Economía y salud
BOLETÍN INFORMATIVO - Año 2014. Julio. nº 80
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Perspective: Governance challenges for the global health enterprise

N. Regina Rabinovich
Harvard School of Public Health, Boston, MA

Regina Rabinovich is ExxonMobil Scholar in Residence, Harvard School of Public Health, Boston, MA and Visiting Scholar, ISGLOBAL, University of Barcelona, Spain. She served as Director of the Infectious Diseases division at the Bill & Melinda Gates Foundation, and was Chief of the Clinical and Regulatory Affairs Branch at the US NIAID.

Over the past 15 years, the global health enterprise has underdone enormous changes. The creation and actualization of the Millenium Development Goals (MDGs) starting in 2000, along with vastly improved financing for priority diseases, from R&D investments through access to commodities for the poorest countries, has transformed what is possible to achieve. Impact on disease control and lives saved has resulted from the creation and implementation of the global funds (Global Alliance for Vaccines and Immunization; Global Fund for AIDS, TB and Malaria) and expanded bilateral programs (such as UK/DFID and US/President’s Malaria Initiative).

The massive scale-up required to implement these funds has expanded the role of non-state actors, including faith-based organizations, civil society, affected communities and philanthropies, as well as the private sector, as critical elements of the “global health architecture”. Faith-based and other non-governmental organizations have a long history of providing medical care in areas of poverty. Affected communities, as a result of HIV activism, have more formally organized for advocacy and prioritization.   Philanthropies, ranging from the Wellcome Trust to new organizations such as the Children’s Investment Fund Foundation, are often focused on driving innovation and the creation of data-driven and scalable interventions. Finally, the private sector actively engage in a variety of roles, from worksite programs in endemic countries, as a manufacturer of commodities at large scale, and a co-funder of national and global efforts (such as through the RED campaign).

These actors are involved in their respective sphere of expertise, and increasingly, engage in global boards, technical advisory groups, and coordinating committees. Their engagement both enriches and complicates the global health governance landscape. Their practical expertise provides value and new points of view, but their role in global and governance is at time challenged by their lack of legitimacy in the national and international framework (Fiedler, 2010).

Much has been written about the governance role of the World Health Organization during this transition (Frenk and Moon, 2013; Ruger, 2014). Lacking a global government, the WHO is the leading UN health organization whose constitutional mandate is to represent countries and their strategic alignment, through the generation of technical consensus on priorities and interventions required to tackle health problems of global significance. Thus, the WHO has legitimacy in its endeavors to manage cross-border pandemics and create consensus around priorities such as eradication initiatives. At the same time, the organization is castigated for lack of transparency, complexity of processes, lack of an appropriate ethical framework, a complex and burdensome human resource infrastructure, and either lacking sufficient funds to accomplish its mission, or seeking too much funding external to that allocated from country budgets. A recent governance scorecard by the Council of Foreign Affairs (Council on Foreign Relations, 2014) also points to the lack of available resources to support the non-communicable disease agenda, in spite of impact on poorest countries. Approvals from the governing body, the World Health Assembly, can create an unfunded mandate and are meaningless without a budget with which to implement.

In spite of the challenges, there is evidence that global governance for health is adapting. WHO has created initiatives to push for attention to a global research framework that reflects national priorities. Both GAVI and the GFATM have functioning boards and systems for decision-making. The GFATM board includes representation from private sector, communities, and other members of civil society. Its new funding model, while generating a “learning curve” for countries to manage the opportunities and requirements for each funding window, does place country strategic plans with input across sectors at the center of the discussion (Kiddell-Monroe, 2013). Moreover, WHO continues to engage with the array of global health partnerships, whether they sit at WHO (Roll Back Malaria, for example), or have become independent organizations (Global Alliance for Improved Nutrition).

One challenge facing the field is how to prioritize the global agenda to replace the MDGs. Termed the Sustainable Development Goals (SDGs), these are a work-in-progress. As of July 2014, 17 priorities were being hotly contested in a multiyear process that started with a High Level United Nations Panel and then transferred to an UN Open Working Group that increases country ownership. Key questions on how these will be implemented and financed remain. There is a call for “universality” – that rich countries, rather than just the poorest countries, must also be engaged for effective global impact. In parallel, expert groups have presented consensus on priorities for achieving health for 2035 (The Lancet Commission on Investing in Health, 2013). Ultimately, good governance –where priorities, leadership, and programs align in intention and commitment– will determine whether the SDGs have the same focus, national commitment, and potential for impact on health and beyond that made progress on the MDGs possible.  While initially uncertain, it is now clear that health will remain on that agenda (Chan, 2014).


Chan M (2014). Health has an obligatory place on any post-2015 agenda. Address to the Sixty-seventh World Health Assembly, Geneva, Switzerland, 19 May 2014. Geneva: WHO; 2014. Available at:

Council on Foreign Relations (2014). Report Card Backgrounder on Global Public Health.  Washington, DC: Council on Foreign Relations, International Institutions and Global Governance Program.

Fiedler DP (2010). The Challenges of Global Health Governance. Working Paper. Washington, DC: Council on Foreign Relations, International Institutions and Global Governance Program.

Frenk J, Moon S (2013). Governance Challenges in Global Health. NEJM, 368:936-42.

Kiddell-Monroe R (2013). A Non-State Centric Governance Framework for Global Health. Working Paper for ISGlobal Think Tank. Barcelona: ISGlobal Barcelona Institute for Global Health. 

Ruger JP (2014). International institutional legitimacy and the World Health Organization. J Epidemiol Community Health, 68:697-700.

The Lancet Commission on Investing in Health (2013). Global health 2035: A world converging within a generation. Lancet, 382:1898-955.

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Editores del boletín: Carlos Campillo ( y Cristina Hernández Quevedo ( Editora de redacción: Cristina Hernández Quevedo ( Comité de redacción: José Mª Abellán Perpiñán, Manuel García Goñi, Ariadna García Prado, Miguel Ángel Negrín, Vicente Ortún, Luz María Peña. Han colaborado en este número: Josep M. Argimon, Alina Baciu, Soledad Benot López, Anna García-Altés, Silvia Garrido García, Paula González, George Isham, Francisco Jódar Sánchez, Inés Macho Stadler, Rose Marie Martinez, Laia Maynou-Pujolràs, Ricard Meneu, Alec Miners, Toni Mora, Ana I. Moro Egido, Pau Olivella, Vicente Ortún, Francis Ruiz, Martin Sepulveda, N. Regina Rabinovich, Eduardo Sánchez-Iriso, David Sánchez Pardo, Marcos Vera-Hernández.