Guiding Principles of Global Health Governance in Times of Pandemics: Solidarity, Subsidiarity, and Stewardship in COVID-19

This article refers to:

Positive Public Health Ethics: Toward Flourishing and Resilient Communities and Individuals

The question of how to allocate responsibilities among different stakeholders in international laws and policies in response to global health threats like pandemics has been widely debated in the field of global health ethics. Scholars such as Prah Ruger, for example, have argued for shared duties of cooperation, based on our shared vulnerabilities and interdependence, for the purpose of upholding the global common good. Her theory, which she has called the Provincial Globalism and Shared Health Governance (PG/SHG) model of global health justice, emphasizes shared responsibilities to effectively and efficiently tackle global health threats. It would be perhaps more precise to say that her PG/SHG account in fact serves the purpose of allocating shared yet differentiated responsibilities. My commentary critically defines these shared yet differentiated ethical responsibilities to address the COVID-19 pandemic by introducing a principled tripartite account of pandemic governance. I will argue that the principles of solidarity, subsidiarity, and stewardship are particularly illuminating in the context of the COVID-19 pandemic and the World Health Organization (WHO) reform. This principled tripartite account of pandemic governance is helpful because it provides practical reasons that justify why some of the laws and policies that Prah Ruger recommends are necessary in upholding the global common good, while others may not be justified. My principled tripartite account of pandemic governance justifies a much more restrained mandate for the WHO than the one that the PG/SHG model supports.

I will first introduce Prah Ruger’s PG/SHG model. Building on her theory, I will critically discuss some of her practical suggestions regarding the COVID-19 pandemic and complement the ethical foundations of some of them by introducing, explaining, and applying the principles of solidarity, subsidiarity, and stewardship to the context of the COVID-19 pandemic and the WHO reform.

PG/SHG MODEL

Prah Ruger’s theory of global health justice is based on the Aristotelian approach to health capabilities. In its commitment to the common good and human flourishing, the PG/SHG argues for shared global health responsibilities and resources. In the particular context of the COVID-19 pandemic, this would mean a common responsibility to share, for example, not only relevant scientific information, such as data on genetic sequencing, but also scarce medical care resources, such as relevant pharmaceuticals, diagnostic tests, and vaccines.

However, since such information and resources are all likely to be patent-protected and privately owned, one may object here and say that discharging this responsibility to share is too burdensome. How to justify such a difficult requirement? Recognizing our mutual susceptibilities to epidemics is certainly the first step, and Prah Ruger’s PG/SHG model aptly describes our shared vulnerabilities and interdependence made evident during the COVID-19 pandemic. The next step, on which Prah Ruger’s model also relies, is identifying our complementary strengths, in working together—and I would add here working in solidarity with one another—to effectively tackle global health threats.

THE PRINCIPLE OF SOLIDARITY

The specific requirements of the PG/SHG model to share responsibilities and resources in order to suppress the COVID-19 pandemic are indeed demanding. However, I would suggest that the principle of solidarity can provide further justification for such duties of global coordination. As a principle of justice, solidarity has the purpose of protecting the human dignity of each and every human life, in the reality of our interconnectedness and mutual vulnerabilities (de Campos 2017). It is the recognition of human dignity, vulnerability, and interdependence that calls for persons and the communities they form to commit to mutual flourishing (Brakman 2020). This means that solidarity requires, as a matter of justice, that both individuals and institutions be committed to promote the good of each and every person – also known as the common good (Brakman 2020). Solidarity therefore entails, in the reality of global health justice, a shared commitment, among all global health stakeholders and institutions, to uphold the good and the flourishing of each individual in every community.

On the standard view, solidarity is an egalitarian unity, bringing together individuals and communities, opposing structural forms of exclusion (Banting and Kymlicka 2017; Jennings 2020). The PG/SHG approach seems to dovetail with this view of global solidarity (Prah Ruger 2015a). However, at the same time, it also calls for a “division of institutional responsibilities for global health justice and labour” (Prah Ruger 2014), which allocates specific responsibilities to individuals, communities, and international institutions based on their abilities (Prah Ruger 2020). This prompts readers to consider a question that Prah Ruger does not fully consider in the context of COVID-19: namely, how to reasonably allocate shared yet differentiated responsibilities among different global health stakeholders with different capacities and mandates? Here, I suggest, a second principle of pandemic governance would be useful.

