Asthma Induced by Isocyanates: a Model of IgE-independent Asthma Cristina E. Mapp, Piera Boschetto, Deborah Miotto, Edoardo De Rosa Department of Clinical and Experimental Medicine, Section of Hygiene and Occupational Medicine, University of Ferrara Abstract. Developments in the understanding of causes and natural history of asthma induced by isocyanates may allow improved preventive strat
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Nisa paper huckelNorthern International Studies Association Conference “Power, Vision, and Order in World Politics” 23-25 May 2007, University of Southern Denmark, Odense Defining, Allocating, Sharing:
Responsibility and Accountability in Global Health
Research Associate: Graduate Research Programme “Global Challenges” – University of First Draft Only! Please do not cite!
Issues surrounding how to govern health from a global perspective generally do not refer to government, (one body that has the authority to make, and the power to enforce, laws,) rather governance, the setting up of processes through the collective efforts of a multitude of actors to identify, understand, or address worldwide problems, (see Thakur/Weis 2006). Over the past ten years there has been a considerable increase in the number of organisations that attempt to address global public health in such a collective way by involving state as well as non-state actors in agenda-setting, decision-making and policy implementation. Such collective efforts, have sparked questions of the legitimacy and long term potential effectiveness of problem-oriented approaches. Although a considerable number of studies have focused on the desirability of inclusiveness and right processes as a possible answer to legitimacy and effectiveness questions, there is an important underlying conflict which still burdens global health governance. It stems from the basic disagreements of who should be responsible for providing health outcomes, what obligations do these parties have, and what consequences do the face if their responsibilities are not fulfilled. The paper addresses this underlying conflict that is manifested in an incongruence between those people, or groups, for which global health organisations are responsible and those people or groups who are able to hold them accountable. The very people that live the poorest health, are the least able to impose costs on an organisation that performs poorly. Those that are able to impose the greatest costs, through the withdrawal of resources are generally are usually distanced from the risk of suffering from debilitating treatable or preventable diseases. The paper explores how responsibilities are defined, both within and outside of the state, looking at the recent strengthening of the social norms and expectations (Grant/Keohane 2005) as well as how responsibilities can be are determined either through explicit agreement, or through a global social contract. Finally, the issue of accountability mechanisms within global health governance is addressed by exploring the potential of external as opposed to internal accountability (Newell/Bellour 2002). Introduction
Issues surrounding how to govern health from a global perspective do not refer to governing in the sense of government, (one body that has the authority to make, and the power to enforce, laws), but in the sense of governance, the setting up of processes through the collective efforts of a multitude of actors to identify, understand, or address worldwide problems, (see Thakur/Weis 2006, Rosenau & Czempiel 1992). In the panel on critical issues in Global Health Governance (GHG), we refer to problems of, and challenges to, the health of persons and the health of peoples. Over the past ten years there has been a considerable increase in the number of organisations that attempt to address global public health in such a collective way by involving state as well as non-state actors in agenda-setting, decision- making and policy implementation. This might be in the form of public-private partnerships, inclusive institutions,1 public-agency consortia, or privately funded and implemented projects within the civil society and philanthropy sectors. Invariably, the number and different types of actors now playing governance roles in global public health has dramatically increased. Setting up rules for and executing public health projects in this way requires us to think somewhat differently about normative and practical issues that surround such ‘governance’ regarding who has the power to make changes and who has the legitimacy to do so. The companion paper on this panel looks more closely at organizational aspects of ‘governance’ and how this affects effectiveness and power asymmetries (Holzscheiter 2007), and my main research focus lies on the foundations of empirical legitimacy in global health governance However, there is an important underlying question which must be addressed before we can begin to examine processes of governance and issues of legitimacy. It arises from the question of which individuals, groups and organisations have the obligation and ability and 1 An institution granting membership to all four categories of actors at least one public and at least one private sector actor ( e.g. states, international organizations, private for-profit actors and civil society organization) and endows them with decision-making rights is considered inclusive (Rittberger et. al. 2007: 10) duty to work towards better health and assist others who live with poor health. Essentially, these are questions of responsibility and accountability. After all, when the fundamental rights to life and health of persons are at stake, there must be some framework for determining: Who should be responsible for providing health outcomes? What obligations do these responsible parties have? Who can be assigned duties and be vulnerable to blame if things go wrong? It is these ethical foundations of global health governance and accompanying complex of problems which are the topic of this paper. It is hoped that with a clearer understanding of how responsibilities and accountabilities are determined in global health governance, that research into aspects of governance processes will be able to focus In order to begin discussing accountability, we first need to define responsibilities and distinguish the relationship between the two concepts. While many use