FIRST EDITIONVOL THREE
An Unhealthy Pairing: How Globalization and Neoliberalism Have Impacted Global Health Governance
In recent decades, globalization and neoliberalism have worked in tandem to utterly change the landscape of global health governance. Nations worldwide have engaged in unprecedented levels of cooperation on healthcare issues, with a new neoliberal focus on improving health for the sake of the global economy. However, an examination of the state of global health reveals the diverse, enduring problems with the current neoliberal lens of globalization. This paper finds that while increased levels of globalization have allowed international organizations to positively impact the state of global health, the dominance of neoliberalism in these organizations has limited their positive effects, sometimes causing explicit harm. Organizational efforts to tackle health-related challenges regarding infectious disease control, environmental degradation, and poverty have failed to see major success on a global scale due to the neoliberal policies promoted by international organizations. This paper contends that the state of global health could see major improvements if international organizations shifted away from their strict neoliberal policies in favour of a more inclusive and equity-driven approach. This would allow for a greater emphasis on long-neglected goals of global health governance such as sustainability, reduced inequality, and global fairness.
Keywords: health, neoliberalism, globalization, World Health Organization, poverty, environment, infectious disease
Globalization has utterly changed the dynamics of the international political economy. As once remote areas of the world have become increasingly connected, this has created both new opportunities and new challenges for policymakers. This is notable in a broad range of fields, including that of global health. As globalization has made health policy a global issue, it created the need for an international approach to health policy and governance. This paper examines how forces of globalization have affected different aspects of this international health governance. Specifically, it analyzes how globalization has given various international organizations the power to change the state of global health. This investigation finds that while globalization has allowed these institutions to have some success in addressing global health challenges, a great number of their efforts in this field have been hampered by the neoliberal ideals they endorse. However, despite the fact that globalization has not significantly improved the effectiveness of global health governance, this paper argues that it does have the potential to do so. If international organizations move away from promoting exclusively neoliberal health policies, these globalizing bodies could take on a positive, leading role in global health governance.
The existing literature on globalization struggles to define the scope and extent of globalization, making its impact on global health difficult to comprehend. In fact, perhaps the only scholarly consensus on globalization is that there is no singular, agreed-upon definition (Lee, 2003: 4). While a universal scope of globalization may be impossible to achieve, what is clear is that the effects of globalization are far-reaching. The KOF Globalization Index, one of the many measures created as an attempt to measure this phenomenon, includes forty-three different variables ranging across cultural, political, and economic disciplines (ETH Zurich, 2022). This not only shows the pervasiveness of globalization but also reveals the various and often conflicting impacts it has on all segments of society. For instance, the widespread international travel made possible by globalization has contributed to the rapid spread of disease across continents, while new global communication channels like the Internet have allowed for broad access to medical knowledge (Zhou and Coleman, 2016: 287, 289). This example reflects how complex it is to accurately evaluate the various widespread impacts that globalization has on initiatives to improve global health.
As a result, this paper will limit its investigation to the role of international organizations that engage in global health policy. Examples of these institutions include the World Health Organization (WHO), the World Bank, the International Monetary Fund (IMF), and the World Trade Organization (WTO), and represent the international health governance framework that globalization has made possible. Within these organizations, globalization allows for international actors to come together through institutions to discuss and implement multinational policies and strategies to address health issues. While the work of international organizations is certainly not the only aspect of globalization relevant to health, these organizations are able to have a major global impact on their initiatives of choice through the aid and exposure these institutions can provide through their high levels of global influence (MacKenzie, 2010: 141). This gives them the power and resources to work toward addressing challenges in three primary aspects of global health, which are discussed in detail in this paper’s three following sections: infectious diseases, the impact of environmental degradation, and poverty-related health issues. Thus, as the last section of this paper will show, the study of international organizations can provide particularly relevant insights both into the impact of globalization on the successes and failures of cooperative global health governance and on more effective and equitable strategies that could be devised and deployed in the future.
