Penn on the World after COVID-19, Global Governance, Public Health The Future of Global Health Governance

Penn on the World after COVID-19 is a joint project of Penn Global and Perry World House. We've asked some of Penn's leading faculty, fellows, and scholars to imagine what the global pandemic will leave in its wake.

Jennifer Prah Ruger is the Director of the Health Equity and Policy Lab (HEPL) and the Amartya Sen Professor of Health Equity, Economics and Policy at the School of Social Policy & Practice and the Perelman School of Medicine at the University of Pennsylvania

COVID-19 has caused extensive death and injury as well as social and economic disorder.  The International Labor Organization (ILO) Monitor states that COVID-19 is “the worst global crisis since the Second World War.”

The world has looked to the World Health Organization (WHO) as the leading global health governor for COVID-19.  But today’s WHO is under fire, with some questioning its relevance altogether.  Former WHO Director-General Margaret Chan expressed skepticism at WHO’s ability to govern global health, stating “[t]he level of WHO engagement should not be governed by the size of a health problem … Others may be positioned to do a better job.”

In the 19th and 20th centuries, international health governance (IHG) focused on cooperation among nations to control the spread of communicable diseases—yellow fever, cholera and the plague—to protect trade and travel among powerful nations. But these older IHG structures have been ineffective in preventing and addressing  challenges like COVID-19.

Thus, a more complex global heath governance (GHG) era began, in which new actors, programs, initiatives, and regimes proliferated and new funding exploded. The WHO World Health Assembly is just one process for global health decision-making. The WHA has been overshadowed by new mechanisms working bilaterally (like the U.S. President’s Emergency Fund for AIDS Relief, or PEPFAR), regionally (like the EU) and through alternative structures (like the Gates Foundation). Often these activities are uncoordinated and their effectiveness is debatable.  

Global health problems have potential solutions in the behavior of global and national actors and institutions, but the current GHG system has too many intractable problems. It is  fragmented and inefficient and suffers from blurred lines of responsibility, inadequate global standards, and undue influence from powerful countries and institutions.

While these problems make it harder for us to tackle COVID-19, there’s a deeper reason the inadequacies of the current GHG framework matter: justice. The human experience differs sharply depending on where in the world one lives.  In a world beset by serious and unconscionable health disparities, humankind needs a new vision, and a new architecture, to ensure health capabilities for all.

There is a better way. In Provincial Globalism (PG), which is a theory of global health justice, peoples’ health needs and their abilities to be healthy serve as the basis of claims individuals have upon society. These are claims of justice, not charity.  In PG, charity and humanitarianism are an insufficient basis for achieving health justice because they depend on hand-outs from others rather than empowering our collective action to solve societal problems that affect us all.

PG entails a duty to address premature mortality and escapable morbidity and necessitates shared health governance, a global health governance theory grounded in justice and the common good, to prevent and reduce inequalities in these central health capabilities.

Shared Health Governance (SHG)  attempts to update our current GHG system to meet the requirements of justice by establishing standards of responsibility and accountability. In SHG, the common good is the proper object of global health, ensuring that all people have the opportunity to flourish. A well-organized global society that promotes the common good is to everyone’s advantage.  

Realizing an SHG framework would require several steps to embody the interests of all, not a chosen few, and provide common good based rules.

First, SHG requires a ‘constitution’ that articulates common principles and common ground, assign duties and delegate functions between various global health actors, and bring coherence, clarity, and legitimacy to formerly chaotic conditions. A constitution will provide the measure to ensure global and national actors and institutions are promoting the common good.

Second, implementing SHG requires a Global Institute for Health and Medicine to provide means to do so.  The Institute would engage internal and external scientists to provide the substantive, objective, and authoritative scientific basis for global health policy. It would also develop and maintain a network of scientific and technical experts across the globe; provide objective advice needed to develop and implement more equitable and cost-effective global health policies; provide a forum for many key stakeholders, not just scientists, in the decision-making process; and be responsible for developing a global health master plan.

Some will ask whether SHG’s conditions are too onerous and implausible. But existing global health threats and health governance problems are arguably far more onerous. Provincial globalism and shared health governance offer promise for a healthier, and more just, future in the world after COVID-19.

The views expressed in Penn on the World after COVID-19 posts are solely the author’s and not those of Penn, Penn Global or Perry World House.