Global health justice and governance

Prah Ruger, Jennifer (2018). 'Global Health Justice and Governance' Paper presented at the annual conference of the HDCA, Buenos Aires, Argentina 2018.


Serious health threats confront humankind. Unconscionable inequalities consign many millions to inadequate health care or no care at all, to a life of destitution and early death. Globalization has accelerated the spread of dangerous contagions at an unprecedented pace. Cross-border issues raise questions about who can receive medical treatment and where, at what cost. These health failures are morally arbitrary, dependent on accidents of birth or nationality, or simply the misfortune of sitting near an infected air traveler. They prod our collective conscience and present compelling moral imperatives.

Global health institutions, including the World Health Organization and other United Nations organizations, the World Bank, the vast numbers of foundations, civil society organizations and other actors, and nations themselves have been unable to address global health problems sufficiently. Health actors have proliferated dramatically, and the global health enterprise has become kaleidoscopically fragmented and chaotic. The modus vivendi underlying the activities and interrelationships of these actors arguably works against resolving the world’s health challenges. Decades old international problems in health governance still persist today. These problems present serious ethical questions and demand a normative theoretical foundation as we seek their solutions.

Theories of global justice fall into four main perspectives: realism, particularism, social contractarianism (society of states), and cosmopolitanism. But health justice remains largely unheeded in these justice theories. More recently, some theorists have turned to health; the perspective most frequently used to ground health obligations is the human rights view. Yet all these frameworks fall short of providing the necessary normative foundation for global health justice. Nor does global bioethics as a discipline address global health justice adequately. Health-sphere actors—global, state, and non-state—need to understand their interests more comprehensively. A more fully developed moral framework and ethical guidelines are essential if health-sphere actors are to tackle global health problems effectively.

Critical and dangerous threats imperil global health. Extreme health disparities, dangerous contagions that can circle our globalized planet in hours, a bewildering confusion of health actors and systems all combine in a kaleidoscopically fragmented, incoherent, and unjust global health enterprise. While a growing body of work in global justice and international relations explores moral issues and global governance, very little of it has linked principles of global health justice to governance to create a theory of global health. But the dangers confronting the world make a theoretical framework essential, to enable analysis of the current system and to ground proposals to reform it and align it with moral values. This project presents a global justice theory—provincial globalism (PG)—and links it with the theory of shared health governance (SHG) to offer an alternative to the prevailing modus operandi, which has manifestly failed to serve global health. The PG/SHG framework advances health capability, and specifically the capability to avoid premature death and preventable morbidity, as the proper goal of health systems. This framework sees human flourishing as global society’s end goal and proposes an ethical demand for health equity as the criterion for evaluating global health policy and law. It examines the current actors in global health, assessing their strengths and weaknesses, and proposes assigning responsibilities to actors at all levels according to their functions and capabilities.

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