New Multilateralism for Promoting Equity and Global South Agency: Principles, politics and strategies for remaking the global health architecture
Sakiko Fukuda-Parr, Alicia Ely Yamin and their co-authors argue that we must go beyond nostalgia for the global health order that was, and focus on creative innovations and coalitions to ensure equity and Global South agency going forward.
As Lina Ghukasyan argued in her 16 June opinion piece, this time demands a reimagining of multilateralism, not a return to arrangements of the past. In no domain is this more apparent than in global health, where the US retreat has upended key institutions, norms and financing. Rather than seeking to repair what we have lost, we need to seize the opportunity to remake a system that is more democratic and meaningfully prioritizes equity.
The architecture of global health is increasingly criticized as being marked by a concentration of power, driven by donor interests and knowledge hierarchies, and, despite decades of anti-colonial struggles for change, trapped in colonialist dynamics and mentality. To the extent it is a system, it is one that fails to deliver equity at critical moments, as vividly demonstrated by the dysfunctions of vaccine production and distribution during the Covid-19 pandemic.
Drawing on a recent convening of scholars held at Harvard, this commentary outlines the principles and strategies for a new multilateralism in global health, focusing on longer term structural changes that are needed to promote health equity and greater agency of the Global South.
Ten Essential Principles
1.Resist dismantling global health infrastructure: Multilateralism – collective resources, action and coordination – is critically necessary for global health. The US retreat and loss of funding for core institutions presents an existential threat. The rest of the world needs to resist the dismantling this infrastructure, while at the same time, the institutions need to be rethought and reformed, and new ones created.
2. Redesign global health architecture for equity: Our starting premise is that the old “liberal world order” within which global health is embedded is not, nor has ever been, designed for equity. Built after the end of World War II, it was designed by the Western powers led by the US to serve their interests. The current phase of the “liberal international order” increasingly resembles a form of privatized multilateralism that prioritizes the interests of multinational corporations, economic elites, and established powers in the Global North. Capitalism has evolved in the 21st century from free market neoliberalism to monopoly capitalism that suppresses competition and finance capitalism that undervalues real innovation. The result is that today our global economic order is poorly aligned with social goals, including global health equity.
3. Appropriate role of global institutions: Multilateralism is critically necessary, but in the current geopolitical and geoeconomic realities, we need to think about the appropriate roles of different levels of global governance: global, regional, national and local. In line with the principle of subsidiarity, global institutions should prioritize addressing those problems that are global in nature - those which cannot be addressed by a country on its own and require collective global action. Provision of essential global public - or common - goods, such as technology for global diseases should be high on that list of priorities.
4. Regional institutions: Collective action can build on common interests and histories of regions and regional institutions could play an important role in global governance. Resource constraints are real but initiatives such as the creation of Africa CDC show the potential of regional institutions as levers to shift power to low- and middle-income countries.
5. Local institutions and civil society: Local governments and civil society – NGOs, community organizations, labor unions, and others - have become first responders to crises and in addressing real needs of people. They have the local knowledge and expertise to build sustainable and effective systems on the ground, which can be monitored in real time for meaningful improvements and accountability. They are often far more agile and innovative than multilateral institutions.
6. Ethical values and human rights: Progressive transformation requires solidarity and commitment based on both ethical values for global equity and justice as well as self-interest. Commitment to human rights as a universal set of values has been weakening in recent years due in part to the failure of governments to deliver on promises related to economic and social rights, and in part to organized opposition to changing norms—many of which relate directly or indirectly to health such as LGBTQ+ rights and abortion. Cynical characterizations of human rights as purely Western and “foreign” coexist with well-founded skepticism of rights that have been deployed selectively by the Global North against the Global South. Building an international praxis of human rights and global justice that addresses the consequences of global economic integration and is fit for purpose in an interdependent world is an urgent priority.
7. Agency and leadership of the Global South: A more democratic global health architecture requires greater agency and leadership from the Global South with alliances with countries of the North. This will require reducing dependent relationships with the North, especially for finance and technology. It will also require a radically different approach to creating knowledge in and about global health, which currently relies disproportionately upon academic and technical institutions in the global North.3,11
8. Technology: In addition to significant technology transfers, major investments are required in the Global South to develop their capacity to manage their use and access new technologies in a rapidly evolving innovation ecosystem to pursue health equity priorities. An important new trend is the emergence of substantial capacity in many middle-income countries. African countries have also taken significant steps in this direction, with the establishment of the Africa CDC, the plan to develop vaccine manufacturing capacity, and other initiatives. A priority must be to reform intellectual property regimes designed for health equity, and more strategically using what policy space that is available within the TRIPS flexibilities. The upending of multilateral trade regimes may also open opportunities for the Global South to renegotiate or to resist retaliatory actions against the use of compulsory licenses.
9. Finance: Replacing financial dependence on the US with dependence on other countries or philanthropies merely perpetuates the power hierarchy of global health. New sources of finance for Global South governments should be explored that reduces dependence, such as the use of a ‘Tobin tax’ on global transactions; airline tax and carbon tax that are already in use by several governments since 2006 to finance UNITAID and its medicines patents pool. Other potential sources to explore include taxes on extreme wealth, sovereign wealth funds, and capital flows involving hedge funds and private equity. Effective measures to ensure the same rate of taxation for multinational corporations and domestic companies in countries where they operate, and curbing illicit financial flows would stem the pillaging of resources from the South to the North, which greatly exceed development assistance flows in the opposite direction. The UN Framework Convention on International Tax Cooperation in development is currently the world’s best chance to rein in this pillaging and establish a common and fair framework under the UN, as opposed to the control of the Global North through the Organization for Economic Cooperation and Development (OECD). Likewise, debt payments extract enormous wealth from the Global South, where payments to service external debt now exceed spending on health in many countries.