the two words interchangeably, in global governance they are not one and the same. Responsibility and accountability are concepts that straddle the line between social ethics and empirical political science. Responsibilities are ethically based obligations and duties which are defined based on the capacity to understand, reason and act (Erskine 2003). Assigning them to the various types of organisations and institutions now active in global public health, requires us to assign moral agency. Accountability on the other hand is an empirical-practical predicament that is to be applied to agents that have been assigned responsibilities. It refers to a system of checks that create the risk of incurring costs for failing to meet responsibilities, thus being ‘held In current debates surrounding global public health and the involvement of the many types of actors now active in this issue area, the question of how to define and allocate concrete responsibilities and link them with mechanisms of accountability, has been largely neglected. Yet, in light of what has been described as the evolution of global public health as a policy space with features of a political “pasture open for all” (Fidler 2007) it is of crucial importance. A considerable number of studies have advocated increased participation of various actor types as an avenue to close legitimacy and effectiveness gaps in global governance2, however there is an important underlying conflict that still burdens the role of the ‘private’ in global health governance. It stems from basic disagreements of who should be responsible for providing health outcomes in the first place, what obligations various types of actors have if they (voluntarily or otherwise) become involved in global health governance, and what consequences do or should they face if their responsibilities are not fulfilled. Importantly, in many instances there is an incongruence between those people or groups, who’s health is the responsibility of global health governance and those people or groups that are able to hold global health governance to account. The very people that live with the poorest levels of health are also the least able to impose costs on an organisation or institution that performs poorly. Those that are able to impose the greatest costs, through the withdrawal of resources or political support are generally not those whose health or well-being are So how has the concept of “responsible for” become so separated from that of “being
accountable to”? Who are the various actors that are involved in global health
governance today, and how are their responsibilities defined? Finally, who has the
capacity to hold these actors accountable, and how can this capacity be utilised to ensure
that responsibilities are fulfilled?
To address these questions the paper will be divided into three sections. In the first, I aim to explore how responsibilities are defined, both within traditional ‘government’ relationships (within the state) and as part of ‘governance’ (outside of the state). I will look foremost at how responsibilities are defined within state and then discuss the problems with transferring or adapting these processes to the global level. I will then proceed to look more closely at the allocation of responsibilities on the global level looking at alternative processes for determining responsibilities based on explicit agreement, 2 Or indeed limit efficiency, as discussed on the accompanying paper (Holzscheiter 2007). norms and expectations arising from ethics discourses surrounding the responsibilities to “protect” and “do-no-harm.” and a global social contract. I will argue the case for the recognition of collective responsibility and the role of global governance institutions for administering the fair distribution of costs for fulfilling collective responsibilities. In final section of the paper, the issue of accountability in global health governance is addressed. The critical question of to whom the various actors that are now involved in global governance are responsible, is juxtaposed against the ability to hold them accountable. This is done on the example of various types of actors that are today active in global health governance and is a debate, which, in light of different capacities of individuals and others to impose costs on those take on governing roles, is of high importance in global health 1 How are Governance Responsibilities Defined and Allocated?
Historically, it is not long since debates on whether sovereigns and states had the obligation to protect human rights such as health (and other rights that influence health) were waged even in states that today have well established health care systems and the obligations of the state to provide basic health-care are taken for granted. The following theoretical account of how responsibilities are defined and allocated within the state, refers to those states with functioning democratic systems of government. Preceding the welfare-state era, sanitation and the provision of medical care was considered either a private matter or provided by a mix of public (e.g. city and state) and private (e.g. church and charitable) institutions to which access was often arbitrary. Over time welfare provision (including health) through the state ran parallel to citizen organisations that took on functions of sanitation and medical services (Loughlin/Berridge 2001). Slowly preference was given to the provisions of basic health services provided for through a redistribution of resources (tax) and needs based assistance: These developments were inseparable from evolving concepts of justice (not only to provide freedoms but provide protection and care) and the possibility to express and demand expectations on governments through democratic institutions. Broadly categorized the responsibilities of the state now lie within the four main functions of security, rule of law, welfare and participation (Zürn 2001). The form and level to which these functions should be carried our are determined internally through election processes, supported by public debate and organised political parties (Smith 1987: 405-406). Responsibilities of the state towards citizens are most clearly defined by those who are able to choose the government, or group/party to lead the government. In a system where all adults are able to choose the government, allocated