Although international organizations are a product of globalization, it must be noted that globalization is merely the means that allows for these organizations to exist, not something that dictates their actions and policy decisions. Globalization itself is not restricted to one particular ideology and is to be clearly distinguished from concepts like colonialism, Westernization, or most notably, neoliberalism (Lee, 2003: 12). Neoliberalism is an extreme form of capitalism that emerged in the late 1970s. It promotes a broad range of economic ideals, most notably free markets, free trade, and limited state economic intervention (Mooney, 2012: 34). It is particularly important to distinguish neoliberalism from globalization, as international organizations are often closely associated with the neoliberal ideology they subscribe to and promote (Mooney, 2012: 55). However, while globalization and neoliberalism are two separate concepts, international organizations have brought the two together by using their global reach to spread neoliberal ideals to various new nations. International organizations have done this by making neoliberal reforms like tariff reductions and the opening of markets requirements for countries to receive aid from these institutions (MacKenzie, 2010: 136). This helped encourage many low-income countries in need of international aid to adopt many neoliberal policies, thereby massively contributing to the ideology’s prominence around the world. Despite this close relationship, it is important to note that globalization and international organizations can exist independently from neoliberalism. This is apparent in the case of the WHO, which only reluctantly adapted its policy initiatives to the neoliberal model after the ideology had become dominant in other international organizations (Chorev, 2013: 638). The WHO initiated several global health projects both before and after this ideological shift, showing that specific institutions, as well as globalization as a whole, exist outside of any dominant ideology (Chorev, 2013: 636). Therefore, while globalization and neoliberalism have worked in tandem for the past several decades, they are in fact separate, independent concepts.
To emphasize the distinction between international organizations and neoliberalism, this paper adopts a liberal institutionalist perspective to critique the still-dominant, albeit increasingly challenged neoliberal ideology that continues to shape the interactions of international institutions and of their member states, and suggests various improvements to the quality of health governance provided by international organizations. The following sections aim therefore not only to analyze the key successes that liberal institutions have had in global health governance, but also to argue that preserving existing liberal international organizations and the Rules-Based Liberal International Order (RBLIO) that they are an integral part of is important to continue these efforts. This paper further argues that these institutions should simultaneously engage in significant reforms to shift away from neoliberal policies that have damaged their efficiency, their effectiveness and, ultimately, their legitimacy with their constituents around the world. With these considerations in mind, this paper can now examine how globalization has impacted governance efforts in key aspects of the global system of healthcare provision.
Infectious and Transmissible Diseases
In their fight to tackle global health challenges, international organizations like the WHO, World Bank, and United Nations have had considerable success combatting the prevalence of infectious and transmissible diseases across the world. Through their mandates, international health organizations encourage countries to set consistent health standards, which helps limit the international spread of diseases (Nadjib et al., 2022: 477). Global vaccination rates for diphtheria, tetanus, and pertussis have risen from 20% in 1980 to 85% in 2019, demonstrating the substantial positive effect these initiatives can have (World Health Organization, 2020: 6). Such drastic progress has been possible in large part due to international vaccine drives, which are now able to access most of the world’s population. Recent examples of these are efforts by the World Bank, WHO, and UNICEF to use their global reach and influence to aid Covid-19 vaccine distribution efforts (UNICEF, 2022: 5). Without the work of international organizations, these efforts might not have been as successful. Their key role could also be seen in a similar way during the SARS epidemic. The WHO issued travel advisories in many affected areas and negotiated the installation of temperature screening devices in the airports of some cities hit hardest by the disease (Zhou and Coleman, 2016: 291-292). These tracking measures helped health officials manage and contain the scope of the pandemic and incentivized local health agencies to take action. On the other hand, the WHO was given a report by Chinese officials warning about the early outbreak of SARS, but it was not able to be translated before the disease spread internationally (Zhou and Coleman, 2016: 292). This shows that if the health organizations had been more globally connected at the time, they may have been able to mitigate some of the harm that SARS caused.
Although international cooperation has increased over time, there is evidence that some health policies advanced by international organizations may not have a truly global scope. This is largely due to the prevalence of neoliberal practices within these institutions, which results in anti-disease campaigns being driven more by market forces than a desire for increasing global access to quality health care. During the era of neoliberalism, the WHO has become increasingly reliant on voluntary donations, which some argue gives the organization a bias toward prioritizing the causes important to these wealthy donors (Chorev, 2013: 655). Many international diseases receive little attention from international organizations, such as the several neglected tropical diseases which are often overlooked and underfunded due to their concentration in low-income areas (Alqassim and El-Setouhy, 2022). As a result, some argue that the global eradication of diseases is not emphasized or achieved, as international organizations neglect these tropical diseases and instead focus on campaigns that are more popular with donors (Molyneux, 2008: 510). While this may be beneficial to these institutions from a financial aspect, from a humanitarian perspective there are concerns that the most vulnerable groups are not getting an adequate share of attention from international health organizations.
