The current global health architecture does not represent this ideal. A major problem with the current system, I argue, is that it can be characterized as operating under the assumptions of a rational actor model of international cooperation. The  current global health environment is comprised of a collection of individual actors who  are rational decision makers. This assortment includes individuals (e.g. a minister of health), groups (e.g. non-governmental organizations like Medicins Sans Frontieres, Oxfam, Self-Employed Women’s Association and foundations such as the Gates, Ford and Rockefeller Foundations), institutions (e.g. the World Bank, UNICEF, WHO, UNAIDS), public-private partnerships (e.g. IAVI and GAVI), and nation-states (and the
public institutions within them such as the legislative body, the executive, the bureaucracy, ministries or departments of state, sub-national bodies and local authorities). This architecture can be adequately described by the rational actor model, because each actor has its own set of goals and objectives and these actors each take account of their own goals and take actions based on analysis of the costs and benefits associated with various options available to them. Moreover, even within many multilateral institutions, the most powerful actors within the institution (especially multilaterals without a democratic governance structure), dominate and effectively control policy and resource allocation decisions in terms of their goals and objectives.
And even many NGOs, which have a distinctly populist fervor, represent themselves and their own interests, not their so-called constituencies, in national-level mechanisms such as the Country Coordinating Mechanism established by the Global Fund.

The current landscape in global health represents a record number of global health actors and financial commitments, both public and private, and is no longer the domain of the UN system and the World Bank. In 2000 alone, over 17 new publicprivate partnerships were launched. In addition to the WHO, World Bank, and the European Union, some of the largest players are relatively new and include the Gates Foundation, the United States President’s Emergency Plan for AIDS relief (PEPFAR) and USAID, The Global Fund to Fight AIDS, Tuberculosis, and Malaria (financed by donations from governments, philanthropists, corporations, etc.), and corporate actors (e.g. pharmaceutical companies.) The Global Fund, for example, now provides roughly 20% of all global funding of HIV/AIDS programs and 65% of funding for TB and malaria. The Global Fund is the quintessential contemporary global health initiative, focused on selective aid for narrow programs of disease control in particular countries and a trajectory of monitoring and evaluation of process and intermediate indicators at the expense of developing broader health systems. Health systems, while not as high profile as specific diseases like AIDS, are an essential building block for sustainable health long term.

A recent study of international cooperation in health identified several key factors that characterize donor support for recipient countries. These factors include a rather narrowly defined set of criteria for success (e.g. performance results based on organization criteria rather than health outcomes), overlapping mandates, competition and duplication of health activities, shifting power structures, and poor coordination.  As a result, most technical assistance, grants and loans actors provide to developing countries comply with donors’, rather than countries’, organizational priorities, policies and values. This phenomenon is known as donor-driven development. And because these efforts are evaluated by organizational criteria (e.g., number of loans dispersed,
amount of funding provided), they are not subject to critical scrutiny in terms of their ultimate impact on health and disease control. In 2006, for instance, the World Bank estimated that half of aid for health in sub-Saharan Africa fails to reach intended recipients (clinics and hospitals.) Another study of children’s vaccines and immunization programs found that countries were delayed in the uptake and financing of new vaccines due to confusing priorities and policies at the global and country level. This confusion and paralysis was created by overlapping interests of numerous organizations such as the WHO, partners of the Task Force on Child Survival, GAVI, the Children’s Vaccine Program of the Melinda and Bill Gates Foundation.

Conflicts among actors create competition and duplication of health activities that stress developing country governments to manage each donor’s project in terms of organizational accounting and reporting requirements. These goals often conflict with what might be best for a recipient country at any given time. The World Bank and wealthy industrialized countries have been the focus of criticism for competitive behavior with other international institutions and countries and with different groups within developing country governments. The World Bank and the Japanese government, for example, have been critiqued for undermining the long term sustainability of Ministry of Health efforts, for example, in tuberculosis control in Nepal where the
Japanese governments’ donation of the TB drug rifampicin distorted the sourcing, prescribing practices and long term sustainability of the Nepalese governments’ tuberculosis control program. In Tanzania and in Kenya donors undermined the governments’ essential drug distribution system in one case and its production of pharmaceuticals for treatment of sexually transmitted diseases in the other by creating their own in facilities and systems parallel to the Ministry of Health. Most donor funding is disease and program-specific, determined by donor preferences and priorities, not health needs, and fails to address weak institutional capacity in country.