10. Governance frameworks: Whatever new funding sources are explored, it will be essential to establish new frameworks of governance based on lessons learned. The concentration of power and funding increases dependency; and while philanthropic actors play an important role, they remain unaccountable and their operations opaque. The funder-recipient relationship needs to be reset within an agreed framework that enables all states, together with civil society, to have a voice in the progressive achievement of health and climate goals through long-term public investment. South-South cooperation should play a more important role. More fundamentally, the current framing asks ‘what can health do for the economy’ and justifies investments as a means to strengthen human capital for production. We need to flip this question on its head to ask ‘what can the economy do to promote global health and human flourishing?’.
Politics and strategies
Who might take up the role of mobilizing and leading the transformation of global health into a more democratic system that can deliver on health equity?
There is no obvious actor who is likely to emerge. China has the political and economic power to lead but has not done so to date. There are other important countries and blocs that could play an important role such as the Gulf States, BRICS, or regional blocs. Yet all of these actors face obstacles such as fragmented domestic politics, constrained public finances, and shallow political support for global health equity. None has the broad financial and political clout to lead a radical transformation, and the current geopolitical environment presents multiple structural obstacles to building a united coalition for reforming global health architecture. The strategy for remaking global health will need to build on multiple alliances on multiple fronts. Building the new global health order requires agility and opportunism.
Where the 20th century multilateralism was dominated by hegemonic powers and funders, and dependent on UN bureaucracies, large philanthropies and private-public partnerships, the architecture of new multilateralism for global health equity will need to will be polycentric and less hierarchical in structure. It will involve states, philanthropies and the private sector, but the role of civil society networks, labor unions, people’s movements, think tanks and academic institutions, local governments, and regional institutions will be critical. Such coalitions are well-placed to build political power and shift discourses on multilateral norms that serve the interest of most states, as shown by the momentum of the movement to develop the UN framework convention on Tax Cooperation to address tax avoidance.
In short, even as we attempt to find our feet in these shifting sands, it is crucial that we reflect on how we got here in order to move toward a global order in which we can advance meaningful progress toward equity. The upending of the global order in which we have been operating for years has created enormous suffering, but this moment calls for creative innovations rather than nostalgia for a global health order marked by colonialist knowledge and decision-making power and the structural privatization of wealth that has gone unabated for decades around the world.
Sakiko Fukuda-Parr is a Professor of International Affairs at The New School.
Alicia Ely Yamin is a Lecturer on Law and Director of the Global Health and Rights Project at Harvard Law School’s Petrie-Flom Center, as well as an Adjunct Senior Lecturer at the Harvard T.H. Chan School of Public Health
The remaining authors in alphabetical order:
Gian Luca Burci, JD is an Adjunct Professor of International Law at the Graduate Institute of International and Development Studies in Geneva
Dr. Paulo M. Buss, MD, MPH, DSc, is an Emeritus Professor at the Oswaldo Cruz Foundation (FIOCRUZ) and Director of its Center for Global Health.
Michael Cohen Ph.D is the Director of the PhD in Public and Urban Policy program at the Milano School of Policy, Management, and Environment, and professor of international affairs at the Julien J. Studley Graduate Programs in International Affairs at The New School.,
Camila Gianella, MSc, PhD, is an Associate Professor at the Pontificia Universidad Católica del Perú.
Jayati Ghosh, PhD, is a Professor of Economics at the University of Massachusetts Amherst
Jonathan Glennie MA is the director of the Global Cooperation Institute
Siri Gloppen, PhD, is a professor of Comparative Politics and dean at the University of Bergen, and the founding Director of the CMI-UiB Centre on Law and Social Transformation (LawTransform).
Joseph Harris, PhD, is an Associate Professor of Sociology at Boston University.
Yanzhong Huang, PhD, is a professor and director of global health studies at Seton Hall University’s School of Diplomacy and International Relations.
Richard Kozul-Wright, PhD, is the director of UNCTAD’s globalization and development strategies division.
Professor Carlos Lopes PhD is an Honorary Professor at the Nelson Mandela School of Public Governance, University of Cape Town, Visiting Professor at Sciences Po, Paris, and an Associate Fellow at Chatham House, London.
Manjari Mahajan Ph.D is an Associate Professor in the Julien J. Studley Graduate Programs in International Affairs and the Starr Professor and Co-Director of the India China Institute at The New School.
Ole F. Norheim, MD, PhD, is the Mary B. Saltonstall Professor of Ethics and Population Health at Harvard T.H. Chan School of Public Health and co-foundedr of the Bergen Centre for Ethics and Priority Setting at the University of Bergen, Norway.
Ole Petter Ottersen, MD, PhD, served as the elected Rector of the University of Oslo (2009–2017) and as President of Karolinska Institutet in Sweden (2017–2023).
Photo by Nataliya Vaitkevich