responsibilities can be said to reflect the will of the people, or will of the majority. Individuals within the state are bound by the social contract to accept this will, and at least abide by the rule of law in when seeking to change the system. In this sense the state has the responsibility to carry out the will of the people. On the global level, the development of responsibility allocation has followed a different path. Rather than demands from citizens on governments increasing and being negotiated over time, global health governance has evolved from early cooperative agreements amongst states to serve own interests, to organised problem-oriented public health measures. Rights to health care and obligations to act have entered the scene comparatively late. For example, according to Lee and others the development of international health co- operation is commonly considered in relation to three periods. First, the nineteenth century, characterised in particular by the first international sanitary conferences; second, the inter-war period characterised by the establishment of international organisations such as the League of Nations; and third the post war era, dominated by the history of the World Health Organisation (Lee 2003; Loughlin/Berridge 2002: 8-9). Following the 1970s and the declaration at Alma Ata to aim for “Health for All” by the year 2000, a new era emerged, temporally located at the turn of the 21st century amongst accelerated globalisation, and the increasing influence of the neo-liberal economic politics of global financial institutions. During this era, a human rights discourses have been used to argue against the decline in the capacity of, and will of, states and state based organisations to effectively manage issues of global public health. This most recent has also seen the emergence of new governance forms, no longer based solely on international cooperation and negotiation. Today, a wide array of new global health governance (GHG) organisations bring together public and private actors, some more some less oriented on concepts of justice and redistribution in their approach. With the well recognised effects that globalisation has on health and the effects that health has on many other issues areas, the debate about “who is responsible” now concerns a multitude of new actors and a strong ethical discourse. The invovled actors may be states, state-based, sub-state or completely independent from states. It is often unclear what explicit responsibilities these multiple of actors have, or what responsibilities they take on by involving themselves in processes of global governance within the health sector. However, actors taking on governance roles without a clear idea of what their responsibilities are, who they are responsible to, how their responsibilities may change, and ultimately how they will be held accountable is a major stumbling block for reaching the goal of adequate health for With the absence of any kind of world government, debates on ‘who is responsible’ need to 1.1 Defining Roles and Responsibilities Within the State.
In advanced democracies, a system of mutual obligations has emerged as part of the development of concept of citizenship, in which all able persons falling within a certain jurisdiction became “citizens” and gain certain rights by taking on responsibilities. Today, the allocation of responsibilities of both state and citizen takes place within a delicate relationship that determines obligations for both. Hence, there are three directional relationships for determining responsibilities that exist within the state context, 1) citizen to citizen (this can also refer to an civil organisation or business), 2) citizen to state, 3) state to citizen. Each directional relationship functions differently in how it defines the responsibilities of the other In the first relationship, citizens are obliged to respect the rights of fellow citizens and their equal access to participation in public life, including those institutions that protect their own- well-being (cmp. Buchanan and DeCamp 2006: 99). These can be seen as passive responsibilities. Other obligations and responsibilities from citizen to citizen are defined
through social norms and expectations, to behave in a certain way or to care for those in
In the second relationship, citizens also have the obligation to act in solidarity with fellow citizens by accepting the outcomes of democratic process and contributing a fair share to the burden of the costs of government (generally through tax). These responsibilities are defined
through the social contract.3
In the third relationship, the state has, the obligation to fulfil the roles that it is given by the citizen, and they and agree to take on. These concrete responsibilities are defined by explicit
agreement.4 While it is the third mechanism for determining responsibilities, that of explicit
agreement, which is most often discussed and applied on the global level, I argue that the first two, social norms and expectations, and the social contract, are just as important for the determination of responsibilities on the global level. The corresponding mechanism for accountability reverses the directional responsibility relationship. In the citizen to citizen relationship, if one citizen fails to respect the rights of another or fails to act in accordance with social norms, they might be held to account by, i.e. risk incurring costs. Such costs range from social embarrassment or even material costs if persecuted through a civil arbitration system. In the citizen to state relationship, if a citizen refuses to fulfil its obligation to contribute to burden sharing the state is awarded the capacity to incur financial or even freedom costs on 3 As in Rawls 1971. 4 Of course, the existence of contractual law also represents a clear definition of responsibilities in the citizen to citizen relationship. the citizen. In extreme cases, if the citizen refutes its obligation to accept the democratic process, its citizenship status may even be withdrawn. Finally in the state to citizen relationship, if a government either does not, or inadequately fulfils the agreed upon responsibilities, citizens are awarded the capacity to incur costs on that government, this may involve debate, protest, strike or ultimately the removal from government. 1.2 Defining Responsibilities Outside of the State.