This inequality is promoted by the neoliberal, market-centric ideology that has been adopted by a majority of international institutions. When there is not a sufficient economic incentive to combat a disease, it may be ignored by a neoliberal-driven policy. This is where a neoliberal, capitalist system falls short of a universal, equity-driven approach to fighting international diseases, as it values economic factors more than human lives (Baru and Mohan, 2018: 5). While the eradication of every single illness appears as an unrealistic goal, international organizations have a bias toward prioritizing disease prevention in Western countries. To achieve a fair and efficient global health governance system, these institutions should reconsider their emphasis on market-driven health outcomes and focus on equitable healthcare research and distribution practices. As demonstrated above, these organizations do have effective disease prevention strategies available; it is the application and distribution of these programs that could benefit from change. Through internal organizational reform in these areas, the fight against neglected diseases could see major improvements while maintaining the well-established health strategies and networks that these institutions provide. Such a reform toward a liberal institutional model could also give these organizations increased legitimacy in currently neglected areas, potentially fostering better cooperation between global citizens and liberal institutions. These proposed reforms will require significant organizational changes, such as decreasing the ability of private donors to dictate where funds are spent, and ensuring that all nations have equitable decision-making power in these institutions. These changes could allow liberal health organizations to increase their effectiveness by making the fight against transmissible diseases truly global.
While globalization has allowed for substantial progress in tackling infectious diseases, the prevalence of neoliberal practices in the international organizations that constitute the existing RBIO has rendered cooperative health governance unequal and Western-dominated. Opportunities provided by globalization would be most effective in the fight against disease if international health organizations reconsidered their neoliberal biases and advanced an approach that truly focuses on and prioritizes increasing global healthcare access for all those in need across the globe.
Health Effects of Environmental Degradation
Environmental issues are an often-overlooked determinant of human health; however, their impact on this field is considerable. The WHO defines health as “a state of complete physical, mental and social well-being not merely the absence of disease or infirmity” (World Health Organization, 1946: 1). Therefore, issues like the environment are within the mandate of international health organizations. Environmental degradation contributes to unclean air and water, exposes humans to toxic chemicals, and increases the risk of extreme, dangerous weather conditions (Lee, 2003: 92-93). Considered together, a healthier environment could prevent nearly one-quarter of global human diseases (World Health Organization, n.d.). This makes introducing effective environmental policies an essential step toward improving global health.
Globalization has provided international organizations with many tools to help combat climate change, allowing them to share climate research and policy recommendations, as well as record the progress of individual nations on climate issues (World Health Organization, n.d.). This contributes to the movement for an international consensus on climate and provides transparency that can help hold countries accountable for the environmental damage they cause. Additionally, international organizations create a space to bring nations together and open a dialogue on international solutions to tackle climate change.
While international institutions do show an ability to induce positive change on climate policies, they also support several policies that have perpetuated more environmental harm than good. Global neoliberal institutions like the World Bank and IMF are large proponents of economic development, and encourage nations to industrialize to achieve their economic goals (Shih, 2000: 635). These policies of economic expansion and resource extraction have a negative impact on the environment, and by extension harm human health (Mooney, 2012: 115). While these initiatives may be beneficial to the economic goals of these organizations, they come at the expense of the global health initiatives they also claim to support. If international organizations wish to prioritize the reduction of health risks caused by this environmental degradation, they must pursue a transition away from their current neoliberal economic practices and toward a sustainable form of globalization. This is a necessary change if these organizations wish to improve their contributions to the state of global health. As this evidence shows, an environmentally conscious approach to international economic development could also be an effective health policy.
International organizations have the potential to help mitigate health risks caused by climate change; however, in practice, their neoliberal ideology has hindered the formation of this international consensus. For real improvements to occur in the global health provision field, policies prioritizing the environment must take precedence over purely economic concerns. This would require significant government coordination and regulation of market forces and networks, thereby reversing dominant neoliberal norms and policies. If international institutions shifted away from neoliberal ideologies to prioritize sustainable programs and practices, they could lead global efforts to create an international structure capable of developing and implementing effective environmental agendas and frameworks of accountability. This would also be beneficial to global human health.