As a result of competition, duplication and poor coordination among actors, the burden and mayhem at the country level is evident in numerous recipient countries. In 2003, the OECD commissioned a study of the effects of donor practices in 11 recipient countries. In that study, five of the highest burdens for recipient countries included: difficulties with donor procedures, donor-driven priorities and systems, uncoordinated donor practices, excessive demands on time, and delays in disbursements.  In another study of donor practices in Mozambique, Tanzania, Uganda, and Zambia, all countries that had successfully received Global Fund resources, researchers found in all four countries difficulties at the country level in incorporation of additional global fund resources above and beyond existing funding and partnerships and concluded these countries were bombarded and overwhelmed by the need to juggle activities among multiple donors.45 In Uganda alone, 20 different global health initiatives were in play.

Common Goals and Common Commitments

While the rational actor model is predominant in global health governance, a few examples of successful collective action stand out as model partnerships for global health cooperation. Successful coordination among agencies can be found, for example, in the Onchorcerchiasis Control Program, the Task Force on Child Survival, and the Global Polio Eradication Initiative. All of these examples of global health cooperation exhibit four general characteristics: partnerships defined by a shared common goal; clear objectives and agreed upon respective roles and responsibilities; delineation of complementary expertise and accountability in the means to achieve goals; and donors’ willingness to step back and allow other agencies to take the lead in goal achievement.

A necessary ingredient to successful collective action on global health is shared common goals. In order to achieve consensus, global health governance must move beyond the rational actor model to a normative model of social agreement theory, in which actors achieve consensus on shared values to achieve stability and social unity. I draw on John Rawls’ notion of an “overlapping consensus” to clarify this dynamic. The overlapping consensus framework emphasizes the need to determine shared values — even values that are shared for different reasons — and emphasizes the necessity to achieve social agreement for collective decision making. Social agreement theory can help us understand how public values are effectively internalized by citizens and their representatives and connected through stable coalitions.

John Rawls draws a sharp distinction between political bargaining models, which I associate with a rational actor model, and conceptual models rooted in political philosophy and legal doctrine. He suggests that political process models based on political bargaining are akin to a modus vivendi — a “social consensus founded on selfor group interests, or on the outcome of political bargaining: social unity is only apparent…”.  A modus vivendi is thus a consensus on “accepting certain authorities, or on complying with certain institutional arrangements, founded on a convergence of selfor group interests” For example acceptance of an international agreement among the G-8 nations as a result of trading favors would be unstable because the bargain would be “contingent on circumstances remaining such as not to upset the fortunate convergence of interests”.  Thus, if the power relations shift or if the position of certain countries changed, and powerful countries were no longer in a position to strike the bargain and hold their countries to it, the international agreement would no longer be followed. Agreements based on modus vivendi are also less stable than agreements based on a true overlapping consensus because the former depend more on “happenstance and a balance of relative forces”. An international consensus on paper, such as the Millennium Development Goals, for instance, does not necessarily signify a true consensus and guarantee achievement of those goals. For example, successful
implementation of polio and smallpox eradication requires each country to continue to immunize their children, even if that country has been free of the disease for sometime. It is especially important for neighboring countries to collaborate in eradication programs to reduce the chance of transmission across borders. Each country has to agree to and commit to achieving this underlying goal.