On the global level, in the absence of a world government, the two way responsibility- accountability relationships that exist between citizens, states and peers are not easily reversed to provide accountability. Power asymmetries are exacerbated, communicative action is obviously more difficult and importantly regulatory mechanisms are absent. Indeed, the very ideas of citizenship, peer relationships, rulers and subjects can, at first glance, seem far fetched for the global arena where citizens have little or no contact with rule-makers and the “imagined community” expands to suddenly encompasses all.5 Still, on the global level, responsibilities do exist and are in fact determined via mechanisms comparable to those listed above: firstly and most obviously via explicit agreements, but also, as I will argue, via social norms and expectations and a slowly forming global social contract. 1.2.1 Responsibilities Determined via Explicit Agreements in Global Health
Most international cooperation bases itself on explicit agreements between actors, most predominantly states, but increasingly also between other types of actors, to take on certain By method of explicit agreements responsibilities may be allocated through formal contract, whether it is a treaty, a memorandum of understanding, or by taking up membership into an organisation the has a pre-existing constitution with clearly stated responsibilities and roles 5 Here I refer to the concept of the Imagined Community from Benedict Anderson (1991). for its members. Actors partaking in contracts have the responsibility to abide by the rules of the contract and act in accordance to the nature and purpose of the contract. There are many examples of explicit agreements in global public health ranging. They range from concrete agreements such a pledges to provide resources or logistical support within a public-private partnership for health, ; to agreeing to spend time and resources for decision- making and strategy formulation within larger organisations. An example of the former would be the pledge by two major pharmaceutical companies to donate medicinal therapies albendazole in whatever quantities necessary to achieve elimination of Lymphatic Filariasis. An example of the latter would be an Association of People living with HIV/AIDS that nominates for membership on the Programme Coordinating Board of UNAIDS and thereby takes on obligations to attend all meetings and participate in governance tasks. A prominent example of a treaty style explicit agreement is the WHO Framework Convention on Tobacco Control (WHO FCTC) which has now been signed by 168 states. Through explicit agreements it relatively easy to allocate responsibilities to actors in global health governance. However, in taking on explicit responsibilities, actors in global governance may also take in implicit responsibilities through their actions. A pharmaceutical company that is a member of public-private partnership will certainly take on more implicit responsibilities than their pledge stipulates, and an NGO working together with a UN Agencies takes on greater responsibilities than to simply participate in meetings. In other words, explicit agreements are accompanies by additional responsibilities which are 1.2.2 Responsibilities Determined via Social Norms and Expectations in Global Health
Responsibilities of the global actors can be determined via building up of social expectations amongst the community of states, epistemic communities and influential individuals that come to expect certain behaviours once a general consensus (or norm cascade) has be reached (Finnemore/Sikkink 1998). Here, the state, as well as other actors come to interact with peers in an situation that can be compared to a community. For example, with the founding of the United Nation Charter, the responsibility of the state to respect the sovereignty of other states was established by explicit agreement, however more recently, the responsibility to protect has been said to have ‘trumped the norm of state sovereignty’ (Grant/Keohane 2005, 7). Through this norm states are assigned the responsibility follow expectations of “good governance” determined by the community of states, independent of how responsibilities had been allocated internally. In global health governance we find a large number of social norms and expectations that define responsibilities for various actors. The responsibilities of states are the most pressingly argued examples here. The responsibilities of states in global public health are; first to “refrain from committing injustices and from supporting states that commit injustices” and second to act as “guarantors of the own citizen’s human rights” (Buchanan and DeCamp 2006: 103). Over the past two decades, the development of global norms to secure heath as a human right has been slowly progressing to put moral pressure on actors in global health governance to recognise certain responsibilities not addressed in explicit agreements. In global health governance we often find a combination of these processes that definine responsibilities. Either social norms can emerge which are then hardened into explicit agreements, e.g. the emerging norm to restrict tobacco smoking was followed by the Framework Convention for Tobacco Control or social expectations on actors emerge following entering into a explicit agreements; e.g. parties to “The Global Fund to Fight AIDS Tuberculosis and Malaria” take on the formal task of gathering and distributing funds for AIDS, Tuberculosis and Malaria projects, but the involved actors also face growing expectations on assuring that funds are distributed into sustainable projects with low overhead 1.2.3. The Global Social Contract
