Global Health Justice and Governance

Abstract

While there is a growing body of work on moral issues and global governance in the fields of global justice and international relations, little work has connected principles of global health justice with those of global health governance for a theory of global health. Such a theory would enable analysis and evaluation of the current global health system and would ethically and empirically ground proposals for reforming it to more closely align with moral values. Global health governance has been framed as an issue of national security, human security, human rights, and global public goods. The global health governance literature is essentially untethered to a theorized framework to illuminate or evaluate governance. This article ties global health justice and ethics to principles for governing the global health realm, developing a theoretical framework for global and domestic institutions and actors.

Keywords:

• global health governance
• global health justice
• health justice
• international health relations
• provincial globalism
• shared health governance

Acknowledgments

This research was supported in part by the John Simon Guggenheim Memorial Foundation, the Patrick and Catherine Weldon Donaghue Medical Research Foundation, the Whitney and Betty MacMillan Center for International and Area Studies, and the Greenwall Foundation. The author thanks Betsy Rogers, Nora Ng, and Isaac Swetlitz for research and editing assistance.

Notes

On connectedness, identities and justice see O’Neill 1994. On plurality, connection and finitude, see O’Neill 1996. The strength or degree of connectedness at the global as compared to the domestic level is a point of contention.

Objection to human capability and the plausibility of a universal or objective account of human flourishing are discussed elsewhere in the context of a universal and objective account of health capability (Ruger 2009b).

Human agency is an essential human good to be protected and promoted. The ability to direct one's own life, to make one's own decisions and choices, is an essential human interest. Human agency is constitutive of human flourishing, as people flourish by making their own decisions and choices. Health agency is a specific type of agency focused on making decisions and choices about one's health. Health agency is a core value, and meeting health agency needs is central to justice in health. That said, health agency is not strictly autonomy about one's health. Health agency is both a more positive concept and one that reflects the interdependency and codependency of individuals. The health capability paradigm recognizes that individual choices do not occur in a vacuum. There are personal and societal consequences accruing from individual choices. Society owes individuals assistance in meeting health agency needs, and individuals owe society responsible exercise of health agency. The privilege of support for individual health agency entails the obligation to make prudent choices that do not cause harm to others.

O’Neill (1996) points out that “[t]he most elementary thought of universalists is formal: there are certain ethical principles or standards which hold for all” (11). “Scope” denotes “who falls within the domain of universal principles” (4)—the applicable domain.

While there is much discussion of universalism in the literature, a useful distinction involves: (i) “universalist content,” duties that apply to and are binding on all; and (ii) “universal justifiability,” duties that “each person, simply by virtue of being rational, has good reason to accept” (Larmore 1996, 57). Some gradualism appears on the justification and agreement front. In terms of justification, on one end principles are justified to everyone; on the other, they are justified only to a chosen few. For agreement, the spectrum extends from agreement by every individual to agreement of a majority to agreement by some. Rawls, alternatively, does not apply egalitarian liberal principles globally and thus does not support an egalitarian liberal cosmopolitanism (Rawls 1999).

Thomas Pogge's definition of cosmopolitanism includes three elements: (i) individualism, humans as the unit of concern; (ii) universality, everyone included equally; and (iii) generality, all persons worldwide must treat all other individuals worldwide as the unit of concern (Pogge 1994b, 89).

That said, of the aspects of human flourishing, it is plausible that health could be considered one of the few goods for which universal justification could be made, in the sense of every individual on the planet accepting the common moral value of health. For PG the overlapping consensus should occur at all levels, from global, to state, to local, to the individual, but it need not require unanimity. The exact balance or tipping point for consensus (majority or supermajority) would need to be worked out. On the issue of ideal situations in assessing people's value and importance of health and life, it is possible that the true test is when a person's or group's health is threatened or could be taken away.

This has been a sticking point for the universality of human rights, which some might argue are universal in content without being universal in justification. Although universalists might agree to human rights and agree that they apply to and can be claimed by all, human rights are not accepted by people everywhere. On human rights as a common concern see Beitz (2001).

Although it may not be definitively proven scientifically, there is sufficient evidence to support justification of health capabilities as intrinsically valued universally (accepted by and acceptable to all persons), and instrumentally necessary, without the fulfillment of which humans anywhere on the planet could not attain other valuable human functionings.

