1 Introduction

This chapter corresponds with the monograph’s research field in that it analyzes a given area of GPG s: global health. This chapter aims to show the role of international institutions in the process of providing health-related global public goods (GPG s) that meet the Sustainable Development Goals 2030 (SDG s).

Why are global public goods so important in ensuring global health? Less than one-third of the world’s population lives in relative prosperity, while more than two-thirds cannot satisfy their basic needs, including health needs. Thus, ensuring global health has become a significant challenge. The problem only seems to have been aggravating recently due to the most serious health crisis in more than a hundred years due to the SARS-CoV-2 virus.

The consequences of the crisis do not only affect health, but also the economy as a whole, which may translate into difficulties with financing GPG s. The war in Ukraine is yet another threat to global health, as it may result in food supply shortages affecting poor countries, implying a serious toll on the health of the regions’ inhabitants. Ukraine produces and exports wheat, corn, and sunflower oil, all of which are imported by low-income countries in Africa and the Middle East. The following countries are fully dependent on wheat imports from Ukraine and Russia: Somalia, Benin, Laos, Egypt, Sudan, DR Congo, Senegal, and Tanzania. This means a catastrophic risk of famine, which will affect the health of people living far from where the armed conflict is taking place.

The chapter contributes to the understanding of the challenges of providing global health GPG s in the context of the new sustainable development paradigm, health crises, and famine caused by armed conflicts.

The content of the chapter is structured into six sections. The first section deals with the concept of global public goods related to global health, referring the various definition in the literature. The second section outlines the issues of governing global health. The third section provides a synthetic analysis of the direct and indirect presence of the global health concept in the Sustainable Development Goals 2030. The fourth section presents selected international institutions which, directly or indirectly, pursue the goal of global health. It also includes the activity of grassroots social initiatives aimed at improving the level of health from a global perspective. The fifth section focuses on the activities of institutions and EU-related initiatives concerning the provision of global health goods. The final section analyzes the anticipated and observed difficulties in meeting SDG s for global health. The chapter ends with the presentation of some conclusions.

2 Global Health and Related Global Public Goods

When discussing global health, we first think of it from the humanitarian perspective, that is equal access to medical care and knowledge. Being a growth driver, it is also of importance in the context of economic growth. In recent decades public health has also risen in significance in terms of safety. This has been due to: (1) the spread of communicable diseases, with poor countries being given the most prominence due to ailing or non-existent health-care systems, (2) biological weapons and bio-terrorism threats, and (3) political strategies used in conflicts and influence gaining.

The term “global health” is not unambiguously represented in the literature. Missoni et al. (2019, based on a literature review largely researched by Bozorgmeher) identify four meanings of global health. The first is “all around the world” or “everywhere.” The second one relates to health problems that are not limited by state boundaries (e.g., pandemics and the spread of communicable diseases). In line with the third approach, the term “global health” is interpreted as a multidisciplinary concept. It implies that, the study of global health is the study of social, political, economic, biological, and technological relationships that affect health in various ways. The fourth approach applies a term introduced by Scholte: “supra-territoriality,” that is, social links which transcend administrative territorial geography (Missoni et al., 2019). Frenk et al. reconceptualize the term “global health” as “the health of the global population, with a focus on the dense relationships of interdependence across nations and sectors that have arisen with globalization” (Frenk et al., 2014, p. 94). For the analysis in this chapter, we define the term “global health” as public health for world’s population with the inevitable impact of globalization processes.

The term “global public goods” (GPG s) is defined as goods that are non-excludable and non-rivalrous in consumption and their provision of benefits to every country (Barrett, 2007). But this is the definition of pure public goods. In addition to pure public goods, impure public goods and club goods are more common in the real world. The concept of global public goods is comprehensively presented in Chapter 1 In this chapter, the focus is on all types of global public goods related to global health. From the point of view of the considerations of this module, it is irrelevant to which category of global public goods the discussed examples belong. However, let us be aware that, like all global public goods, global health-related goods are characterized by differing intensities of consumption characteristics (non-excludable and non-rivalrous).

The literature provides varying definitions of global public goods for global health. They may be broadly interpreted as cross-border functions or interventions that contribute to a higher level of health and which are not produced by market forces (UN, 2020).

