernmental cooperation (Dodgson, Lee, & Drager, 2002). While global health governance seeks to address shared problems, there is a lack of a formal authority to create and enforce a system within which policies are made. Even if global health policy-making does occur, there is a breakdown in the implementation of these policies, given this lack of legal enforcement over states even if they subscribed to such regulations and agreements.
The shift in global health governance occurred for various reasons. Part of this has been the understanding that states alone cannot address transboundary problems, health problems that originate in one state but that have effects on others, as well as the value of pooling resources to respond to shared problems. Another important cause for the entry of new actors in global health governance has been a growing disenchantment with the response of “traditional” health organizations, such as the World Health Organization, which has been limited in its approach due to their lack of authority on states and has been plagued by budgetary issues. While regional organizations are also not new, in the past years we have seen an increased interest by these institutions to be involved in a more direct manner in health. This is partly motivated by their interest to address common health issues as well as to have an influence in global negotiation processes through health diplomacy (Amaya, Rollet, & Kingah, 2015). The growing involvement of regional organizations, specifically, and the regional governance level, more in general, have contributed to the multi-level character of global health governance, with two-way vertical interactions between the various levels (Lizarazo & De Lombaerde, 2015).
Health diplomacy is a diffuse term that is described according to its use. For instance, it has been used to explain health negotiations, the health impact of non-health negotiations, and the goal of using foreign policy to support global health. It has also been used to describe efforts to improve health within the larger context of supporting state interests (Feldbaum & Michaud, 2010). Beyond the confusion of the term “health diplomacy,” it is well recognized that global health diplomacy is taking place. This is defined as the processes by which government, multilateral and civil society actors attempt to position health in foreign policy negotiations and to create new forms of global health governance (Kickbusch, Silberschmidt, & Buss, 2007). However, health diplomacy occurring at the regional level is still an unexplored topic despite the empirical evidence pointing toward its existence.
The European Union (EU) is the most widely studied regional organization from which we can draw the most examples. The EU created its own legal instruments, including the European Court of Justice (ECJ), which has proven to have effects on the development and implementation of national health policy in the member states. In addition, the EU has gained an influential role in reforming the “global social governance system” not only as donor but also by shifting the agenda in global spaces for interaction such as the World Health Assembly. Needless to say, the EU is a special case due to its special nature, which combines supranational and intergovernmental features.
Given that most regional organizations were created partly to compete in the international markets as a result of globalization, most of the research on regionalism and health has focused on the issue of trade (Deacon, Ortiz, & Zelenev, 2007; Jarman & Greer, 2010). Indeed, trade has recently been an important issue for pharmaceuticals particularly due to the restrictive intellectual property (IPR) practices included in regional arrangements and, more importantly, in North-South free-trade agreements. The resulting fragmented global IPR regulatory framework is the result of complex policy and negotiation processes in which pharmaceuticals have a non-negligible weight. Power asymmetries characterize the processes of negotiating, implementing and adjudicating trade agreements (McNeill et al., 2017). This regime has met with strong questioning and criticism from the side of non-governmental organizations (NGOs) and other civil society actors. International organizations (such as the UN Committee on ESCR, the WHO, or UNASUR) have voiced similarly critical opinions (‘t Hoen, 2002; Mercurio, 2010). There are strong doubts about whether the expected positive effect of IPR protection on research and development weighs up against the cost of access to medicines. Although there is no sufficient scientific evidence (yet) to establish the “socially optimal” levels and duration of IPR protection, it can be argued that pharmaceuticals are overprotected from a public health and societal perspective (Stiglitz, 2009).
Beyond trade, in other areas of the world, regional organizations are just beginning to demonstrate their relevance for health diplomacy. In this special issue, we explore health diplomacy from a regional perspective. The articles in this special section, as well as others such as Collins, Bekenova, & Kagarmanova (2018), present the examples of regional involvement in health diplomacy by discussing how regional bodies are using it as a tool toward different health policy goals (the EU, Association of Southeast Asian Nations [ASEAN], African Union [AU], Southern African Development Community [SADC], and Union of South American Nations [UNASUR]). The Vincent Rollet article, “Health interregionalism in combating communicable diseases: EU cooperation with ASEAN and the African Union,” discusses how the EU cooperates with the AU and ASEAN in the area of communicable diseases. In this article, Rollet provides insights into how the EU conducts “interregionalism” with its counterparts, specifying how we must single out true interregionalism effects from those that occur from multilateral or bilateral efforts. The way this occurs not only explains how the EU cooperates with other regions but also has effects on the health initiatives that are proposed.