The state of being human confers status. Justice requires treating people with respect and treating them equally in morally relevant ways. PG provides an account of morally salient human characteristics that warrant respect and thus require protection and promotion. Meeting these needs is essential for humans to flourish. Respecting people means respecting people's interests, and a primary human interest is leading a good life (Kymlicka 1989, 10–12). Some argue that interests form the basis for duties and rights. Raz's theory of rights holds others under a duty based on individuals’ interests or well-being: “‘X has a right’ if and only if X can have rights, and, other things being equal, an aspect of X's well-being (his interest) is a sufficient reason for holding some other person(s) to be under a duty” (Raz 1988, 166) and “[r]ights are grounds of duties in others” (Raz 1988, 168). Buchanan discusses “the connection between equal concern and respect for persons, human rights, and basic human interests” and that “we show equal concern and respect for persons” “[ ] by acknowleding that there are human rights.” (Buchanan 2004, 90). However, an account of individuals’ interests in well-being or quality of life is still necessary for fleshing out the content of such rights, supporting the view that the deontological idea of equal respect ultimately needs a substantive theory of the good for a theory of duty, obligation, and rights. Some question health's role as a prerequisite to other rights (Caney 2005, 120); others would also argue that health is not an uncontroversial human interest. For a discussion of types of well-being and a conception of “equality of resources,” see Dworkin (2000).

Different types of contract theory apply for the domestic, international, and global realms. There are individual-centered and people-centered approaches. Rawls puts forth procedures for the domestic and international realm; in the latter, for instance, he outlines a people-centered approach whereby the contracting parties are peoples (liberal and decent peoples). Principles of international justice under this approach are principles to which liberal and decent peoples agree. In Rawls's ideal theory, other kinds of peoples are not party to the contract (these peoples are outlaw, benevolent absolutist, and societies with unfavorable socioeconomic conditions) (Rawls 1999). For critiques of Rawls's methods, see Buchanan (2000), Caney (2002), Kuper (2000), and Tan (2000). Rawls's assumption that the contract would include elements of human rights is tautological, given that the liberal and decent peoples privy to the contract would accept human rights and those peoples who do not accept human rights are excluded from the contract (Beitz 2000, 685–686; Caney 2001, 131). Rawls's theory has been criticized for, among other things, not considering the interdependence or domination that exists in the global realm (Pogge 1994a, 196). Others note Rawls's intended focus on the foreign policy of liberal peoples (Freeman 2007), an alternative to realism with fair terms of cooperation based on reciprocity. For an alternative view on reciprocity called “diffuse reciprocity” see Keohane (1986).

See, for example, Gauthier and other contractarian scholars who argue that principles are moral if rational agents accept them (Gauthier 1987). See also prudential and moral reasons for human rights and the conversion of “prudential choice into rational choice within the moral point of view” (Nickel 2007, 91). For critiques of the justice-as-mutual advantage methodology see Brian Barry, especially issues of inequality in power and self-interest (Barry 1989).

See, for example, Jurgen Habermas's argument for “discourse ethics” (Habermas 1990a, 1990b). Methodologically, the justification for a set of principles or values, for example, is that they are the object of agreement after having been subject to discourse under ideal speech situations.

See Kamm (1992, 355) restating that individuals are all “ends-in-themselves”; Nagel (1995), reiterating that individuals have equal moral status that requires respect and they can't be used as means to ends, corresponding with the inviolability of persons emphasized also by Nozick (1974). Critiques include: Equal moral status does not constitute rights of any kind; it is too indeterminate in that it does not tell us what morally relevant characteristics of individuals merit respect. It doesn't consider outcomes or consequences. Deontologists would counter that equal respect grounds rights, including human rights, through free choice or autonomy. This does not answer the question, however, of which freedoms to secure, or what personal characteristics require respect. Respect for persons or equal moral status, which is at the center of deontological theory, is not enough for a theory of justice, which needs an account of individuals’ morally relevant characteristics that require protecting and promoting (Caney 2005, 71–72; Griffin 1988).