Poverty-related health issues
Poverty is often referred to as a disease, and it certainly does have a negative effect on human health. Poverty contributes to a variety of health concerns, including malnutrition, unsafe living environments, and the inability to afford healthcare (Alqassim and El-Setouhy, 2022). Overall, it is estimated that one-third of global deaths are due to poverty-related causes (Mooney, 2012: 3). Even in relation to the two aspects of health previously covered, poverty makes living a healthy life much more difficult. In terms of infectious diseases, when people living below the poverty line become ill, they are less likely to be able to afford the necessary healthcare to treat their illnesses. This is a systemic problem, as low-income countries are less likely to have publicly funded healthcare systems, meaning structurally disadvantaged individuals in the global south might need to pay out-of-pocket for most treatments (Mooney, 2012: 4). Regarding environmental concerns, individuals below the poverty line are less likely to be able to find proper shelter from environmental disasters and would suffer first if food production were to be affected. Additionally, low-income countries in the global south are among the most affected by climate change, making the environment a major health concern for many of the world’s disadvantaged communities (Mooney, 2012: 112). As these examples show, the persistence of poverty creates a wide variety of health challenges for economically disadvantaged people worldwide.
International organizations have placed considerable emphasis on their efforts to reduce global poverty. The first of the United Nations’ Sustainable development goals is the elimination of poverty, demonstrating the importance placed on this issue (United Nations General Assembly, 2015: 14). As a result, international organizations have engaged in many efforts around poverty reduction. Studies have found that a highly globalized economy is strongly related to a high GDP per capita, with international economic integration specifically being a key variable (Dreher, 2006: 1100). Many international organizations are strong advocates and facilitators of this economic globalization, suggesting that they are central contributors to economic growth. The World Bank and IMF recommend policies to countries in the global South that emphasize economic integration and generating growth through the expansion of markets, while providing loans to help realize these goals (Nadjib et al., 2022: 473). These neoliberal economic policies promoted by international organizations aim to advance the goal of economic growth and to subsequently reduce poverty and improve global health.
As suggested by Dreher (2006), it may very well be true that global neoliberal policies have led to economic growth. However, this growth does not necessarily translate to reduced levels of global poverty or a significant improvement in global health (Schrecker, 2016: 956). The major flaw of global neoliberal institutions is that they focus on national economic growth but neglect the economic inequality that this growth creates, both between countries as well as within them (Chorev, 2013: 645). While economic growth is generally good for the citizens of a country, if its effects benefit only a small minority of the population, then it will largely be ineffective at reducing poverty. This can be considered a primary concern, as the world has seen growing disparities of wealth on both the national and international levels, all while poverty has remained a persisting issue (Mooney, 2012: 37).
This inequality of both income and health is not merely a coincidence or an unrelated phenomenon; it is, at least in part, furthered by the neoliberal policies of international organizations (Schrecker, 2016: 954-955). Policies such as lowering taxes on corporations and the wealthy are central to neoliberalism, and a large number of countries have seen a reduction in these taxation levels in recent decades (Mooney, 2012: 38). This lowering of tax revenue removes a primary way in which governments can redistribute income and help raise low-income citizens out of poverty. The World Bank, IMF, and other Western-led international organizations have also promoted policies that increase barriers for low-income people to access healthcare. The World Bank has explicitly called for the privatization of healthcare in countries, recommending that medical fees be charged to users (World Bank Group, 1986: 38). These kinds of policies make healthcare unaffordable for the most vulnerable people, further amplifying health inequalities. Therefore, despite claims by several Western-led international organizations that they are working towards the elimination of poverty, neoliberalism’s prevalence on the international stage causes these organizations to prioritize unequal economic growth over poverty reduction, thereby allowing poverty-related health issues to persist.
Overall, globalization does not appear to have helped cooperative governance efforts to reduce poverty-related health concerns. However, this failure is largely attributed to neoliberal policies, not the existence of global institutions themselves. International organizations have the potential to reduce global poverty if they prioritized the adoption of policy measures that diminish inequality and benefit the worst-off, over the promotion of neoliberal economic policies. If economically driven institutions like the World Bank would match their policies to the social goals of organizations like the United Nations, progress could be made toward ending poverty and its negative impacts on health. Even though their effectiveness in achieving this goal has been limited until now, globalization forces and the RBLIO that coordinates them have the potential to improve this aspect of global health through the cooperative governance system created by international organizations.