Finally, responsibilities can be seen to stem from a slowly emerging global social contract. Although not nearly as advanced as on the state level, it is a particularly useful concept when looking at the development of global governance institutions and interaction between different The idea of a global social contract presupposes the existence of a global society formed out of an interest to secure order and justice for the members of that society.6 It is debated as to whether such a society exists on a global level, but, especially amongst commentators of global health, there are a considerable number that support its development (Kickbusch 2004) or even suggest its nascent formation (Fidler 2007). The large number of explicit agreements and social norms and expectations amongst global actors can be seen as expression of a desire to live with such a contract. However, a social contract goes further than these two mechanisms for identifying responsibilities, it requires a concept of citizenship for the global The actors involved in global health governance are not like citizens and states in terms of a subordinate-superior relationship, nevertheless individuals and organised collectives can be seen as having the capacity to take on the role as global citizens. Such organised collectives might be states, or state-based organisations, but also civil society organisations, for-profit organisations, state-based organisations, and collectives any kind that act with a degree of independence and identity. Indeed any actor that has the capacity to steer its own actions and participated in global governance, can be seen to take on role of global citizen. Key to the question of who can be considered a global citizen is whether an actor can ba allocated ‘moral agency.’ Erskine (2001) argues that it is quite possible for collectives on the global lavel to be assigned ‘moral agency, despite some scholars arguing that only possible for individual. The idea that collectives or institutions have moral agency means that they are 1) vulnerable to blame, 2) can be ascribed duties, and 3) can be held morally accountable (Erskine 2001: 67). Importantly on the global level it deflects from concepts that suggest that due to anarchy (the absence of any recognized common superior authority) any action in 6 Based on a Rawlsian understanding of social contract theory, whereby all ‘rational’ actors, when placed behind the veil of ignorance would choose to live with constraints for the purpose of having order. one’s own interest is acceptable and the doing otherwise is charitable and therefore not connected with the need to be held accountable. However, moral agency cannot be attributed to just any group individuals. Moral agency requires certain capacities on behalf of a collective, summarized by Erskine as 1) the capacity for moral deliberation i.e. understanding and reflection, realised in organised collectives through a central decision-making authority with the ability to arrive at a unified course of action 2) the capacity to act on decisions, without being burdened by instability, the arbitrary power of a few individuals (either intern or extern) or restriction of freedoms. (Erskine 2001: Actors that fulfil the criteria for “moral agency” and are involved in global health governance take on responsibilities that, on the abstract level, are similar to those of state-citizens, namely: the obligation to act in solidarity with fellow citizens by and accepting a burden- In global health governance today, there are many actors that would fulfil Erkine’s criteria as having ‘moral agency’ and therefore could be handed the responsibilities of global citizenship. In the following section, I will take a look at a few of these actors and their 2. Governance Responsibilities and Actors in Global Health Governance
2.1 Who is are Actors in Global Health Governance?
As the interest of this paper is to examine the allocation of responsibilities and accountability with respect to the recent trend towards an increasing number and diversifying types of actors in global public health, I am interested in what types of collectives we might ascribe moral agency in this issue area. Indeed the list is long some of the most obvious being: states, patient interest groups, health insurance companies, UN specialised agencies, globally and locally active NGOs, philanthropist foundations, medical professional associations and medical product manufactuers. Literally hundreds of thousands of collectives with the capacity to deliberate, act and take on responsibilities. For the purpose of this paper, I will take five prominent actors that represent that current wave of interest in global public health. These five actors are involved in global health governance and specifically, (but by no means exclusively) activities concerning immunization as a specific global public health issue. They have been selected for analysis here do to their The first is a typical example of the actor-type “state” or more precisely “donor” or OECD state.” For purpose of analysis, I will take the state of Norway, which has been particularly active in global public health projects in recent years and has certain capacities which would bind it to specifical responsibilities in the case of a global social contract. The second is an example from the philanthropic sector, chosen because of its high level of public attention in recent years: The Bill and Melinda Gates Foundation. The third is UNICEF, an example of an intergovernmental organisation and UN Specialised Agency, whose mandate is based on approval from states of the UN Economic and Social The fourth is Merck & Co. an example of an actor from the for-profit sectors whose business activities are directly concerned with the health sector and is globally active. The final example of an actor in global health governance is the Global Alliance for Vaccines and Immunisation (GAVI) an example of a global health governance institution which, in the case of a global social contract, could fulfil the role of collecting resources and ensuring that costs of providing justice are evenly distributed. These five examples and the categories types they represent are by no means exhaustive, but they serve as quite contrasting examples in a comparison of the ways their responsibilities are defined, and who is able to hold them to account. In the following section I will look at each of these actors in turn and draw out more specific responsibilities each of these actor take on have in the sub-field of immunization according to explicit agreements, social norms and expectations and the global social contract. 2.2 For what Outcomes are Global Health Institutions Responsible?