For example, historical facts about the evolution of health systems and systems of cooperation to protect and promote health provide evidence of health's value in diverse social and cultural contexts. Historical facts and cross-cultural empirical comparisons are relevant. First, as societies/countries grow economically they spend more publicly in real and percentage terms on health. Second, as societies/countries develop they tend to pass legislation and establish national health systems to guarantee access to health care and financial protection from its costs for all citizens (e.g., Western Europe, Japan, Republic of South Korea). Third, this trend occurs even in some societies/countries with limited income (e.g., Kerala, Thailand, Malaysia, Mexico, Chile). Fourth, this historical fact occurs in societies/countries with different cultures and ethnicities—from East and South Asia (Japan, Malaysia, Thailand) to Latin America (Brazil, Chile, Mexico) to North America (Canada) to Europe (United Kingdom, France, Germany), to southern Africa (South Africa). Historical and comparative evidence suggests there are historically and culturally invariant, common human health needs that all societies eventually come to acknowledge and seek to meet among their citizens.

There is also a tension here in the difference between objective interests, for example, in health, and subjective self-interest, in terms of preferences (Ruger 2011a; 2011b). John Stuart Mill (1978), along with a number of libertarians and neo-classical economists, for example, note that people are best placed to determine their own interests, that they are more motivated to protect their own interests than others are, and that individuals should be responsible for their own interests. Some behavioral economists, with empirical evidence to support their claims, disagree, arguing that people don't always know their interests or don't always have the ability to pursue them (due to errors caused by heuristic devices, bounded rationality, problems discounting, and so on). Therefore, paternalism, being unavoidable in some situations, is acceptable because it helps individuals make choices that are in their best interest (Thaler and Sunstein 2003).

This universalist theory is thus grounded in our common human health needs and vulnerabilities for which there is overwhelming empirical natural and social scientific evidence. This evidence provides support for all humans having morally relevant characteristics (health needs and vulnerabilities) in common. Moreover, historical facts and cross-cultural studies demonstrate that the ability to address these shared human needs and vulnerabilities requires shared and joint efforts to co-produce the conditions for solutions (e.g., in the form of health systems, with health insurance, organization, and delivery).

This methodology also recognizes objections to universality that question objectivity, a trans-communal ground or standpoint, independent vindication, and individuals’ independence from context (even under a veil of ignorance) or tradition. In comparing the methods used in this project to that of the Rawlsian (“reflective equilibrium”) or Habermasian (“discourse ethics”) projects (Habermas 1990a), this approach finds certain health goods, needs, and capabilities that are derived from human knowledge, science, research, and experience (including moral experience). The PG approach is not a metaphysical notion; rather, it works from human experience and knowledge. It incorporates validity and reliability, because this method seeks to measure the true value of health for/in our individual and social (political) experience. Does what we observe in the real world about how individuals and societies value health and how important health is to other types of functioning align with what our theory of the value of health asserts? This methodology seeks to capture this alignment.

Validity and reliability are employed as criteria for justification and assessing the universality of health values and principles. Validity connotes the extent to which the method of determining the (non)universality of health is actually doing so, and reliability connotes the extent to which the method turns up the same result or similar results time after time. The proposition is that public and moral reasoning normatively justifies health's universal value, and empirical reasoning (empirical evidence from historical facts, cross-cultural comparisons, basic, and natural and social sciences) demonstrates health's universal value and importance; the combined methodology aims toward validity and reliability as compared to other methods, for example, hypothetical agreement approaches.

There is also Pogge's global resources dividend concept whereby states and governments pay dividends on any resources they sell or use. The dividends raised then go to reduce poverty globally (Pogge 2008). See also Steiner on a right “to an equal portion of all such unowned things” (Steiner 1994, 270).

See Beitz (1999) for arguments to apply Rawls's difference principle globally to address global inequalities and to maximize the state of the globally worst off person (or group of persons). One reason is because global and domestic systems of interdependence and cooperation are similar. Goodin (1985) offers an alternative approach: a duty to the vulnerable manifested in a mandate of international aid.

There is also a cosmopolitan-inspired literature calling for humanitarian assistance (Singer 1972) rather than focusing on distributive justice.

A search for global justice also calls up various manifestos of social movements, which are not necessarily supported by theorists. Among the calls for global or international distributive justice are fairer trade policies, global commons and multinational corporation taxes (Commission on Global Governance), world debt cancellation among highly indebted poor countries, migration and immigration liberalization, and Tobin tax on international money markets.