It is clear that global health as a concept cannot be just simply physically delivered. However, the provision of global public goods can contribute to global health by serving selected population needs.

In the context of a healthy society, examples of needs provided for by the supply of global public goods are: peace and security, fundamental rules of behavior, and regulations to protect health or knowledge of how to prevent and treat diseases (Moon et al., 2017). Health-related global public goods should, therefore, target these areas. Moon et al. (2017) divided GPG s into three categories: research/assessment, normative functions, and managing externalities.

In the first category, research/assessment, the following were classified as key for health: health technology R&D, marketing approval (e.g., the Food and Drug Administration [FDA], the European Medicines Agency [EMA]), health technology assessment (e.g., UK National Institute for Clinical Excellence [NICE]), product quality assessment (e.g., World Health Organization [WHO]), pre-qualification, good manufacturing practices (GMP s) certification, guidelines/forms (e.g., treatment guidelines, reimbursement decisions), delivery/health systems research/implementation research.

For the second category, normative functions, they named standard setting (e.g., International Classification of Diseases [ICD], Codex Alimentarius [GMP]), regulation (e.g., Framework Convention on Tobacco Control [FCTC], WHO pre-qualification), and policies to preserve the efficacy of antimicrobials.

The last category, managing externalities, embraced public goods such as: communicable disease surveillance, strategic stockpiles of drugs and vaccines for pandemics, and early-warning systems for natural disasters.

Barrett (2007) divided GPG s with respect to who provides and finances the GPG. He distinguished the following categories: single best efforts (only a single successful intervention would be required, all the other countries are beneficiaries), weakest links (can only be provided with the active participation of every country, requires universal cooperation), aggregate efforts (depends on the total efforts of all countries). All these GPG categories need financing. However, Barrett points out two other categories of GPG s which do not need financing: mutual restraint and coordination.

For the analysis in this chapter, it seems reasonable to address why it is worth delivering certain public goods in the health domain globally. Isn’t the care of national systems sufficient? There are a number of arguments for the delivery of GPG s:

1. –They offer potential benefits to all countries, even if single countries bear the costs.
2. –Local measures may not ensure that the goal is met, even if huge outlays are made (preventing climate changes, containing the virus from spreading).
3. –Certain public goods, for instance, the weakest links category, would not be effectively delivered if not for international cooperation.
4. –International cooperation consists of information exchange and may prevent global health emergencies.
5. –Acting globally, it is possible to partly attend to health prevention and promotion, which largely determine healthy life expectancy.

As pointed out by Barrett (2007), global public goods must be supplied voluntarily. International cooperation could be a kind of organized volunteerism. Therefore, the chapter argues that international cooperation is possible thanks to the major role of international organizations.

3 Global Health Governance

Improving the health of the world’s human population is among the main challenges of the 21st century. The various aspects of ensuring healthy societies require the interaction of countries within a region and even between continents. Hence the importance of global health governance (GHG). GHG may be understood as “formal and informal institutions, rules and processes by states, intergovernmental organizations, and non-state actors to deal with health challenges that require cross-border collective action to be addressed effectively” (Fidler, 2010, p. 3).

GHG forms a complex system that can be characterized as multi-sectoral, multi-actor, multi-institutional, multi-principle, and multi-instrumental system, as described in Chapter 2 In the context of Chapter 2, for each of these characteristics, some main developments can be discerned:

1. –Subjects: As in the general case of global governance, differentiated governance systems have emerged in GHG, depending on the fields of action. Interventions stem from differentiated measures to raise the level of global health. For example, prevention against communicable diseases (vaccination), health promotion for non-communicable diseases, clean air, access to nutritious food, systems for monitoring the spread of diseases, or building effective and efficient health systems. Over time, the thematic scope of the system has expanded considerably. Moreover, some IO s have increased their area of interest. The best example is the World Bank (WB), which has entered the remit of the WHO and, up to a certain point, competed with it.
2. –Actors: As Moon writes, “GHG can best be characterized as a network, in which independent purposive actors negotiate the rules that will regulate their relations, rather than a hierarchy or market” (Moon, 2021, p. 235).
3. –Legal forms and competences: Hundreds of actors have engaged in GHG influencing agendas, rulemaking, implementation, monitoring, and enforcement (Moon, 2021). These actors work in different forms of formal and informal governance arrangements. Some institutions are large, international treaty-based organizations with strong bureaucratic and financial support (WHO, WB). Others consist of transnational private (Bill and Melinda Gates Foundation [BMGF]) or hybrid arrangements (Gavi, the Vaccine Alliance). In addition to structures with a strong formal basis, the occurrence of civil society organizations (CSO s) is also observed.
4. –Principles: In the case of GHG s, the adoption of common principles seems unproblematic. However, the history of the WHO shows that adopted priorities for international action can be influenced by international politics (Moon, 2021).
5. –Instruments: In the case of GHG, soft instruments such as monitoring, persuasion, dissemination of standards, information exchange, etc. predominate among the instruments used.

