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Legitimacy and global governance in managing global public health [Elektronische Ressource] / Carmen Huckel Schneider

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Carmen Huckel Schneider Legitimacy and Global Governance in Managing Global Public Health Dissertation zur Erlangung des akademischen Grades Doktor der Sozialwissenschaften In der Fakultät Für Sozial- und Verhaltenswissenschaften Der Eberhard-Karls-Universität Tübingen 2009 ii Gedruckt mit Genehmigung der Fakultät für Sozial- und Verhaltenswissenschaften der Universität Tübingen Hauptberichterstatter: Prof. Volker Rittberger, Ph.D. Mitberichterstatter: Prof. Dr. Martin Nettesheim Dekan: Prof. Dr. Ansgar Thiel Tag der mündlichen Prüfung: 12.02.2009 iii iv Abstract This dissertation is concerned with health governance on the global level, where over the past fifteen years a number of new organisations have emerged that address major global public health issues. Three examples are the Global Fund to Fight AIDS, Tuberculosis and Malaria, (GFATM), the Global Alliance for Vaccines and Immunisation (GAVI Alliance), and Joint United Nations Programme on HIV/AIDS (UNAIDS), each of which are examined in depth in the dissertation. These organisations differ significantly from intergovernmental organisations such as the WHO and can be classified as organisations of ‗global governance‘. Two basic observations provide the motivation for study.
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Carmen Huckel Schneider


Legitimacy and Global Governance
in Managing Global Public Health




Dissertation
zur
Erlangung des akademischen Grades
Doktor der Sozialwissenschaften
In der Fakultät
Für Sozial- und Verhaltenswissenschaften
Der Eberhard-Karls-Universität Tübingen


2009




ii

Gedruckt mit Genehmigung der
Fakultät für Sozial- und Verhaltenswissenschaften
der Universität Tübingen







Hauptberichterstatter: Prof. Volker Rittberger, Ph.D.
Mitberichterstatter: Prof. Dr. Martin Nettesheim
Dekan: Prof. Dr. Ansgar Thiel
Tag der mündlichen Prüfung: 12.02.2009



iii

iv Abstract
This dissertation is concerned with health governance on the global level, where over the past
fifteen years a number of new organisations have emerged that address major global public
health issues. Three examples are the Global Fund to Fight AIDS, Tuberculosis and Malaria,
(GFATM), the Global Alliance for Vaccines and Immunisation (GAVI Alliance), and Joint
United Nations Programme on HIV/AIDS (UNAIDS), each of which are examined in depth
in the dissertation.
These organisations differ significantly from intergovernmental organisations such as the
WHO and can be classified as organisations of ‗global governance‘. Two basic observations
provide the motivation for study. First, the work of each of these organisations can be said to
be based on principles that shift away from intergovernmentalism, towards managerialism and
cosmopolitanism. Second, despite this break with the conventional model of
intergovernmentalism, these organisations are increasing their operational scope in terms of
determining rules for action, and gaining funding. The dissertation proceeds to address the
question of how GHG Organisations – having moved away from the conventional model of
global level governance of intergovernmentalism – come to be accepted as legitimate
governing organisations.
Following a historical tracing of the evolution of governance in the area of global health, the
dissertation proceeds to provide a basis for examinations into the legitimacy of GHG
organisations via a systematic description of what legitimacy entails, the formulation of a
conceptualisation of the legitimacy suitable for the global level, and the development of
methods suitable for empirically examining the legitimacy of GHG organisations. The second
part of the dissertation contains an examination of three GHG organisations and how they
have come to experience differing levels of legitimacy amongst stakeholders.



