Global Health Governance in International Society, by Jeremy Youde

Global Health Governance in International Society, Jeremy Youde (Oxford: Oxford University Press, 2018), 224 pp., $81 cloth, $79.99 eBook.

Global health governance has become a go-to area of work at the intersection of international relations (IR) and global health, where scholars and practitioners alike seek to understand the dynamics among the multiple actors working together to combat transnational health threats and improve global health outcomes. Jeremy Youde, already the author of a leading book on this topic (Global Health Governance, 2012), adds a much needed theoretical discussion to this debate with his latest offering.

While other contributions in the arena of global health governance are not without conceptual grounding, this book represents a new departure for global health governance in its application of one of the grande dames of IR theory—the English School—to a new empirical setting. As Youde asserts, “English School theory is uniquely placed to explain the growth and maintenance of global health governance” (p. 30), both through its normative assumptions and through the recognition of an international society in which a group of actors are bound together by common interests. Conversely, Youde also clearly illustrates how the empirical study of global health governance can contribute new perspectives to English School theory by bringing in greater consideration of the roles of international political economy (IPE) and of nonstate actors.

Youde’s dominant argument is that “the diplomacy, initiatives and commitments [in global health governance] reflect its emergence as a secondary institution in support of a larger primary institution of moral responsibility within international society” (p. 3). He begins the book with an empirical analysis of the evolution of global health governance through a series of collective health activities. He then examines the contemporary global health architecture and the current state of development assistance for health (DAH), before considering specific case studies such as the West-African Ebola outbreak and China’s transformative role in global health.

Two of Youde’s insights are particularly pertinent. The first is the introduction of the IPE lens to a discussion of global health governance and international society. Youde opens his argument by heralding that contributing to global health governance is part of what it means to be a good international citizen, and suggests the unanticipated volume of resources that states dedicate to global health efforts is evidence that international society has come together to share common values around health (pp. 93–4). Too often in the broader public discourse, terms such as “philanthropic giving” are used to describe such contributions without any greater consideration of the conditions that led to such giving in the first place. Youde, however, situates DAH in what he sees as a “growing recognition that there exists a sense of moral responsibility and obligation within international society,” suggesting that “actors have a responsibility to address those issues that seemingly may not directly affect them, but present negative repercussions for the greater international community” (p. 3). Moreover, Youde rightly highlights that tracking the flows of DAH allows us to understand not just the power dynamics of global health governance but also the evolution of international society over time (p. 113). In doing so, Youde does a service to both the field of global health and to English School thinking.

The second pertinent insight comes in Youde’s explanation of why vertical health interventions for specific health conditions are prioritized over horizontal concerns that involve primary health care or the strengthening of health systems. The World Health Organization’s director general, Tedros Adhanom, has been on a mission to provide universal health coverage to all, but his efforts have met stiff resistance from some states. For Youde, the situation illustrates a classic divide within the English School between solidarists and pluralists, where the former discern a broader definition of self-interest and therefore a slightly larger scope for international cooperation than the latter. Youde argues that the current composition of global health governance is stymied by pluralist interpretations, with states easily believing that offering support to prevent or contain the next pandemic is in their self-interest but not being able to muster support for a far-reaching program such as Health for All.

While it is undeniable that this book provides some conceptual clarity to some of the issues surrounding global health governance, there are a couple of areas that could have been further expanded. First, one is left wondering about the balance between the solidarist and pluralist accounts of international society put forward by Youde. Though the author rightly concludes that the aim of global health governance has a solidarist orientation, with international society sharing responsibility for global improvements for health, the pluralist contentions to the challenge of sovereignty and the dominance of Western states are not fully explored. Youde discusses such contentions when he looks at the tensions between donors who prefer to contribute their funds as they choose and global health governance champions who suggest that we have moved beyond narrow self-interests to a more diverse and cosmopolitan ideal (p. 113), yet there is room here for deeper insights. Where does the future of global health governance lie, and how can we overcome the pluralist limitations to improve health globally? The suggestion that international society will adapt and evolve to be more inclusive of such pluralist concerns feels at times simple.

One could also question the assumption that dominates this whole book: that international society recognizes a moral obligation surrounding global health. While I agree that this is the basis of global health governance, I think the evidence Youde presents, particularly around the Ebola outbreak, demonstrates the opposite. At a point of crisis, states and nonstate actors pulled away from this shared moral responsibility proposed by the English School and demonstrated a securitized protectionist approach that favors their own people and interests. Though Youde suggests that the delay in responding to Ebola were teething problems of a nascent institution in international society, I would suggest that during a time of crisis forces related to IPE, such as economic protectionism, played a larger role in states’ reactions than the book suggests. Indeed, the Ebola outbreak demonstrated that the inherent challenge to a governance arrangement based on collective notions of responsibility is that such an arrangement absolves actors of their individual responsibilities to each other within this governance matrix. While members of international society have recommended multiple reforms subsequent to the outbreak, it is unlikely that many of these will be implemented, with pluralist considerations by states continuing to dominate global health activity and global health financing.

Nevertheless, Global Health Governance in International Society is a much needed breath of fresh air, as it unashamedly introduces an IR theoretical perspective that many in global health tend to avoid. Global health governance practitioners, particularly those working in the inner circles of the global health governance matrix, would do well to read this and recognize the everyday practices and tensions they face.

—Clare Wenham

Clare Wenham is assistant professor of global health policy in the Department of Health Policy at the London School of Economics and Political Science.