This is more demanding than a goal of the right to “subsistence” (Jones 1999; Shue 1980). David Miller, known as a nationalist in global justice debates, supports an account of global justice principles including basic human rights, non-exploitation of the vulnerable and “the obligation to provide all political communities with the opportunity to achieve self-determination and social justice” (Miller 2000, 177). This account is also more demanding than cosmopolitan principles of minimum adherence to the no-harm principle.

On the debate about special obligations to co-citizens and co-nationals (compatriots and non compatriots) see Barry (1996), Goodin (1988), and Moellendorf (2002). On questions of principles of justice applying to institutions because that is the primary means of interconnection or can apply even when institutions are lacking (institutional view) compared to principles of ethics for person and group conduct (interactional view), see Pogge (1992; 1994b).

More general arguments for moral universalism in contrast to cultural relativism are found in objections to morally repugnant and evil practices, customs, and norms (e.g., slavery, widow burning, killing of Jews, genocide, etc.; Gewirth 1994); relativism's inability to provide normative criteria for judging and condemning (and justifying condemnation of) social practices (Nussbaum and Sen 1993); and that many cultures themselves question cultural relativism (Nussbaum 2000). Suppression of cultural diversity and lack of attention to the role of moral contestation within cultures are responses, however, to moral universalism. See Walzer 1987 on social criticism and critical interpretation.

There is resistance to this approach. Samuel Black argues that a “distributive theory, that ascribes rights and claims on the basis of certain universal attributes of persons, cannot at the same time restrict the grounds for those claims to a person's membership or status within a given society” [“fallacy of restricted universalism”] (Black 1991, 357). This is a point well taken, but it doesn't address the position of analysis and whether one takes the duty bearer's perspective or the entitlement bearer's perspective, or both. Taking the entitlement bearer's perspective first and then the duty bearer's perspective second, the stages are to identify an overarching goal first and then second to assign different duty bearers to achieve this goal. Global interdependence and systems of cooperation are not the same as national ones, and we need different but related cooperative systems to address the same overarching human needs. Thus, the domestic and global realms of cooperation are disanalogous in political, economic, institutional, and pragmatic ways that do not threaten the global importance and scope of cosmopolitan principles of justice. Some examples of more recent and more conciliatory approaches include Tan (2004), Brock (2002), and Eckersley (2007).

Of course there is more to social identity than just national identity, not just by local, community, national (state), or global level, but also by group affiliation (e.g., gender, race, ethnicity, class, caste, occupation, sport or other types of avocations, etc.), and there seems no limit to the types of social that may constitute forms of identity for individuals. There is also no reason why political identities cannot be established to support global health justice. On self-determination (relational model) and global democracy see Young (2000). On the ethics of identity see Appiah (2005).

See, for example, Miller (1998). On membership and special obligations, see, for example, Tamir (1993) and on mutually reinforcing separate levels of political agency and community, see Kymlicka (2001); for arguments concerning the state as a political community, see, for example, Walzer (1980).

These arguments overlap with the nationalism and political obligations literature (Horton 2006; Horton 2007; Miller 1995; Tamir 1993). Associational relations have also been argued to affect duties of justice in the economic and political realm (e.g., welfare and protection of compatriots prioritized over those of others; Mason 1997; Miller 1988). State and nation are used inter-changeably herein.

This component of PG is related to but distinct from the concept of solidarity. There are numerous definitions and conceptualizations of solidarity, as Wilde (2007, 173) notes: “The paradox at the heart of solidarity has long been evident. On the one hand it has connotations of unity and universality, emphasising responsibility for others and the feeling of togetherness. On the other hand it exhibits itself most forcefully in antagonism to other groups, often in ways which eschew the possibility of compromise.” One characteristic tends to be its either-or, us-versus-them, “in or out” group mentality, which does not mesh well with contexts in which multiple identities, relationships, affiliations, and motivations for cooperation exist. There are many different ways in which people think about solidarity and yet, despite comparisons between solidarity and justice, there is limited discussion of obligations and actions required by solidarity in health and health care, domestic or global. This gap contrasts with various theories of justice in health care. For example, Wall (2009) and Houtepen and ter Meulen (2000b) critique justice as a concept for being too individually focused, reliant on “cold” calculations of obligations, universalistic, and weak as a support for distribution. Of course, there are many different theories and applications of justice along the spectrum from libertarian to communitarian, yet there is no one-size-fits-all conception of justice against which solidarity might come up as “the” winning idea. Houtepen and ter Meulen (2000a) talk about the move from “voluntary solidarity in reciprocal arrangements” to “organised and enforced solidarity” in the modern welfare state, what they call “contractual solidarity.” PG employs the concept of plural subjecthood, which, while related to solidarity, defines our affiliations and obligations in ways that represent nuances along the spectrum from the individual to the collective, both domestically and globally.