THE PRINCIPLE OF SUBSIDIARITY

Subsidiarity is a structural principle that clearly locates the proper level of decisional authority among multi-level stakeholders, according to a bottom-up approach (Brakman 2020). Subsidiarity recognizes the value of first trying to solve problems locally and moving up to higher levels of governance only as necessary (de Campos 2017). The PG/SGH model “allocates duties along a continuum from global to domestic spheres” (Prah Ruger 2015b). In other words, the PG/SGH model assigns responsibilities for global health according to a top-down perspective. However, the PG/SHG model also determines that national governments have the primary responsibility for pandemic risk reduction, given that they are “best situated to manage and coordinate across sectors and across local, national, and global levels” (Prah Ruger 2020).

Although PG/SGH model’s top-down perspective and the allocation of primary responsibilities to local governments may not be mutually exclusive, they might be difficult to reconcile if allocation begins at the global level while the most immediate and stringent duties remain at the local level. Also, one may question if a bottom-up approach would not be more consistent with the PG/SHG requirement of shared responsibilities and resources, where inclusion and participation of local communities in decision making are arguably key. The principle of subsidiarity here would adequately respond to these difficulties, by proposing a bottom-up perspective that allocates duties first to local communities and then to higher levels only in so far as the lower-level communities need assistance. This coordinated interaction between higher and lower-level communities requires a communication that is truthful and accountable to justify a legitimate intervention. This leads us to the third principle of pandemic governance.

THE PRINCIPLE OF STEWARDSHIP

Stewardship is a regulatory principle that determines when intervening and assisting are reasonable and legitimate acts of care and when not, further complementing and specifying the principles of solidarity and subsidiarity. The steward is the regulator, guardian, or leader who has a specific duty of care in their mandate. The key element of such mandate is the requirement of truthful and accountable communication between the steward and those under their leadership. The PG/SGH model also calls for mutual accountability and communication that is “truthful, transparent, and consistent”, especially in the context of the COVID-19 pandemic when the lack of truthful and accountable communication has eroded WHO’s public trust (Prah Ruger 2020).

As the global health steward par excellence, the WHO has a duty to foster truthful and accountable communication among all global health stakeholders. But the question here is: how to do that if the public trust in the WHO has been eroded and if the WHO is “overcommitted, overextended and in need of reform” as the organization has itself acknowledged (WHO 2013, para 50)?

THE UPSHOT OF MY PRINCIPLED TRIPARTITE ACCOUNT OF PANDEMIC GOVERNANCE

When it comes to WHO reform, my tripartite framework calls for a much more restrained mandate for the WHO than Prah Ruger’s model. Currently overcommitted and overextended, the WHO should do less. The three principles of pandemic governance that I have presented would provide the ethical reasons for such a minimalist mandate. First, as the principle of subsidiarity requires, the WHO would do well to delegate more global health functions to other stakeholders more capable and best situated to realize them. Secondly, as the principles of solidarity and stewardship require, WHO would do well to focus exclusively on ensuring that shared responsibilities are communicated in a truthful, evidence-based, consistent, and timely manner to ensure accountable coordination. WHO would be a better leader if instead of trying to expand its power, resources, and control over other global health stakeholders through its institutional reform, WHO would do only one thing and do it well in the hopes of reclaiming public trust.

CONCLUSION

Prah Ruger’s sophisticated capabilities approach to global health justice predicated on the Aristotelian understanding of common good has moved the field of global health governance forward and deeper. Her PG/SHG model, in general, and her practical suggestions regarding the COVID-19 pandemic in particular could, however, benefit from a more thorough justification. This, I suggested, could be achieved through a closer examination of the principles of solidarity, subsidiarity, and stewardship.