v

vi Acknowledgements

I am very thankful for the support that I have received from staff and fellow students at the
University of Tübingen over the course of my dissertation preparation. First and foremost I
would like to thank my doctoral supervisor, Prof. Dr. Volker Rittberger who has not only
offered guidance for this dissertation, but accompanied my growth and development as a
scientist over the past years.
This dissertation was prepared as part of the Graduate Training Unit ‗Global Challenges:
Transnational and Transcultural Solutions‘. I was supported through this unit with generous
financial assistance, without which I would not have been able to undertake the necessary
research to write this dissertation. Special thanks also go to Prof. Dr. Martin Nettesheim, my
second supervisor within the research unit for his support.
My empirical research was conducted with the generous cooperation from staff at UNAIDS,
GFATM and the GAVI Alliance who granted me their time and helped organise and
participate in extensive interviews. Thanks also go to the many members of staff and
volunteers at state institutions and nongovernmental organisations around the world who
responded to my questions.
Numerous people have closely followed the progress of my dissertation and helped me look
objectively at tough questions and kept me on track until the very end, especially Kathy
Huckel, Jessica Ellis, Daniella Schmitt, Thorsten Göbel, Leonard Seabrooke, Annette
Goerlich, and Kerstin Göller.
Finally, special thanks go to Martin Schneider, for whom this dissertation is written. He
accompanied me at every possible moment with encouraging words and unconditional
support.


vii

viii Contents
Acknowledgements ..................................................................................................................................... vii
Contents ........................................................ ix
List of Tables and Diagrams ....................... xiii
Abbreviations .............................................................................................................. xv
Introduction
Global level approaches to health challenges ....... 1
Chapter One
Legitimacy and global health governance: Trends, challenges and questions ................... 7
1.1 GHG organisations .................................................................................................................................. 9
1.2 Political environment ............................. 11
1.3 Legitimacy as a key factor in global health governance ........ 14
1.4 Examining legitimacy: finding appropriate methods ............................................................................. 19
1.5 Limits of the study and contents of the dissertation .............. 23

Chapter Two
From international cooperation in health to global health governance: Insights from
historical perspectives ........................................................................................................... 27
2.1 Understanding and defining global governance .................... 29
2.2 From international cooperation in health to global health governance .................. 30
2.2.1 International Sanitary Conferences – early ad hoc multilateralism................ 31
2.2.2 The OIHP and the establishment of permanent institutions for health .......................................... 34
2.2.3 Complex international bureaucracies ............................................................................................. 35
2.2.3.1 Disease-focused approaches of the 1950s and 1960s 36
2.2.3.2 Systems based approaches and the Declaration of Alma Ata................. 37
2.2.3.3 Inter-agency conflicts and monetary policy ........................................................................... 38
2.2.4 Opening up to CSOs ...................................................... 40
2.2.5 Public-private partnerships ............ 44
2.3 GHG organisations ................................................................................................ 49
2.3.1 Inclusive decision-making structures ............................. 50
2.3.2 Active managerial follow-up ......... 52
2.3.3 Narrow, disease-oriented focus ...... 52
2.3.4 Organisational sophistication ......................................................................................................... 53
2.3.5 Engaging in legitimation strategies 54
2.4 Conclusions ........................................... 55

Chapter Three
Legitimacy in global health governance .............................................................................. 57
3.1 Legitimacy, a contested concept ............ 58
3.1.1 Empirical-analytical vs. normative-prescriptive approaches ......................... 60
3.1.2 Rule-makers and rules.................................................... 62
3.2 Legitimacy – from government to governance ...................................................... 63
3.2.1 The legitimacy of state governments ............................................................. 63
3.2.2 The legitimacy of IGOs ................. 64
3.3 Legitimacy on the global level .............................................................................. 70
3.3.1 Legitimacy in social relationships.. 70
3.3.2 A definition of legitimacy in global governance ............................................ 72
3.3.3 Good governance – ‗by‘ and ‗for‘ the people ................ 72
3.4 Bases for legitimacy of global governance organisations ...................................... 75
3.4.1 Sources of legitimacy ..................................................................................... 76
3.4.2 Manifestations of legitimate governance ‗by‘ the people .............................................................. 76
3.4.2.1 Public governance - state delegation ...................... 76
3.4.2.2 Participatory governance - stakeholder representation ........................... 77
3.4.2.3 Fair processes ......................................................................................... 78
3.4.2.4 Indirect participation – via transparency and accountability .................................................. 79
3.4.3 Manifestations of legitimate governance ‗for‘ the people.............................. 81
3.4.3.1 Right Purpose ......................... 81