In the case of the evolution of GHG s, an additional feature should be mentioned: the sources of funding and the associated pressure on expenditure allocation. Funds raised in the form of statutory contributions from countries affiliated to an international institution appear to be less subject to pressure from donor countries. In the case of funds from donors not bound by co-financing treaties, there is a risk of dedicating the donation to a specific purpose that the donor has, not necessarily the international organization.

There are at least two main risks in the way of proper GHG: the risk of inefficient and ineffective governance resulting from the structure of the IO network and the risk of insufficient financial resources.

The first one stems from underperformance in managing a network of fragmented actors. This is due to uncoordinated initiatives, often competing for funding. Such undertakings are typically focused on certain diseases, types of intervention, and population groups. Globally, it is the lack of a coordinating body and even of any adjustment mechanism that is to blame. This leads to an inefficient allocation of resources, carried out on the basis of ad hoc criteria decided by the attractiveness of aspects such as donor indications, public opinion assessment, foreign, economic or security policy priorities, etc., rather than the rationale of global health needs (Lee & Brumme, 2012).

The second risk stems from irrational priorities in the global community. It is worth noting the proportions in health spending by key institutions, such as the WHO, versus the incomes of top managers or the world’s military spending. The Health Assembly – approved program budget for 2018–2019 totaled US$4.4 billion (WHO, 2020). During the 2008 financial crisis, when the world economy was deep in recession, the Wall Street bankers paid themselves bonuses amounting to US$18.4 billion (Węcławski, 2015), while in 2019 alone military spending was estimated at US$1.922 trillion (Glapiak, 2020).

According to Frenk (Frenk, 2010, p. 1): “Health has been increasingly recognized as a key element of sustainable economic development, global security, effective governance and human rights promotion.” Hence, it seems obvious to link global health to the Sustainable Development Goals Agenda 2030.

4 Global Health in Sustainable Development Goals 2030

The health-related targets are not limited to only SDG 3; many of the SDG s also have targets directly and/or indirectly related to health, reflecting the complex pattern of health determinants.

WORLD HEALTH ORGANIZATION (2017A, 3)

Ever since the 1990s, the assessment of countries’ economic development has come to include broadly understood human health. Amartya Sen, the Nobel prize winner, pioneered this approach. His theory inspired the Human Development Report 1990: Concept and Measurement of Human Development (UNDP, 1990). In later years there were numerous international discussions, which had laid the foundations for what gave rise to the Millennium Declaration of 2000. Another major step involve human beings in the assessment model of sustainable economic development was the United Nations Conference on Sustainable Development of June 2012 which decided on the development of the Sustainable Development Goals (SDG s).

The determinants of global health are multifaceted and encompass a range of factors, beyond those exclusively associated with the development and accessibility of health technologies. They include such areas as the development of communication technologies, consequences of climate changes, energy prices, environmental pollution, food quality and accessibility, the level of social inequality, and consequences of economic crises:

1. –Communication technology has massively affected the transmission and storage of information on hazards, e.g., epidemiological hazards.
2. –Climate changes have their adverse effect on food supply and water access, and in extreme cases some areas are exposed to the risk of flooding, which forces their inhabitants to migrate.
3. –Energy prices affect the prices of food and medicine transportation, as well as the accessibility of travel to medical facilities, which is of particular importance in poorer regions of the world. Energy prices will also affect living conditions in low temperatures, which may, in turn, influence the level of health.
4. –Environmental pollution impacts human health through the respiratory system (air pollution), as well as through contaminated food and water (e.g., microplastics).
5. –Shortage of nutritious and diversified food directly affects the health of the population.
6. –Social inequality leads to economic crises affecting real disposable income, which inhibits access to medical benefits and supplies.
7. –Economic crises national health systems to reduce health-care financing and so do international organizations, which find it increasingly difficult to raise funds.

