Making international health regulations work: lessons from the 2014 Ebola outbreak.

• Author: Lee, Tsung-Ling
• Position: III. International Financial Institutions and the Global Governance of Health through V. Conclusions: Advancing Global Health Security, with footnotes, p. 970-987

3. INTERNATIONAL FINANCIAL INSTITUTIONS AND THE GLOBAL GOVERNANCE OF HEALTH

   Instead of analyzing the 2014 Ebola outbreak as partly a function of the WHO's institutional and governance failures, the Article now broadens the discussion and situates the debate in the context of the global governance for health. Admittedly, confluences of historical factors--civil wars, colonialism, and slave trade--have lingering effects on the fragile health systems found in West Africa. Since the Article is interested in promoting international cooperation in the realm of the global health security vis-a-vis international organizations, this Part focuses the International Financial Institution's (IFI) structural adjustment policies (SAPs) in particular, and foreign aid in general. In so doing, this Part highlights the need to embed public health norms in an international system and the need to re-establish the WHO's leadership in the realm of global health. The discussion here does not, by any means, suggest that past IFI practices are indicative of its future role in global health. Rather, the discussion here highlights that economic development remains the primary goal that guides the IFI's development projects, which, at times, can be in conflict with public health. The discussion also underscores a normative need for the WHO to voice moral concerns on behalf of the world's most vulnerable populations, as mandated in its Constitution.

   The involvement of the IFI in failed or failing states' health systems is well documented. (201) The World Bank's poverty alleviation mission often overlaps with the WHO's public health mandate. The World Bank's involvement in the economic and social developments in countries receiving support often has concomitant effects on the population's health. (202) Beginning in the 1990s, the World Bank's involvement in health projects also increased substantively, as it was increasingly recognized that health is integral to an individual's and a country's economic productivity. Yet the IFI's policy prescriptions for improving health and wellbeing in the recipient country remain grounded in neoliberalism: competitive markets are viewed as a crucial component of a functional healthcare system. (203) Many scholars and practitioners thus credited the World Bank's neoliberal agenda as a key contributor underlying the fragile health systems found in West Africa. (204) Despite the IFI's historical role in failed states' health systems, some scholars remain optimistic about the potential role of the IFI in shaping global health. Political philosopher Jennifer Prah Ruger, for instance, argues that the World Bank, with its enviable financial clout, can help establish good governance in health sectors at the country level. (205)

   From a development perspective, good health is essential for economic productivity. (206) Prompted in part by the escalating health care costs globally, the World Bank began to incorporate health into its development paradigm beginning in the 1990s. The 1993 World Development Report, Investing in Health, helped inaugurate a market-based view of health systems. (207) The World Development Report identifies four key underlying factors that explain the rising health care cost worldwide: misallocation of funds to less cost-effective intervention, inappropriate deployment of medical staff and resources, inequity in access to basic health care, and the disproportionate cost of healthcare compared to income growth. (208) The World Bank's policy prescription focused chiefly on improving health indicators through a three-pronged approach: educating girls and empowering women, focusing on cost-effective public health services, and, most controversially, promoting "greater diversity and competition in the financing and delivering of health services." (209) The 1993 World Development Report soon became the blueprint for the World Bank's health projects. Unlike the WHO, the World Bank enjoyed considerable financial leverage from its lending practices with recipients, and it extended the World Bank's reach beyond the economic sphere. Some scholars go further and argue that the World Bank, with its enviable financial clout, has replaced the WHO as the lead agency in health, sidelining the WHO to technical support in health matters. (210)