ix 3.4.3.2 Problem-solving capacity ....................................................................................................... 82
3.4.3.3 Right approach ................... 83
3.4.3.4 Effectiveness and Efficacy ..... 84
3.2.3.5 Organisational efficiency ....... 85
3.5 Legitimacy – between global governance organisations and stakeholders ............................................ 87

Chapter Four
Stakeholders in Global Health Governance ........................................................................ 89
4.1 Why are stakeholders vital for legitimacy? ........................... 90
4.2 Who are stakeholders in global health governance? .............. 92
4.2.1 Ranking stakeholders ..................................................... 93
4.2.2 Classification of stakeholders ........................................................................ 97
4.2.3 Dynamic stakeholders .................. 102
4.3 Analysing stakeholders‘ positions ....................................... 104
4.4 Claims and behaviours of GHG organisations and their stakeholders ................................................. 107
4.4.1 GHG organisations and their relationships with states ................................ 108
4.4.1.1 Donor states .......................................................................................... 109
4.4.1.2 States burdened by poor health ............................................................ 110
4.4.2 GHG organisations and their relationships with IGOs . 116
4.4.3 organisations and their relationships with business sector actors ....................................... 119
4.4.4 GHG organisations and their relationships with CSOs 120
4.5 Stakeholder values in public communication ...................................................................................... 123
4.5.1 Stakeholders on legitimate governance ‗by‘ the people ............................... 126
4.5.1.1 Public governance ................................................ 126
4.5.1.2 Participatory governance ...................................................................... 127
4.5.1.3 Fair processes ....................................................... 131
4.5.1.4 Indirect participation ............ 133
4.5.2 Stakeholders on good governance ‗for‘ the people. ..... 135
4.5.2.1 Right Purpose ....................................................................................... 135
4.5.2.2 Problem-solving capacity ..................................................................... 137
4.5.2.3 Right approach ..................................................... 139
4.5.2.4 Effectiveness and efficacy .................................... 142
4.5.2.5 Organisational efficiency ..... 145
4.5.3 Stakeholders‘ and other patterns of legitimation ......................................... 146
4.6 Stakeholder opinions: survey research ................................ 148
4.6.1 Expressed opinions ...................................................... 150
4.6.1.1 Stakeholder views on public and private actors global health .............. 150
4.6.1.2 Stakeholder views on GHG organisations ............................................................................ 154
4.6.1.3 Stakeholder views on legitimate governance ‗by‘ and ‗for‘ the people ............................... 157
4.7 Discussion ........................................................................... 160
4.8 Introducing case studies ....................................................................................... 164

Chapter Five
Case Study - UNAIDS .......................................................................................................... 165
Public governance with a focus on problem-solving capacity ......... 165
5.1 UNAIDS and its political environment ............................... 166
5.2 Aims, scope and historical developments. ........................... 169
5.3 Basis for the legitimacy of UNAIDS ................................................................................................... 171
5.3.1 Governance ‗by‘ the people ......... 171
5.3.2 Governance ‗for‘ the people ........ 176
5.4 UNAIDS and its stakeholders .............................................................................................................. 184
5.4.1 Perceptions amongst stakeholders of UNAIDS‘ legitimacy ........................ 185
5.5 Outlook: The future of UNAIDS ......... 195

Chapter Six
Case Study - GFATM.......................................................................................................... 197
Inclusive governance with focus on efficacy ..... 197
6.1 Background: GFATM engaging in governance ................... 199

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