The 79th World Health Assembly (WHA79) is a critical juncture for global health cooperation, taking place at a time when the very foundations of multilateralism are under threat. As we navigate this complex landscape, it's essential to recognize that the future of global health governance hinges on the actions of middle powers, particularly those in the Global South.
The Rupture of the Rules-Based Order
In his address to the Australian parliament, Canada's Prime Minister Mark Carney painted a stark picture of the current international order, describing it as not in transition but in rupture. This rupture is evident in the withdrawal of the United States from the World Health Organization (WHO), leaving a significant funding gap and forcing the organization to cut its budget.
What makes this particularly fascinating is the underlying power dynamics at play. Great powers, with their ability to compel, often dominate the global stage. However, as Carney argues, middle powers possess a unique convening power, which can be instrumental in shaping the future of global health.
The Role of Middle Powers
Middle powers, especially those in the Global South, must step up and drive the much-needed reform of WHO. This reform is not just about structural changes; it's about restoring legitimacy and ensuring that WHO can effectively fulfill its core functions.
One thing that immediately stands out is the trust factor. WHO's authority has always been rooted in the trust and belief of its member states. If WHO is seen as a residual institution, used only when convenient, its legitimacy will erode, hindering its ability to perform critical tasks such as surveillance, standard-setting, and emergency coordination.
Variable Geometry and Coalition Building
Carney's concept of 'variable geometry' is a strategic approach that middle powers can adopt. Instead of waiting for a comprehensive multilateral settlement, which may take years, these powers should form diverse coalitions based on shared values and common interests. This approach allows for flexibility and speed, addressing specific issues like pandemic preparedness, antimicrobial resistance, and digital health governance.
The WHO reform process, while necessary, is often slow. Variable-geometry coalitions can provide the normative and financial infrastructure that a reformed global health architecture desperately needs. The Framework Convention on Tobacco Control serves as an inspiring example of what can be achieved through such courageous steps.
The Political Dimension: Engaging the Global South
Finland's President Alexander Stubb adds a crucial political dimension to this discussion. He emphasizes that the Global South is not a passive observer but a decisive actor in shaping the next world order. The triangular contest between the Global West, Global East, and Global South is evident in WHO's governing bodies.
Stubb challenges the West to view engagement with the Global South as a power-sharing negotiation, not a mere communications exercise. This perspective is especially relevant for global health, where a reformed WHO governance structure must reflect the current distribution of disease burden and health capacity, not the power dynamics of 1948.
Structural Reform and Legitimacy
Stubb calls for concrete structural reform of global multilateral institutions, advocating for new permanent representation for Asia, Africa, and Latin America. This is not just a rhetorical concession but a necessary condition for legitimacy.
For the European and other Western middle powers, this reform is uncomfortable but essential. Being present is not enough; leadership requires showing a willingness to cede structural power. Resisting governance reforms that would make multilateral institutions truly representative is a double standard that could cost the West its last chance at meaningful engagement.
Key Outcomes for WHA79
As we approach the World Health Assembly, three key outcomes are crucial:
Driving the Reform Process: Middle-power coalitions, especially those from the Global South, must take the lead in driving the architecture reform mandate agreed upon at the WHO Executive Board meeting. This process should have genuine political ownership, clear timelines, and accountability benchmarks.
Addressing the Digital Health Governance Gap: The issue of digital health governance must be tackled with binding intent, moving beyond voluntary guidelines. The potential for new technology to deepen the divide between developed and developing nations is a real concern, especially in the context of health AI, platform accountability, and data governance.
Naming the Bilateralism Risk: The rise of bilateral health deals, which often transfer costs onto partner countries, poses a structural challenge to multilateral health governance. Legal and institutional frameworks must be strengthened to protect countries from asymmetric bilateral compacts.
Conclusion
The World Health Assembly presents a narrow window of opportunity to act. The allure of bilateralism, with its transactional nature and domestic appeal, will only grow stronger if the multilateral alternative fails to deliver. Middle powers in global health diplomacy have the power to convene, the institutional credibility, and the political relationships to shape a better future. The question is, will they demonstrate the will to use these assets, recognizing that inaction is a choice with dangerous consequences?