   It is worth noting that while, in general, health outcomes (such as life expectancy and infant mortality rates in developing countries) have improved considerably since the World Bank's involvement in the health sector, the extent to which the improved health outcomes can be attributed to the World Bank's projects remains highly disputed: the World Bank in fact conceded that it is difficult to gauge the success of its advice and investment programs in improving health outcomes because of the difficulties in qualifying it. (211) A considerable body of literature suggests that the World Bank's involvement in health and economic projects in Africa contributed to the diminishing role of the state as the primary provider of healthcare and other basic social welfare. The waning role of the state in the realm of welfare provision in part explained the slow containment of the 2014 Ebola outbreak. Opponents of the IFI's neoliberal agenda have long warned that the market-oriented policies are often ill-equipped to accommodate social welfare concerns. (212)

   Notably, much of the 1993 World Development Report's policy recommendation echoes the World Bank's now famous study of Sub-Saharan Africa, published in 1981 (the "Berg Report"). This report cites the inefficient use of government resources as a key cause of the poor economic performance in Africa. (213) In broad strokes, the Berg Report recommends reducing public expenditure on social welfare to remedy poor economic performance in Africa, and the IFI embraced the neoliberal ideology that underlies the Berg Report wholeheartedly: IFI loans were conditioned on commitments of its recipients to market-based reform. (214) This loaning practice was grounded in an unyielding faith in the market, which was perceived as an effective engine for coordinating individual needs and societal interests, in keeping with the IFI's neoliberal development paradigm. (215)

   Consequently, the IFI's lending practices have resulted in diminishing healthcare spending in recipient states--as recipient states embraced neoliberal economic policies, hospitals and healthcare job opportunities became fewer, and healthcare quality and the qualified healthcare workforce also decreased considerably. (216) The dramatic reduction in social welfare spending has reversed much of the health progress achieved in recipient countries over the last five decades. (217) A waning healthcare infrastructure also has spillover health and security implications because it creates a gap in global health security. (218)

   Incidentally, as the SAPs became increasingly pervasive in countries in Africa during the 1980s and early 1990s, the role of local faith-based organizations, international nongovernmental organizations (NGOs), and humanitarian networks also became more prominent, if not critical, in providing social services. (219) The waning role of the government in providing basic social services in the two decades since the SAPs were implemented created a space for NGOs to overtake the welfare function that was previously the exclusive domain of the government. The shifting roles between the state and the non-state actors proved to be problematic, at least in terms of coordination, as was evident in the 2014 Ebola crisis.

   However, beginning in the 1990s, health began to gain considerable political traction in the international development discourse; this discourse resulted in an unprecedented number of global health initiatives, programs, organizations, and actors in the global health landscape. Most commonly, these new initiatives tended to focus on specific interventions or practices--for example, the Global Fund to Fight AIDS, Tuberculosis and Malaria, Global Alliance on Vaccines and Immunization, and The Vaccine Alliance. This diversity of global health actors, issues, and activities reflected the growing political interest in improving health, but the uncoordinated, and often ad hoc initiatives also produced an incoherent legal order, resulting in uncertainty about the normative principles that guide global health.

   As a legacy of SAPs, nongovernment actors and international aid organizations--MSF being most prominent--became the primary providers of health care. As these aid organizations tend to focus on specific disease prevention, this incidentally overshadowed the need for horizontal integration of health services at national level. Likewise, because local and international NGOs tend to focus on vertical programs, targeting specific diseases and population groups, this further diminished the need for developing comprehensive public health systems and surveillance at national and regional levels. While the involvement of NGOs in the realm of disease prevention is welcome, local and international NGOs have different functions, aspirations, capabilities, and emphases, which create a fragmented healthcare landscape.

   The increased influence of the IFI and the multiplicity of new actors in the realm of global health contribute to what scholars commonly term "fragmentation" and "duplication." (220) The WHO now operates in a competitive environment where international and local actors, at times, compete against each other: recipient states now partner with international agencies based on what best matches their preferences. (221) This phenomenon of fragmentation is not isolated to the realm of global health. (222) Scholars also observe that the international climate change governance exhibits a similarly fragmented characteristic. (223) Although, some scholars argue that fragmentation is not necessarily a bad thing because fragmentation can catalyze competition...