There are additional reasons for a distinction between social agreements based on an overlapping consensus and those that result from political bargaining. First, as Rawls notes, the object of an overlapping consensus is itself a moral conception, such that it is valued in itself. Second, the overlapping consensus is affirmed on moral grounds and includes “conceptions of society and of citizens as persons, as well as principles of justice, and an account of the political virtues through which those principles are embodied in human character and expressed in public life”.
In other words, it represents a consensus among elites, and in this case, citizens as well, on the public good, which may rise above the intersection among group- or self-interests. Third, the overlapping consensus is more stable because it is not simply a balance of power, but is instead a reasonable consensus. A modus vivendi, by contrast, reflects a temporary agreement among different and opposing peoples and parties. Thus, the overlapping consensus framework increases stability because those who affirm a decision “will not withdraw their support of it should the relative strength of their view in society increase and eventually become dominant”. Fourth, a social agreement framework attempts to draw out “certain fundamental ideas viewed as latent in the public political culture of a democratic society”.52 As such, it attempts to tap into individuals’ true values, even if individuals and their representatives have difficulty articulating those values in a completely theorized way. Fifth, this type of framework contrasts legitimate political authority with political power. For example, it differentiates “an account of the legitimacy of political authority” from “an account of how those who hold political power can satisfy themselves, and not citizens generally…”. Stability is not promoted, by “bringing others who reject a conception to share it, or to act in accordance with it, by workable sanctions…”.  Instead, it is promoted by a reasonable consensus on a political conception that is politically legitimate. Political legitimacy, in turn, involves a “public basis of justification and appeals to public reason, and hence to free and equal citizens viewed as reasonable and rational”.

From this social agreement perspective, legitimate political authority is not just a matter of political philosophy; it has pragmatic advantages in forging consensus and coalitions in global health cooperation. In this way, a social agreement framework helps illuminate the rational actor model because it throws light on how political actors can undermine the conditions for reasoned agreement on common interests. It calls for research to examine whether the conditions of international diplomacy help produce an informed, reasoning, and deliberative decision making and implementation process.

At the national level, a social agreement model of policy-decision making emphasizes public deliberation, responsible leadership, and mass communication and relies on popular sovereignty and political leadership to enhance deliberative public debate and public reasoning in order to agree on the common good. In many developing countries common ground for reaching agreement on the ethical principles that govern health and health care has yet to be achieved, yet it must be realized to establish accord on policy and implementation to achieve equity in health.

Governance to Achieve Equity in Health

Reducing global health disparities requires social organisation and collective action of four key functions: redistribution of resources; related legislation and policy; public regulation and oversight; and creation of public goods. Redistribution of resources is conducted between groups within and between societies. Policy measures are required to make transfers and include progressive taxation, equitable and efficient risk pooling, redistributive expenditure patterns, subsidies and cash transfers. In many countries, especially those in the developing world, the distribution of resources within society is inequitable. In such areas of social organisation and collective activity, ethical commitments are required.

Ethical commitments are required because without such norms, it is not possible to socially organize and redistribute resources; the efforts to do so must be voluntary and not coerced, and they must be based on moral grounds. This is because individuals must sacrifice some of their resources and autonomy to be regulated and redistribute those resources to others. Once individuals internalise these ethical commitments, they freely enter into them and create obligations for individuals to obey them. Individuals also need to internalise public moral norms that motivate their social action towards other regarding or altruistic behaviour. Individuals who are willing to give up some of their autonomy and resources through collective action can take steps towards achieving this goal.

Internalizing a public moral norm of equity in health at the collective and individual levels is important because the regulation of self and society requires not just self- and national interest or even legal instruments, but individuals and groups armed with internalized public moral norms — as part of their own internal value systems – to inform choices individuals make for themselves, their institutions and their society to take positive measures to ensure that all individuals have the opportunity to be healthy. Such internalization in turn leads to domestic and global policies to ensure the long term sustainability of an ethical demand for equity in health.

A paradigmatic change from rational actor to normative commitments in global health governance also changes the framework for evaluating the health activities of global and domestic actors. Domestic (national and sub-national governments) and global (the World Health Organization, the World Bank, the Gates Foundation and bilateral aid and assistance) actors in a global health governance architecture must be evaluated in terms of their effectiveness in contributing to and advancing the overarching goal of equity in health. Thus, even though wealthy foundations and
powerful developed countries have a legal right to spend their money in accordance with their own objectives, they have an ethical obligation to do so in a manner that will improve the prospects of achieving equity in health in conjunction with the constellation of other actors in the domestic and global arena. This is a one goal, multiple actors, approach to global health governance, in contrast to a multiple goals and multiple actors approach that characterizes the current disjointed, ad hoc, redundant and ineffective system.