If the responsibilities of entities outside of the state are determined through a combination of formal agreement and social expectations, and at least in part the recognition of a social contract it is worth looking at what concrete responsibilities might be derived from these Buchanan and DeCamp write that with a growing concern about global health, the stage for assigning responsibilities has now been set following three developments: first, widening recognition and available information on the nature and causes of global health problems, second a greater capacity to ameliorate them and third, a growing human rights discourse based on a cosmopolitan ethical perspective that “provides a normative basis for taking global health seriously as a moral issue”(Bucahanan and DeCamp 2006: 96). However, they recognise that concrete conclusions about who should do what to solve health problems are There are two basic moral obligations that can be said are assigned to actors in GHG, partly through explicit agreements, partly through social expectations and norms, and partly through participation in a global social contract, the first is based on responsibility to ‘do-no-harm’, which basically assigns the responsibility to any actor to ameliorate those (health) problems that “are caused by injustices they commit or support” (Buchanan and CeCamp 2006: 102) This responsibility can be applied in many ways; for example applied to business actors it can refer to the responsibility for the well-being of consumers and workers; applied to donors it refers to the responsibility to be sure that their funds are not used for the proposes of committed injustices; applied to actors from sectors other than health, it refers to refers safeguarding against negative cross-sector effects. Going beyond the responsibility to do-no-harm are responsibilities placed on actors to assist
and protect, or in other words, humanity and benevolence. This is likened to social
responsibility which is multidimensional and goes beyond just being respectful of others to encompass solidarity with others and working towards achieving positive human rights for all. As mentioned above, the responsibility of states to assist and protect its own citizens has become strong enough to justify intervention in some cases. But in global health governance this does not just refer to states, but all organizations who have the capacity to assist those that cannot help themselves. Some examples are that several NGOs have their main aim to gain awareness of health crises and call states and other large organisations into action, business actors have the responsibility to assist building sustainable communities in areas where they are active, wealthy states have the responsibility to assist others other through development Coming back to the five prominent examples of actors in GHG introduced in the previous section, what concrete responsibilities to do-no-harm and assist and protect have been allocated through explicit agreements, social norms and expectations and the global social 2.2.1 Case Study: Responsibilities of Actors Addressing Global Immunization
In the 1960s vaccination programmes were rarely included in the activities of national health services of developing countries and often many years lapsed between the development of new vaccines with the potential of relatively cheap widespread coverage and their actual widespread use in immunisation programmes. In 1972 the WHO declared the establishment of immunisation programmes a priority and in 1974 the World Health Assembly created the Expanded Programme on Immunisation, and made the recommendation that WHO member- states develop immunisation programmes against several diseases. UNICEF worked with the programme as an operational partner. By 1991, the WHO and UNICEF reported that the goal of immunising 80 percent of the world’s children had been achieved. After that, rates of immunisation stabilised and in some countries actually fell for several years and by 2000 both the WHO and UNICEF had considerably reduced the resources being put into immunisation programmes (Weeks 2000: 2-4). Many donor-states had come to rely on bi-lateral programmes for immunisation. Around the turn of this century a new drive to boost immunization coverage saw the establishment of new public-private partnerships and global governance institutions with the aim of significantly increasing immunization coverage. The number and types of actors involved in this sub-sector dramatically increased including not only those with a direct interest, e.g. states with low rates of coverage or vaccine manufacturers but also those various donors and partners from non-health sectors. The state of Norway, Merck &Co., the Bill and Melinda Gates Foundation, UNICEF and GAVI are five such actors. How are their responsibilities for action on immunization defined through explicit agreements, social norms and expectations and the social contract? Below I will give a brief account of how some of the responsibilities of these actors are defined. Norway, has one of the highest per capita incomes in the world and high rates of immunization of its own population. It has taken on considerable responsibilities via explicit agreements, pledging high levels of funding for UNICEF, the World Health Organisation, other health based projects and offering debt relief for several poor countries under certain conditions. As a member of the OECD Development Assistance Committee (DAC) Norway is embedded in considerable social norms and expectation on how much development aid should be administered, and how it should be prioritized distributed. Specifically, the norm of do-no-harm is particularly strong. Norway has the implicit responsibility to ensure that their aid projects to not contribute worsening pressing health sector problems that hinder immunization activities such as personnel shortages or inflation. Through the social contract Norway is expected to show solidarity and a willingness to contribute its fair share to the burden of global immunization. This may be measured on a combination of Gross National Income as a percentage of global national income, relative to population. Merck and Co. is directly involved in the vaccine manufacture. As a private actor it is not elected by any public constituency that determines it