And, thus, we do have special obligations of justice to fellow compatriots that derive from our joint commitments to each other to achieve state (national) goals of health equity and to take on respective roles and responsibilities in meeting these goals.

This approach enables balancing our legitimate partiality toward compatriots (our domestic subjecthood) with our partiality toward foreigners (our global subjecthood). Even if our partiality in the global realm may not be as strong from an attachment or identity perspective (see later discussion on moral motivations), it may be very strong in terms of our commitment to global and domestic health equity, which, empirically, requires assuming roles and responsibilities that incorporate both moral motivations simultaneously. Thus, these moral motivations can be compatible, rather than mutually antagonistic.

This is also consistent with the literature in moral psychology and social psychology, which points to attachments, identities, and moral values (commitments to principles) as motivating forces for people's actions, but it does so in a way that brings these three motivations together in the idea of plural subjecthood. That said, attachments, which appear to be primarily for very close relationships, may have more of a hold in plural subjecthood at the individual level and less so at the state (national) and global level where identities and moral values could be a greater motivating force. If attachments can be said to be operating at the state (national) level, then they can serve as motivation there as well. For example, through our social identification with fellow countrymen and fellow human beings and through our commitments to common or shared goals with those who share our identity, we create joint commitments to solving common problems, like health protection and promotion.

In the distinction that is often made in positioning one's analysis between a duty bearer's perspective and an entitlement bearer's perspective, this approach takes the entitlement bearer's perspective first and then the duty bearer's perspective.

By committing to this health cooperation, all participants in it are on both the giving end and the receiving end of the system. In health cooperation, individuals and groups must espouse and follow individual- and group- level rules and standards to ensure effective and efficient health production at the individual and group level. This is somewhat similar to and different from the reciprocity-oriented motivation of a system of cooperation based on mutual advantage (“when a number of persons engage in a mutually advantageous cooperative venture according to certain rules and thus voluntarily restrict their liberty, those who have submitted to these restrictions have a right to a similar acquiescence on the part of those who have benefited from their submission. We are not to gain from the cooperative efforts of others without doing our fair share” [Rawls 1971, 343]). The difference lies not in the notion of entitlement or reciprocity per se, but in the different organizational structure of SHG, which tends toward systems thinking and joint production through respective roles and responsibilities. Moreover, it isn't always clear that in some cases states are actually acting as a system of cooperation; rather, they are taking decisions based on the aggregation of preferences or the strongest preferences (which can be manipulated by wealth). An underlying theory of social cooperation is necessary to support health cooperation through the state, rather than taking it as a given in a “liberal,” or “democratic” society.

As one scholar notes, there exist “values that can be justified to all persons when those persons’ reasoning is not distorted by self-interest, factual mistakes, complacency and so on” (Caney 2005, 49).

“System” here means a global health system in systems theory. This system is a set of parts working collaboratively, each performing particular functions, in the global context to achieve global health justice. See Dooley (1997) on complex adaptive systems.

I thank an anonymous referee for suggesting that this article's work is in two distinct, but related areas, one on the theory of global justice and another on global governance, and that while PG and SHG go together, each could be mixed and matched with other theories of global justice and of global governance, respectively.

The World Health Organization, for example, is a product of post–World War II liberal values and provides global public goods such as the coordination of disease surveillance and outbreak control. See a short discussion of liberalism and public goods (Rao 1999).

Nor, arguably, are the Millennium Development Goals (MDGs), for example, which arise out of the current global health architecture. Currently, global heath governance is power and interest driven, consistent with a realist and neorealist (gains for most powerful nations) description. See critique of international regimes and a focus on reflecting and reinforcing dominant discourse and underlying power politics (Keeley 1990).