Recommendations and Conclusion
After examining these three aspects of global health, it appears that globalization has had mixed success in addressing global health challenges. The ability of international organizations to bring a broad range of actors together in global health policy discussions has been overshadowed by the neoliberal policies pursued by many institutions that are harmful to the state of global health. However, this is not to signify that globalization can only be a hindrance in discussions of global health. Instead, this paper argues that globalization can be a positive force if the cooperative governance it brings to global health challenges – as manifested through international organizations – shifts away from neoliberalism and neoliberal policies. If such transformations were to be implemented, there are several other perspectives that could replace the dominant neoliberal ideology in health governance. For this shift to materialise, some may argue that a complete restructuring of the global financial system is needed, with the abolition of capitalism and its accompanying institutions. This paper opts for a more moderate approach, perhaps best aligned with a liberal institutionalist view that advocates for an ideological reformation of existing institutions and of the RBLIO they constitute. It should not be forgotten that international organizations, despite their flaws, have made significant progress in improving many aspects of global health. Therefore, the focus should be on reforming these institutions to better work toward these strengths, instead of opting for an abolition of the system itself. The RBLIO does not need to be abolished for neoliberal policies to be replaced on the global stage. Instead, the structure of international organizations could be used to transform the state of global health governance into a more collaborative and equity-driven field.
The history of the WHO provides an excellent example of how such a change can be possible. When neoliberalism became the dominant global economic ideology, the WHO had to shift away from some of its core principles in order to stay relevant and assimilate into this new ideological landscape (Chorev, 2013: 655). Originally, it supported ideals like equity and universality in health care which lost favour in this neoliberal transition (Chorev, 2013: 638, 640). For organizations like the WHO, transitioning away from neoliberalism would largely involve reverting to former principles like these which are critical for good health governance. It must be noted that simply reverting to pre-neoliberal policies could not represent the entire transition, as new, forward-thinking changes would be required as well. However, it is important to note that for organizations like the WHO that existed before the rise of neoliberalism, a tested non-neoliberal method of operation already exists. This serves as evidence that international organizations can function successfully without a large neoliberal presence.
Despite this, there are a wide variety of practical concerns about how such a fundamental change can be initiated. Scholars and advocacy groups must carefully consider any major changes to institutional policies. However, this paper has specifically intended to demonstrate that this is a task worth pursuing. A neoliberal-centric health philosophy has played a key role in preventing some significant improvements to the state of global health. Such an alternative would need to prioritize health equity over economic concerns, emphasize the health needs of the world’s most vulnerable populations, and embrace sustainability in all initiatives. Globalization presents many opportunities for progress in the governance of global health, and even more opportunities for failure. If a strong ethical framework is maintained, the forces of globalization can be harnessed to create an effective, equitable system of global governance centered around the international organizations of a reformed and revitalized RBLIO.
Globalization has been a force of change in the field of global health governance, as well as in the international political economy as a whole. International organizations – which coordinate globalization forces and contribute to international governance efforts – have had many successes in addressing global health challenges, but also significant failures. Indeed, this paper examined the efforts these organizations have deployed to tackle the effects of infectious diseases, environmental degradation, and poverty on human health. A common theme among these topics though, is that the neoliberal policies that have been associated with globalization over the past decades have caused considerable harm to the development of global health governance. As a result, this paper also argues that if international organizations could be less guided by neoliberalism, then they could harness globalization forces to advance relevant health governance initiatives by creating international dialogues, upholding global accountability, and promoting equitable and sustainable health policies.
This is certainly not a conclusive study of international health organizations, as there is a broad range of literature and perspectives on the topic. Particularly, future studies should consider the more recent trends in global health governance, such as the rise of many new non-governmental organizations which may grow to challenge some of the established health institutions covered in this paper. Additionally, liberal institutionalists must continue to develop measured alternatives to neoliberal health governance should they wish to remain a viable alternative to the status quo. Ongoing globalization forces bring forth unprecedented opportunities to achieve substantial improvements to the state of global health. For these efforts to be effective and legitimate across the globe, international actors and scholars must instill in the current RBLIO equitable and sustainable norms, principles and practices of global cooperative governance.
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