responsibilities, still, Merck & Co. dispose of a considerable share of the knowledge and financial resources required to achieve increased immunization rates. This makes Merck & Co. an actor with a high capacity to share burden. Merck and Co. has entered into a large number of explicit agreements to take on responsibilities for health and immunization globally. These include commitments to assist patients that fulfil needs criteria, pledging to donate large quantities of medicines and vaccines and entering into price agreements. As a prominent and highly profitable actor, considerable responsibilities have been placed upon Merck and Co. through social norms and expectation. First and foremost, these come under the category of do-no-harm and activities of “Corporate Social Responsibility”. Through the social contract, Merck & Co is expected to use its capacity to contribute to increased immunization rates to surrendering some of its comparative advantage in knowledge and financial resources. The Bill and Melinda Gates Foundation (B&MG Foundation) has an endowment of $US334billion, mostly stemming from the personal wealth of Bill and Melinda Gates and Ted Turner. The foundation has become a prominent player in global public health due to the enormous funds committed to various public health projects and the outspoken promotion of issue-specific narrow-target health projects as good “investments” in public health. The B&MG Foundation have entered numerous explicit agreements to commit funds, but has also entered into roles of strategic importance for example at GAVI. Here they have the explicit responsibility to “make an active and effective contribution to the Board’s collective performance”7. There are considerable responsibilities placed on B&MG Foundation from social norms and expectation, often aimed at principles of do-no-harm considering the commitment of the foundation to very specific narrow approaches. Within the global social contract, the B&MG Foundation resources should contribute to burden sharing, but there is no 7 Information accessed online 22. May 2007 at: http://www.gavialliance.org/Governance/gaviboard_functions_operations.php specific responsibility to focus more on health or immunization than other pressing global problems. Boosting the funds of coordinating global governance institutions could be considered the most appropriate method of contributing to burden sharing. UNICEF is a specialised UN-Agency and can be considered a global governance institution in that various other global citizens participate in the central decision-making structures and operations of the organisation. With its capacity to deliberate and come to decisions, as well as having an identity greater than the sum of its parts, UNICEF can be assigned moral agency and have responsibilities. The reduction in funding for immunization programmes in the mid- 1990s is an example of how UNICEF set priorities and acts upon them. Still, the capacity to contribute to burden sharing is often limited to allocated funds and resources. Today only around half of UNICEF incomes comes from public sources such the UN Economic and Social Council members. UNICEF has explicitly agreed to combine immunization programmes with micro-nutrient supplements to work towards specific targets in immunization coverage. It has also agreed to take on the tasks of vaccine procurement for GAVI. The social norms and expectations that surround UNICEF’s immunization work relate (amongst others) to keeping appropriate relationships with other relevant actors, and exercising restraint in adopting approaches demanded by resource rich donors. UNICEF’s role in the social contract is not only to contribute to burden sharing, but to coordinate and fair Finally, the Global Alliance for Vaccinnes and Immunization is an inclusive global governance organisation. These organisations are said to be “obliged to create or collect resources needed for the fulfilment of collective responsibilities and ensure that the costs of fulfilling those responsibilities are distributed fairly (Buchanan and DeCamp 2006: 100)”. GAVI has a clear role on the global social contract, although this is not the specific responsibility that it has taken on through explicit agreement: which is to: To provide cash support for countries with GNI per capita of less than $1000 for immunization programmes. The responsibilities of GAVI determined through social expectation and norms as to ensure the coordinated projects are sustainable and meet the needs of those that require immunization, rather than the needs and priorities of those that donate funds. These are just a few consideration of how responsibilities are defined different through the three mechanisms explicit agreement, social norms and expectation and the social contract and are summarized in the following table. Table 1: Responsibilities of Example Actors in Immunization
Social Norms and
• Use full capacity to reach own aim of • Fulfil allocated roles as board member • Fulfil allocated roles a board member The table above demonstrates that each of these actors have different yet clear responsibilities depending on their level of involvement and varying capacities. What this method of determining responsibilities does not do apportion blame or define obligations through processes of guilt or cause. No one actor can be allocated blame for poor health outcomes but all actors have responsibilities to contribute to solutions. This is collective responsibility. Recognising collective responsibilities helps to avoid the problem of “duty dumping”, which is to “ascribe obligation to individuals or institutions without offering adequate justification or recognising complexities in cause and affect”. Indeed the causes of poor health (at a whole community of society level) are almost always so complex that direct or sole causes and effect can never be determined. Indeed trying to isolate sole causes can only serve to excuse certain actors from their fair share of collective responsibility. It is for this reason, that all five of the actors taken as examples here are ascribed duties according to principles of solidarity and their capacities. On an abstract level this mirrors how the responsibilities of states and citizens are determined on the domestic level. 3. Holding Global Health Governance Accountable
