The Primacy of the Westphalian System in a Web of Global Health Governance


In the past decade, we have observed unprecedented high level health diplomacy and “health interventions” within the international arena. Major world powers, philanthropic organizations and NGOs have allocated enormous resources to support global health initiatives. Universities around the world are opening new departments of global health and expanding research in the field. Both public and private actors are collaborating on projects to improve the health of populations globally. Further, there is a rapid diffusion of medical technology and expertise. As such, many commentators have described the current period as the golden age of global health.

Amidst this high circulation of professionals and capital, there is poor coordination of activities, competition among diverse agencies, overlapping interventions, waste of resources, and gaps and unmet needs across the crowded global health landscape. NGOs and humanitarian organizations are tacitly partitioning and claiming zones of operation in sovereign territories. There is also an emergence of critical discourses concerning viral sovereignty, intellectual property rights and bioterrorism. The WHO faces continuous challenges to its preeminence as the world’s governing health institution. The Commission on Social Determinants of Health has stated that the factors affecting health are far-ranging, thus legitimizing the proliferation of actors such as the World Bank, IMF, WTO, G8, g20 and other regional bodies into the domain of health. The architecture of global health governance is blurry.

In the quest for direction, it is important to conceptualize the role of the state and its obligations to its citizenry. The Westphalian settlement delineates the contours of modern international relations and ascribes to the idea that the nation-state is at the center of relations and forms the highest decision making entity. Young notes that “a governance system is an institution that specializes in making collective choices on matters of common concern to the members of a distinct group.” 1 The nation-state’s primary goal is to protect its citizens. The primacy of the nation-state is highly relevant when collectively dealing with external actors and matters effecting life and death, such as healthcare delivery. Nation-states are in unique positions to govern the health of their populations. Groups of people in a political union usually share similar characteristics and are more sensitive to cultural nuances. An important premise of health governance at the national level is that it has the potential to develop accountability, to generate feedback between citizens and their governments, to create room for self-appraisal and improvements, to build trust and foster bonds between national leaders and ordinary citizens, and to decrease long-term dependency on external parties.

History shows that citizens around the world are not passive: they remain active agents engaging in dialogue and negotiations with stakeholders and governments. The South African Treatment Action Campaign (TAC) informs our understanding of local actors generating national structural changes. This grassroots activist movement was highly successful in forcing the Mbeki Administration to provide antiretroviral treatment for many South Africans. TAC actions were influential in compelling the pharmaceutical industry to drop legal efforts to prevent the importation of cheaper antiretroviral drugs and other medicines for South Africans.

The displacement of principles of the Westphalian system of interaction among sovereign states for one of a sovereign state seeding authority to a wealthy philanthropic organization will fundamentally alter the international system, causing unknown consequences. Challenges to state authority are not novel, however, the emergence of globalization and the asymmetry of power and resources wielded by major NGOs and philanthropic organizations are new.

 Many raise the concern that corruption and mismanagement in the global south preclude donors from direct transfer of resources to host governments. They argue that there are systemic problems at the highest levels of governance.  Despite these assumptions, state sovereignty should not be compromised. Donors must work diligently with national governments to forge a productive relationship.

The primacy of national governments in the web of global health governance does not seek to exclude traditional actors; rather, this paradigm embraces shared and coordinated health governance. The WHO and other intergovernmental institutions must form part of global health governance. NGOs and other none-state actors must coordinate activities through national governments.

1. Young, Oran. (1994:p26) International Governance: Protecting the Environment in a Stateless Society. Ithaca, NY: Cornell University Press.


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