Shared Health Governance

How do multiple actors in a global health governance system work together to achieve a common goal. Although the overarching framework espoused here delineates duties and responsibilities for both national and international actors, the primary duty falls to nation-states who have the most direct and prior obligations. Individual nationstates must assume primary responsibility for health policy within their own borders and must generate the majority (and eventually all) resources for health, with a goal toward reducing entirely aid from multilateral, bilateral, or NGO sources. The extent of extra-national or international obligations is thus defined in the context of the scope and limits of national obligations. Secondly, it is important to highlight the need for a variety of institutions; the framework presented here and elsewhere   is one I call shared health governance, whereby state and international governments and institutions along with non-governmental organisations, communities, businesses, foundations, families and individuals are responsible for shared governance in correcting global health injustice. Global and national institutions and actors’ roles relate to the functions and their comparative roles in dealing with deprivations in health functioning and health agency.

Global actors and institutions, whether they act bilaterally (especially direct overseas development assistance, trade agreements) or multilaterally (through eg, the United Nations system, World Bank or International Monetary Fund), are obligated to remedy global inequalities that exist in affluence, power, and social, economic and political opportunities. Global actors and institutions, while serving a secondary rather than primary role in achieving just health outcomes, nonetheless represent the will of the international community not only to function collectively on national interest but to rectify global market failures, create public goods and address concerns of fairness and equity on a global scale. Global actors and institutions should have a supportive and facilitative role such that countries can develop, flourish and promote health. The focus should be on a broad approach that deals with all determinants of health and poverty,
not a narrow, technical approach. In terms of the macrosocial environment, global actors and institutions should pursue the following: facilitate growth in developing countries; promote global financial stability; finance global public goods; develop country participation in global fora; provide debt relief and development assistance; offer fair trade and open markets to developed countries; provide technical assistance and know-how to developing countries; and finance global public goods.

Global health institutions have a more narrow set of obligations and duties around four sets of work: generate and disseminate knowledge and information; empower individuals and groups in national and global fora; provide technical assistance, financial aid and global advocacy for equitable and efficient health systems; and coordinate institutions to exclude redundancies.59 In terms of generating and disseminating knowledge and information, global health institutions can help create  new technologies; transfer, adapt and apply existing knowledge; manage knowledge and information; create and set standards and international instruments; and help countries develop information and research capacity. In terms of empowering individuals and
groups, global health institutions can aid in reforming state and local institutions; encourage political will for public action; help governments improve public administration; provide greater voice in national and international fora; and assist states in ensuring greater citizen participation in decision making. Finally, in terms of health system development, global health institutions can provide technical assistance in the following key domains: equitable and efficient health financing; training of medical and public health professionals; management of tertiary, secondary and primary care facilities; regulatory agencies; and standardised diagnostic categories. Global health organisations can also provide financial aid and mobilise resources for health systems
development and specific disease areas, and offer global advocacy.

Individual nation-states have primary and prior obligations to reduce health inequalities. Firstly, state actors and institutions assume primary responsibility for creating conditions to fulfil individuals’ capability to be healthy; states are in the most direct position to reduce the shortfall between potential and actual health.  This includes efforts to deal with the social, economic and political determinants of health. Secondly, states assume the primary responsibility for creating an institutional framework for equitable and affordable healthcare and public health; this includes allowing equal access to quality health-related goods and services, and to proximal and controllable determinants, including nutritiously safe food and potable drinking water, basic sanitation, adequate living conditions, healthcare,public health surveillance and health literacy. Regulation and stewardship of the health system is a critical state action.

Conclusion

Global health actors must work together and in a supportive and facilitative role vis-a-vis state actors and institutions to correct global health injustices. State governments, institutions and actors, along with non-governmental organizations, local communities, businesses, foundations, families and individuals must assume a prior and direct role and responsibility, through a framework of shared health governance, at the level of the nation-state. A moral framework should be applied to all global health policies. Reducing gaps in preventable mortality and morbidity is an essential common goal of the global health community in the 21st century.