Global health disruptors: The end of the cold war, in the British Medical Journal

The cold war was a period of extreme political tension between the Soviet Union with its satellite states and the United States with its allies. This tension was reflected in global multilateral agencies, including the World Health Organization. The end of the cold war transformed the dynamics of economic and health development at global, regional, and national levels. This political earthquake brought a seismic shift from international to global health.
The cold war enabled corrupt governments and illegitimate military dictatorships to become the norm in the developing world. We witnessed gross mismanagement, human rights abuses, and economic collapse in sub-Saharan Africa. The United Nations and related institutions became ideological and diplomatic battlefields in which newly independent African, South American, and Asian states were used as pawns. Rogue beneficiaries traded their votes for patronage and money from either side.
The end of the cold war in 1989 ushered in a new era of world politics and development in which health has played an ever increasing role. Two aspects are particularly important.
Firstly, the principles of development assistance were transformed from being purely donor and ideologically driven to a more negotiated practice guided by pacts, such as the Paris Declaration on Aid Effectiveness and the Accra and Busan accords. These instruments promote country led, sector-wide approaches, which advocate for integrated and sustainable programmes, rather than standalone project implementation.

But the reality has been very different from the principles. Impatience from some Western donors means that they instead championed the creation of disease focused global health initiatives such as the Stop Tuberculosis Partnership, the Global Fund to fight Aids, TB, and Malaria, Gavi, the Vaccine Alliance, Roll Back Malaria, and the Global Health Workforce Alliance. These initiatives shaped global health after the cold war. They provided an alternate outlet for funding streams, which supported the approach taken by the millennium development goals, but they have produced mixed results and their future remains uncertain. One of the survival strategies of these new institutions, such as UNAIDS, is to campaign against the “exceptionalisation” of HIV. Another is to promote an expansion of their mandate to include universal health coverage, as lobbied for by some Global Fund supporters.
Secondly, the rise of civil society and the movement on social justice, equity, and women’s rights has shaped global health governance. This movement has led to more transparency and accountability by governments and non-government actors around the world, but in a very uneven way, with not enough voices from the global south or from women. Today, the influence of civil society is shrinking again, as liberal democracies are being weakened. But there is some hope, as the African Union is in the process of reforming itself to become a people centred organisation embracing governments and civil society. Today it has a strict zero tolerance policy on illegitimate governments, which has had far reaching positive results. It has also prioritised health. Many new global health actors have emerged on the African continent, and funding has grown substantially.
Now a new paradigm is unfolding in resourcing development assistance. The Bretton Woods Institutions are being challenged by Japan and South Korea and by new development banks that have been created in Asia. China is emerging as a major donor, and Chinese investments can be accessed more easily than Western investments as they have fewer conditions. At the same time, countries receiving this Chinese aid are more vulnerable and face problems with the quality of outputs. As global negotiations become more difficult, there is an emerging tendency towards regionalisation. Examples include the America First Initiative, Brexit, and the European Union, and Japan is focusing more on supporting its neighbouring countries. All these are at the expense of supporting global multilateral agencies such as WHO, which is struggling to deliver its growing mandates with insufficient budgets.
There are currently no clear political blocs negotiating at the governing bodies of WHO, as was the case during the cold war. Many countries are now more regionally aligned, with submissions organised together and with shifting alliances becoming the norm. On key issues, negotiating groups form around the rich and poor, with developing countries rallying around the Group of 77 and China as a bloc. The EU, Latin America, the Caribbean, Africa, and Asia Pacific negotiate together. The world is less polarised than it was during the cold war, and health diplomacy is more flexible. But there are indications that the new multipolar world could lead to new ideological and economic divisions and, some say, a new cold war with the main differences being between the USA and China. This notwithstanding the global health agenda holds the promise that countries will join forces to implement the agreed sustainable development goals; as a common effort to deliver the required global public goods by 2030.