3.1 To Whom are GHG Actors Directly Answerable?
Ultimately, beyond the responsibility to ‘do-no-harm,’ each ‘GHG-relevant organisation’ is responsible to those that they have the capacity to ‘assist and protect.’ There is no one actor with the capacity to provide health for all, therefore responsibilities are divided and shared. At the state level in functioning democracies responsibilities are determined by those who also have (at least in part) the capacity to hold whoever is responsible, accountable. Responsibility and accountability is linked by the nature of the relationships found at the state level, whether it be citizen-citzen, citizen-state, state citizen. On the global level, the assigning of responsibility functions in a similar way, but mechanisms of accountability do not. In this concluding section, I will briefly take a look at this predicament of accountability in global health governance. The function of accountability is to ensure that those that wield power (whether it has been delegated or has arisen from resource capacities) are answerable for their conduct (Newell and Bellour 2002: 5). Almost all actors in global health governance are subject to some kinds of checks and balances by others who can incur costs for inappropriate conduct. However, not all of these checks and balances are designed to ensure that responsibilities towards global health are fulfilled. More often than not, accountability mechanisms have the primary function to ensure completely different responsibilities are fulfilled as a priority. Actors from for-profit sectors are probably the most clear examples here. Merck & Co. is listed on the New York Stock Exchange and the company’s board of directors has the explicit primary goal protect the interest of stockholders, who in turn can object to board or company decision. Stockholders have the capacity to hold executives accountable, through internal mechanisms of reprimand, or rejection of company (selling stock). When holding executives accountable, it is unlikely that stockholders have Merck & Co.’s responsibilities to burden sharing in global Another type of actor that is often cited as having “accountability problems” is civil society organisations (Baker 2003; Jordan 2005, Benner, Reinicke, Witte 2004)), which have such widely varying accountability processes that their sheer diversity can cause problems of credibility. Jordan (2005) sites Ebrahim’s three types of accountability mechanisms for NGOs as examples: 1) “Membership organizations…(that) are principally accountable to their members and … use franchise, reform and dues as accountability mechanisms; 2) Service organizations (that) are principally accountable to their donors and … use performance assessment, evaluation, reporting requirements, laws and self-regulation as principle accountability mechanisms; and 3) networks of NGOs (that) are principally accountable to the organizational members.” It is clear that within civil society organisations, as with business, responsibilities for public health action are rarely aligned with accountability mechanisms. The case of failed states hardly be mentioned, as they are such blatant examples of actors not Indeed, all types of global health governance actors are embedded in accountability mechanisms that do not necessarily have represent a two-ways relationship between allocating responsibility and ensuring answerability. 3.2 Alternative Mechanisms of Responsibility
According to Newell and Bellour (2002: 5), “mechanisms of accountability can take a diverse range of forms from formal top-down processes of elections, hearing and consultations to bottom-up strategies such as citizen juries, popular protest or participatory budgeting. The purpose of bottom-up accountability strategies is to maximize the capacity of resource poor While the accountability mechanisms described above consider internal accountability, by which only the members or stakeholders of the respective organisations are entitled to act as principals and to hold the power-wielders accountable, the notion of external accountability can be used to empower those groups who seek out “bottom-up” strategies. Essentially, these are persons and groups to whom actors in global health governance are responsible. “This dimension of accountability is of crucial importance, as it allows for the creation of a relationship between agents and principals that goes beyond the traditional delegative model and opens the discourse towards the wider effects of the activities of states, International Organisations, NGOs and private companies in global governance.” (Bartsch et. al. 2006). According to Blagescu et. al. it creates “…a more balanced accountability, in which the voices of those most affected by an organisation’s activities are not overshadowed by the interests of the most powerful stakeholders“ (Blagescu/de las Casas/Llloyd 2005: 20). Grant/Keohane (2005) in their analysis of different types of accountability of in world politics offer two types of external accountability which are particular suitable for “bottom-up” First, peer accountability: where “organizations that are poorly rated by their peers are likely to have difficulty in persuading them to cooperate and, therefore will have trouble achieving their own purposes” Grant/Keohane 2005: 9). This can be achieved via regular public reviews and ratings of an actors actions or performance. Once peers have a greater ability to judge an actors fulfilment of their responsibilities they will act accordingly. Second, public reputational accountability, which can be applied in situations where the a loss of reputation is a considerable cost for an actor. Through techniques such as public debate and protest, an actor who does not fulfil responsibilities is exposed. Both of these types of accountability mechanisms require considerable less material resources than accountability mechanisms that rely on coercion such as the withdrawal of funds. (See also Buchanan and Keohan 2006: 422-424). However, they are certainly not cost-free. Many actors and semi-organised collectives are still far from having the organisation, material, or knowledge capacity to engage even in ‘bottom-up’ accountability mechanisms. There is however, great room for such capacities to be strengthened. All actors in global health governance have the responsibility to pool resources to maximize outcomes. Ultimately, it is concluded that responsibilities on a global level are shared between different actors. Actors can be linked together in their responsibilities through the recognition of a global social contract and through explicit agreements and social norms and expectations. What therefore needs to occur on the global level is to firstly determine which actors have moral agency, secondly, to appeal to their mechanism of deliberations to recognize their moral responsibilities and finally link these responsibilities to alternative mechanisms of accountability. Most importantly, it cannot be acceptable that responsibilities are defined solely by those who that are able to impose immediate costs and the capacity for more actors to be able to engage in accountability mechanisms needs to be strengthened. References
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April 2013 Prescribing in General Practice INTRODUCTION This guidance was put together by the Clinical and Prescribing subcommittee to meet the increasing demand from individuals and organisations for information relating to prescribing in general practice. Doctors have specific clinical rights and responsibilities in relation to prescribing, and as most general practitioners wo