In case we still had some doubts about the post-2015 world, the ugly Crimea episode has more or less erased them. The world will be multi-polar in the coming decades, whether we like it or not. The unipolar – western/donor and especially US dominated – era of the MDGs is no longer. So called “responsible stakeholders” and “strategic partners” turn out to be actors who have their very own interests, and they don’ necessarily align with those of the West (or even OECD countries). Some even say we’re back in the 19th century. I don’t think so (even if realists seem to have the edge for the moment over cosmopolitans), if only because governance in the 21st century will inevitably have to be more complex and multilayered than a century ago, but nevertheless, it seems time the global health community adjusts to this new geopolitical reality, going beyond rhetoric.

In spite of the current UHC momentum, mainstream global health decision making is still largely dominated by the West, in many platforms and institutions, with Bill Gates and the US administration as some of the most obvious examples. That needs to change, soon, as distrust of the so called “true motives” of the West is rapidly increasing in many parts of the world, rightly (the West’s double standards make it rather vulnerable) or wrongly (there’s quite some nasty domestic and politically inspired anti-western propaganda at work too in places like Russia, Uganda,…). This overall distrust will affect global health too and in fact already does so. You can already see traces of this in the international homophobia & HIV commotion, for example (and of course the polio eradication drive has had its setbacks as well). The only way to take away some of this distrust is by adjusting governance and power centres. Global health governance should be no exception to this general rule.

So in addition to global health hubs  in Geneva, New York, Washington, Seattle, London, .. let’s also set up new global health intiatives, programs, and decision making centres in places like Dubai, Beijing, Moscow, Rio, Delhi…  After all, we’re still stuck with a geography of ‘Bretton Woods legacy’ institutions, to a large extent. A new NCD decision making platform for example, or a post-MDG UHC financing vehicle for LICs don’t need to be based in Geneva, I’d say.

Over to the global health philantropists then. For all his flaws, Bill Gates’ work in global health has been terrific, and I know for a fact he’s being widely applauded in China too (although perhaps more for his entrepreneurial skills than for his global health track record); he’s also one of the people who seems to understand that innovations (including pharma breakthroughs can come from everywhere, but he needs  credible counterparts and successors from other parts of the world – Carlos Slim doesn’t quite fit the bill. Bloomberg is obviously welcome on the global health scene, but we also need many more Asian, African, Latin American “faces of global health” with key seats at the table of international decision makers (and preferably not experts and philantropists who had their main education in the West). Committed philantropists from other parts of the world are thus more than welcome, especially if they have leverage over their own decision makers.  Margaret Chan, who sits somewhat on the fence, is a good start, but many more global health ‘key influencers’ from other parts of the world are required to change the impression about the ways of global health decision making.  Obviously, global health decision making should be democratized in many other ways – we don’t expect a global health “nirvana” to come from a more diverse mix of philantropists and experts –  but that’s for another blog post.

The post-MDG health agenda should also reflect this new geopolitical reality. Instead of an MDG+ health agenda – which would still feel like a Western or, worse, ‘donor logic’ agenda, global health should be firmly integrated in a “grand bargain” (see the work by my colleague Gorik Ooms), and linked with sustainable development, food security, etc. Credible post-2015 financing for this bargain is also a must, with the West playing its proper role, ideally by taxing the winners of globalization (parts of the financial sector, multinationals, … and basically everybody else who benefits from the so called “superstar economy” ).

If that doesn’t happen, a very likely scenario, unfortunately,  chances are that global health will increasingly have to operate within more regional ‘influence spheres’ (including perhaps transatlantic partnerships), and will lose some of its truly ‘global’ aspirations and credentials, with exception of some areas that really require global collaboration. Talk of global health ‘partnerships’ replacing the donor/recipient logic of the past will ring hollow in such an environment, and it’s not exactly what is needed in this very challenging era.

Put differently,  if globalization decreases, global health might be one of the first victims. It’s definitely one of the most vulnerable ones, as it’s for a reason that ‘global health diplomacy’ has been a rather popular term recently.

Even if a multi-polar world seems fairer than a uni-polar world, the abovementioned scenario is not something to look forward to. So better to nip it in the bud, and do at least what we can in the global health community to avoid it, by adjusting governance to the multi-polar world .

In many ways, global health is already becoming more global, but more is needed. Soon, I’m afraid.

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