There are numerous interrelated and codependent tasks in the global health system: the financing, delivery, and organization of health care and public health; the aggregation and sharing of information and knowledge; the development and oversight of expert providers—epidemiologists and social scientists, for a few examples. See case studies illustrating how donors, governments, experts, communities, and individuals can work together to deliver health care and achieve results (Levine et al. 2007). See especially the multinational and regional efforts such as eradication of smallpox worldwide, elimination of onchocerciasis in Africa, elimination of polio in the Americas, Chagas disease control in the Southern Cone, and guinea worm reduction in Africa and Asia.

This coincides with the normative realist claim that states (nations) have a duty to pursue national interests and have special duties and obligations to their own citizens, first and foremost. Moreover, there is no incentive for states to meet the needs of foreigners or foreign nations, and they only do if their citizens want them to. For a discussion of normative realism and other varieties of realism, see Teson (1993–1994, especially 559–560). If interests, either national or individual, are viewed more objectively rather than defined by the narrow self-interest of much thinking in rational choice, such duties and obligations could fit within the overarching PG and SHG framework.

Voluntary commitments are not just on the part of individuals, but professional and nonprofessional groups as well, such as doctors, nurses, and medical specialty associations.

The critique of realist, neorealist, liberal, neoliberal, regime theoretical frameworks is evident in the value these approaches offer to global health equity; evidence suggests that “cooperation” in these forms does not always lead to good or positive outcomes, not to mention not furthering health justice. Cooperating on selfish projects benefits actors and their partners, but may bring intended or unintended harm to others, and cooperating on nonselfish projects can work in many contexts. See Ruger (2011a) for examples.

Weiss, for example, distinguishes between “governance” as a set of “values, norms, practices, and institutions” and “government,” which is associated with “political authority, institutions, and effective control.” A government would be able to enforce compliance, mobilize resources, and achieve greater degrees of policy coherence than governance alone (Weiss 2009, 257). Hence the challenge of managing state and nonstate actors in the absence of world government or centralized power.

Moreover, the immediate and local nature of meeting health and health agency needs requires the support and legitimacy of local and national health systems. The sovereign state is naturally placed to serve this role, given its central functions in revenue raising and redistribution and policy legislation and implementation, functions that cannot at present be legitimately performed on the world scale. The state is a functional structure through which individuals cede some resources and autonomy to pursue common goals. The importance of the shared political unit of the state cannot be altogether disregarded, for moral, functional, and empirical reasons.

The health capability paradigm is an approach in which health and the capability for health are moral imperatives. It is motivated by the Aristotelian notion of human flourishing, aims to remedy shortfall inequalities in central health capabilities, and involves a norms-based approach to health promotion and a joint scientific and deliberative process for policymaking. This process is based on principles of medical necessity, appropriateness, and cost-effectiveness (Ruger 2009b).

Constructivism allows for nonstate actors to serve as “norm entrepreneurs” or to form “transnational advocacy networks” to work toward norm convergence (Finnemore and Sikkink 1998; Keck and Sikkink 1999).

Charles Beitz distinguishes between moral cosmopolitanism, in which institutions in international relations should be based on cosmopolitan moral ideals, and institutional cosmopolitanism, in which political institutions in international relations entail authority of some sort of supranational agency, a world government or associated regional bodies, for example (Beitz 1994). There is also the “cosmopolitan democracy” or “global social democracy” project by David Held (1995; 2004), about which there is much criticism that genuine and authentic democracy cannot be achieved at the global level. For critiques of “cosmopolitan democracy,” see for example Archibugi's review (Archibugi 2004).

See for example, Hobbes (1994), who discusses coercive power to avoid a state of nature: “Hereby it is manifest that during the time men live without a common power to keep them all in awe, they are in that condition which is called war, and such a war as is of every man against every man.”