“The role of regional health diplomacy on data sharing: The SADC and UNASUR cases,” the Ana B. Amaya, Stephen Kingah, and Philippe De Lombaerde article in this special section, investigates another area of health diplomacy at the regional level by explaining how member states share data with their regional bodies (in this case UNASUR and SADC) and with global health institutions such as WHO. This article uncovers the potential for regional bodies in the global South to serve as hubs for data sharing and research generation. Importantly through this case study, the authors define the roles of regional organizations as having a vertical and horizontal dimension. They explain how regional organizations can play a vertical role by translating global goals into regional and national targets and mobilizing resources to reach these goals. Horizontally, regional organizations can “contribute to better evidence-based policy coordination and provide data and policy support to address cross-border policy challenges.”
Finally, in “Health diplomacy: For whom? By whom? For what?” Bindenagel Šehović (in this special section) explores how health diplomacy promotes the right to health. The author explores how the idea of the right to health evolved, particularly at the state level and what health diplomacy's role is within the changing global health governance landscape. Her article finalizes with a reflection on how health diplomacy is likely to evolve as a result of new epidemics and the legacies of globalization.
As other authors have stated, global health governance is at a crossroads (Ng & Ruger, 2014), and it is in desperate need for innovation (Smith & Lee, 2017). The same challenges from over a decade persist, and a new framework needs to be developed to address common health issues. We believe regional organizations have the potential to contribute to this next phase.
This special section is a product of the EL-CSID project on European Leadership in Cultural, Science and Innovation Diplomacy, coordinated at the Vrije Universiteit Brussel (VUB) and funded by the EU's Horizon 2020 research and innovation program under grant agreement Nr 693799. The Amaya et al. article was written in the framework of the PRARI project (Poverty Reduction and Regional Integration: A comparative analysis of SADC and UNASUR health policies). PRARI is an Open University social research project funded by the UK Economic and Social Research Council (ESRC) with grant ref. ES/L005336/1.
Amaya, A.B., Rollet, V., & Kingah, S. (2015). What's in a word? The framing of health at the regional level: ASEAN, EU, SADC and UNASUR. Global Social Policy, 15(3), 229–260.
Collins, N., Bekenova, K., & Kagarmanova, A. (2018). Negotiated health diplomacy: A case study of the EU and Central Asia. The Hague Journal of Diplomacy, 13(4). doi: 10.1163/1871191X-14010032
Feldbaum, H., & Michaud, J. (2010). Health diplomacy and the enduring relevance of foreign policy interests. PLoS Medicine, 7(4), e1000226.
Jarman, H., & Greer, S. (2010). Crossborder trade in health services: Lessons from the European laboratory. Health Policy, 94(2), 158–163.
Kickbusch, I., Silberschmidt, G., & Buss, P. (2007). Global health diplomacy: The need for new perspectives, strategic approaches and skills in global health. Bulletin of the World Health Organization, 85(3), 230–232.
Lizarazo Rodriguez, L., & De Lombaerde, P. (2015). Regional and inter-regional economic rules and the enforcement of the right to health: The case of Colombia. Global Social Policy, 15(3), 296–312.
McNeill, D., Barlow, P., Deere Birkbeck, C., Fukuda-Parr, S., Grover, A., Schrecker, T., & Stuckler, D. (2017). Trade and investment agreements: Implications for health protection. Journal of World Trade, 51(1), 159–182.
Mercurio, B. (2010). Reconceptualising the debate on intellectual property rights and economic development. Law and Development Review, 3(1), 64–106.
Merson, M. H., Black, R. E., & Mills, A. J. (2012). Global health: diseases, programs, systems and policies. Burlington, VT: Jones & Bartlett Learning.
Pyone, T., Smith, H., & van den Broek, N. (2017). Frameworks to assess health systems governance: A systematic review. Health Policy and Planning, 32, 710–722.
’t Hoen, E. F. (2002). TRIPS, pharmaceutical patents and access to essential medicines: Seattle, Doha and beyond. Chicago Journal of International Law, 3(1), 27–46. Retrieved from www.who.int/intellectualproperty/topics/ip/tHoen.pdf