With such a broad array of global health determinants, it is clear that pursuing the third SDG (Goal 3: To ensure healthy lives and promote well-being for everyone at all ages) is partly realized through other SDG s. It includes, in particular, the following goals: Goal 1 (End poverty in all its forms everywhere), Goal 2 (End hunger, achieve food security and improved nutrition and promote sustainable agriculture), Goal 4 (Ensure inclusive and equitable quality education and promote lifelong learning opportunities for everyone), Goal 5 (Achieve gender equality and empower all women and girls), Goal 6 (Ensure availability and sustainable management of water and sanitation for all), Goal 7 (Ensure access to affordable, reliable, sustainable and modern energy for all), Goal 10 (Reduce inequalities within and among countries), Goal 13 (Take urgent action to combat climate change and its impacts), Goal 14 (Conserve and sustainably use the oceans, seas and marine resources for sustainable development), Goal 15 (Protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification, halt and reverse land degradation and halt biodiversity loss). The aforementioned goals are strictly related to the health of the world’s population. The pursuit of the remaining goals, which were not directly mentioned in this paragraph, will indirectly improve humans’ living conditions, which, in turn, will positively affect their health.

In addition to the actions of “ordinary citizens,” governments, and national NGO s, international organizations play a leading role in achieving the goals of Agenda 2030. International organizations serve as pivotal actors in this regard, gathering a diverse array of states and private entities. The following section provides a succinct overview of selected institutions and concise depictions of their respective missions.

5 Governing Global Health by International Organizations and its Impact on Sustainable Development

As mentioned earlier, GHG forms a complex system that can be characterized as multi-sectoral, multi-actor, multi-institutional, multi-principle, and multi-instrumental system. The institutions that manage, finance, and deliver global public goods related to global health form a network rather than a hierarchy. These institutions come in diverse legal forms and operate in different geographical areas and sectors related to global health. For the purposes of this subsection, we propose to present them in three subgroups: classical international institutions, civil society organizations, and initiatives based on information and monitoring systems.

6 Regional Public Goods in Health Care: the European Union Experience

In the European Union, health policy is the responsibility of member states, especially in terms of financing and managing health systems. However, it does not mean that the EU alone is totally passive in the area of health.

Analysis of Article 168 of the Treaty on the Functioning of the European Union (TFEU) shows that a substantial part of areas where EU institutions should be involved concerns ensuring health across borders, i.e., combating, warning against, and examining the causes of epidemics. Article 168 is about measures in the area of both veterinary and phytosanitary studies to directly protect public health. In other words, it concerns problems on which a part of the objectives of Agenda 2030 is focused.

In its activity so far, the European Union has demonstrated health efforts from two perspectives: long-term efforts aiming to provide good health to the community’s inhabitants and crisis management in health emergencies.

7 Causes of Hampering the Supply of Global Public Goods for Global Health

In spite of the efforts of existing international institutions (and any other more or less formalized organizations) to supply global public goods in health care, the results are not spectacular. A lot of work is still required, as well as extensive funding to global public goods, in order to meet the global health goals of Agenda 2030.

It was the coronavirus pandemic that painfully brought to light the limited effectiveness of activities for the health of the international community. From the very onset of the pandemic we have observed inequality in access to medical supplies and medications, from personal protective equipment to vaccines.