Grant and Keohane organize this differently in world politics and discuss “‘participation’ and ‘delegation’ models of accountability.” They conceive of accountability as “[implying] that some actors have the right to hold other actors to a set of standards, to judge whether they have fulfilled their responsibilities in light of these standards, and to impose sanctions if they determine that these responsibilities have not been met” (Grant and Keohane 2005, 29). They conclude that democratic states and multilateral organizations (as opposed to NGOs, transgovernmental networks, and firms) are “the only types of organization in world politics consistently subjected to delegated as well as participatory accountability,” and that multilateral organizations are “in general more accountable than NGOs, firms, transgovernmental networks, and nondemocratic states—not less accountable” (40). In global health, however, the line between delegation and participation is often blurred since those who have been entrusted with powers (e.g., a Minister of Health in a developing country) are often both an “instrumental agent [] of the public” and a “discretionary authorit[y]” (31). Grant and Keohane also note that “accountability mechanisms … always operate after the fact: exposing actions to view, judging and sanctioning them” (30), and while this ex post view is consistent with the literature on accountability, the mutual collective accountability (MCA) idea seeks fluidity between ex ante (and not just the ex ante threat of a sanction, but the ex ante standard-setting that facilitates self- and peer-regulation through, for example, peer review or reputational concerns) and ex post assessments. MCA emphasizes the former even more in light of systems of governance today and in the future that may have fewer and fewer formal sanctioning instruments at their disposal.

It is especially important in global health to address issues of attribution as different from contribution. If attribution is impossible or difficult to separate from contribution, then ex post evaluation and levying sanctions for sub-par execution will be impossible or difficult at best and may be open to considerable criticism, ultimately undermining the accountability framework. In global health activities in which multiple actors are working on the same problem, it can be difficult to tease out empirically the independent or separate attribution of any given actor (e.g., the World Bank). For more on social scientific methodologies and studies of impact evaluation in global health governance see Ruger (2011a). Also, accountability in this framework applies within and across institutions. For example, a health economist working at the World Bank is accountable to the institution for achieving the goals and objectives to which the World Bank has agreed, and similarly the health economist and the World Bank as an institution are accountable to the Global Fund or PEPFAR (President's Emergency Program for AIDS Relief) program for achieving goals and adhering to standards and procedures agreed to between these institutions.

For a discussion of accountability and intergovernmental institutions, see Woods (2003).

A major focus here is on greater uniformity in preventing, protecting, and promoting health and eliminating unacceptable health deprivations. Having common health and health care standards still allows variation in how health systems achieve this ideal. However, the aim is that the key components of a health society will be standard and uniform across systems, but will find different expression in different cultures and communities. This can be achieved with attention to this ideal, better learning, and diverse, imaginative, rigorous talent and effort devoted to creating optimal health societies and systems. For example, a health capability perspective condemns wrong practices such as norms about AIDS and its spread/prevention in Africa that have negative health consequences, but different countries will go about using evidence-based knowledge to improve health in different ways.

Moreover, there is not and will not in the foreseeable future be a command-and-control type of global system of either government or governance, nor is this type of centralized power likely justified, necessary, or effective. Rather, a system of checks and balances helps to ensure that power is divided. To the extent concentration occurs in the global health system, it is to determine and establish a global health strategy to benefit all, not to favor certain or powerful actors, including countries.

There are a number of noncoercive, noninterventionist ways to address violations of global health justice principles, including, but not limited to, persuasion, criticism, condemnation, mediation, incentives, regulation, and sanctions. On coercion and military and other types of intervention see Bernstein 2006; Follesdal 2006; Nickel 2006.

Legitimacy attaches to specific types of institutions, such as state (national) governments, whose legitimacy or “right to rule” entails moral reasons for complying with institutional rules coupled with the use of coercion to compel compliance or noninterference with compliance. But such conceptualizations of legitimacy are less applicable to international/multilateral institutions with less “coercive power” (Buchanan and Keohane 2006) and to other types of organizations. Buchanan and Keohane are critical of the standards of legitimacy they call “state consent, consent by democratic states, and global democracy,” (412) and instead propose a six-part standard for global governance institutions that eschews clarity on “what global justice requires” and a “principled specification of the division of institutional labor for pursuing global justice” (418). Their “minimal moral acceptability” requirement marks global governance institutions legitimate if they do not violate uncontroversial human rights, even if they fail to promote them (419–420). Of course, we can't just accept disagreement and uncertainty as an excuse for inaction in the presence of unacceptable health consequences and wasted time and resources: Failing to act is not an option. Taking action is a moral imperative. I've argued elsewhere for incomplete theorization and partial agreements in efforts to provide greater clarity, even incrementally, amid wide disagreement. PG provides a basis for the first step in laying the foundation for legitimacy assessment. Moreover, while ad hoc assessments of the legitimacy of particular institutions are certainly helpful, in the global health context of diffused authority shared by multiple actors and institutions, an overarching assessment of the global health system's legitimacy and the respective roles and responsibilities of various institutions and actors is warranted. The legitimacy of the WHO, for example, may vary depending on whether it is scrutinized in the context of the global health institutions regime (including the Global Fund, World Bank, Gates Foundation, and others), against a global public standard of health justice, or as a stand-alone assessment without global health systemwide benchmarks. A narrow view of the WHO has led to perceptions of illegitimacy and ineffectiveness, yet a comprehensive view might recognize the impracticality of expecting more from the WHO than it is able to offer, especially in the context of an increasingly plural and fragmented global health landscape.

In some cases existing international norms and laws provide standards of legitimacy, for example, the Charter of the United Nations, Articles of Agreement of the World Bank, and Constitution of the WHO, that sets out standards for procedural legitimacy in the establishment of the World Health Assembly. In other cases, new standards are required, for example, a new Global Health Constitution, specifying general principles and purposes of global health policy and governance, general and specific duties and obligations, and respective roles and responsibilities. The purpose of the WHO, like that of the United Nations and the World Bank (from postwar reconstruction to poverty reduction), has changed over time, and it is no longer able to “act as the directing and coordinating authority on international health work” (Article 2(a), WHO Constitution).

See Hurrell (2005) on the distinction between self-interest and coercion for a definition of legitimacy that is “distinguishable from purely self-interested or instrumental behavior on the one hand, and from straightforward imposed or coercive rule on the other” (16). The use of international organizations as instruments for achieving the rational self-interest or national interest of wealthy actors undermines the legitimacy of such institutions, as have criticisms of the World Health Organization (Walt 1993).

The rush to develop more new nongovernmental and multilateral institutions in global health is in part a reflection of a global health public that has lost faith in the core group of international health organizations (such as the WHO, UNICEF, the World Bank, and UNAIDS.) These organizations failed to adapt to new global health challenges and alternative ways of working together to maintain or enhance their effectiveness and efficiency (Buse and Walt 2000). Allegations of corruption in Global Fund dispersements currently threaten the legitimacy and long term stability of that organization (Hausman et al. 2011).

These elements together also help in addressing problems that arise from differences in or lack of information (e.g., World Bank and WHO have different indicators or measures of impact; other actors may be less transparent in providing information); from effectiveness; from efficiency evaluation (e.g., the impact of a Global Fund grant or World Bank loan is as dependent on the Ministry of Health and other donors [e.g., PEPFAR)]for success—joint assessment facilitates these evaluations); and from respective roles and responsibilities (goal alignment and agreement create greater certainty regarding overarching objectives and institutional division of labor for achieving health goals). This standard also avoids problems caused by the lack of a shared moral view for assessing global governance institutions.

Disentangling global health and foreign health policy goals from geopolitical and militaristic interests is important and provides further justification for putting forth a theory of global health justice and global health policy that does not try to do too much, such as elaborate all necessary conditions for a just world order. For this, theories of global justice and global policy have been amply criticized. Nor does the theory seek: (i) a “single integrated legal instrument,” (ii) “nested regimes” or “regime complexes,” or (iii) complete fragmentation. For more on these types of governance structures in the context of climate change see Keohane and Victor (2011) or Michonski and Levi (2010), and in the context of plant genetic resources see Raustiala and Victor (2004). Moreover, previous analyses in international and domestic health law suggest that legal instruments have been limited (Ruger 2008), and that a single international legal treaty will want in effectiveness. Rather, previous work on the increasingly plural and fragmented nature of global health governance, which has evolved over time through independent decisions on various health issues (e.g., AIDS, TB, malaria, SARS, avian flu, etc.) by both state and nonstate actors and an anchor institution (WHO) that is no longer capable of interinstitution coordination (Ng and Ruger 2011), suggests that a more effective approach involves a constitutional structure with clear principles and allocations of power and responsibility along functional lines. Such an approach allows for different actors to work alone but with greater accountability to others in the joint enterprise of global health production. The rerouting of financial and political resources in global health from the WHO and a small group of core global health institutions to a greater number of actors in various issue areas is a trend whose reversal is unlikely.