In particular, market failures and the institutional deficits are to blame for failed management and supply of global public goods:

1. –Market failures appear when players’ optimization decisions do not reach the social optimum. In the case of health decisions, market failures are connected with externalities, public goods, and information asymmetry. They also entail consequences for the present and the future generations. When a person decides whether or not to be vaccinated, they focus on the benefits and costs while ignoring the positive externalities imposed on strangers.
2. –Yet another market failure is related to insufficient efforts targeting epidemiological surveillance and intelligence.
3. –The world’s wealthy countries are more willing to subsidize the fight against hazards they may be directly affected by themselves. Hence the worse results in providing GPG s with regards to measles, poliomyelitis, and dracunculiasis.
4. –High income elasticity and low price responsiveness of certain medications and treatment regimens motivate pharmaceutical companies to concentrate on diseases that are more important for high income countries.
5. –The activities of numerous international institutions (formal and informal) are not necessarily coordinated, which impedes their effectiveness and efficiency on a global scale.
6. –The activities of public and private (as well as charity) organizations often produce impressive results. However, according to Peacock (2022), there are many potential conflicts of interests in the case of public and private partnerships that are neither democratically elected nor publicly accountable.

8 Conclusions

The SARS-Cov-2 pandemic highlighted the importance of global public goods in the area of health, which contributes to the realization of the Sustainable Development Goals 2030. The global public goods in health that were provided by international institutions during the pandemic included: monitoring of virus spread; quarantine requirement and enforcement; development of the vaccine and medications; knowledge of how to treat it, what the symptoms are, and therapeutic procedures; acquisition and dissemination of knowledge on how to protect oneself on a daily basis to avoid infection; acquisition and dissemination of knowledge of how to organize hospitals or the health-care system; vaccination programs for indigent regions; social campaigns convincing member of the public to get vaccinated; joint purchase of medications, medical supplies, personal protective equipment, etc.

Fruitless efforts of certain institutions were also very conspicuous. In the initial phase, ineffective action allowed the virus to spread around the world. When the pandemic became established, huge deficiencies were disclosed, in particular in personal protective and medical equipment (ventilators). As a consequence, disparate access to medical technologies, including but not limited to vaccinations and therapeutic interventions, has been observed. The period of the pandemic has served as a litmus test for the efficacy of global and regional institutions, which regrettably, have not all emerged unscathed. The roots of this failure, resulting in excess deaths and lasting complications, are to be traced back to institution underfinancing, lack of adequate coordination, lack of proper preparation for a fast production of, for instance, personal protective equipment or vaccines, and nationalism, which was particularly noticeable in vaccine redistribution. Sharing intellectual property rights also became a problem.

The year 2022 is a time when the prospect of maintaining global health and pursuing the Sustainable Development Goals 2030 seems extremely difficult. Events of the past 2 years will have serious consequences, which will require international organizations to intensify their efforts to accumulate financial sources and step up activities to provide global public goods.

The war in Ukraine entails a real risk of reduced food supply worldwide. This will particularly affect poor countries that need the most support in building better living conditions, including the aspect of health. Moreover, the war is accompanied by economic sanctions imposed on Russia and Belarus, which is globally driving energy prices. As already mentioned, it also has an adverse effect on global health. Economic sanctions hit both sides of the conflict, hence economic problems are to be expected. Regrettably, they will be negatively reflected in the level of accessible funds devoted to global health.

Economic problems may be aggravated by subsequent COVID-19 lockdowns and the related disrupted supply chains (e.g., lockdown of Shanghai, a city of 24 million people in April 2022⁴). Problems related to the economy and access to gas may affect the pace of realization of Goal 7 (Ensure access to affordable, reliable, sustainable and modern energy for all) and Goal 13 (Take urgent action to combat climate change and its impacts).

Each armed conflict causes forced migration, which normally entails a deterioration of the refugees’ living conditions, and thus their health. According to the UNHCR, the number of refugees has been steadily growing for 11 years due to persecution, armed conflicts or human rights violation. In mid-2022, the number of people fleeing reached 103 million people.⁵ Given the current elevated figures and the exponential surge in refugee populations, it will be challenging for international and national organizations to realize Target 10.7 (Facilitate orderly, safe, and responsible migration and mobility of people, including through implementation of planned and well-managed migration policies).

It seems that in order to achieve the health-centered goals of Agenda 2030 it will be necessary to focus maximum efforts on coordinated international cooperation to boost effectiveness and efficiency of global public goods provision. The world cannot afford to waste any funds due to particular interests, fragmentation of efforts, lack of coordination, no success guaranteeing priorities in place, or failing to conscientiously pursuit them. The situation demands that the international community be open to global needs, dialogue, and acceptance of compromise, which is normally not satisfactory for all sides. The world is facing a difficult task indeed.