The Making of Global Health Governance

The Making of Global Health Governance

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The Making of Global Health Governance China and the Global Fund to Fight AIDS, Tuberculosis, and Malaria Nicole A. Szlezák

the making of global health governance Copyright Nicole A. Szlezák, 2012. Softcover reprint of the hardcover 1st edition 2012 All rights reserved. First published in 2012 by PALGRAVE MACMILLAN in the United States a division of St. Martin s Press LLC, 175 Fifth Avenue, New York, NY 10010. Where this book is distributed in the UK, Europe and the rest of the World, this is by Palgrave Macmillan, a division of Macmillan Publishers Limited, registered in England, company number 785998, of Houndmills, Basingstoke, Hampshire RG21 6XS. Palgrave Macmillan is the global academic imprint of the above companies and has companies and representatives throughout the world. Palgrave and Macmillan are registered trademarks in the United States, the United Kingdom, Europe and other countries. ISBN 978-1-349-43755-9 ISBN 978-1-137-02083-3 (ebook) DOI 10.1057/9781137020833 Library of Congress Cataloging-in-Publication Data Szlezák, Nicole A., 1972 The making of global health governance : China and the global fund to fight AIDS, tuberculosis, and malaria / Nicole A. Szlezák. p. cm. ISBN 978 1 137 02082 6 (hardback) 1. World health. 2. Public health International cooperation. 3. Medical policy. 4. AIDS (Disease) Social aspects. 5. Tuberculosis Social aspects. 6. Malaria Social aspects. I. Title. RA441.S96 2012 362.1 dc23 2012011136 A catalogue record of the book is available from the British Library. Design by Integra Software Services First edition: September 2012 10987654321 Printed in the United States of America.

Contents List of Tables Author s Note Abbreviations and Acronyms 1 Globalizing Public Policy: The Health Sector 1 2 Public Health in the Twenty-First Century: Beyond the Multilateral Institutions 11 3 The Global Fund Experiment 43 4 How the Fund Operates in the Global Domain 75 5 The Local and the Global: HIV/AIDS in China 91 6 The Fund s Impact on China s HIV/AIDS Policy 119 7 Public Health Policy Making in the Global Domain 145 Notes 153 Bibliography 161 Index 185 vii ix xiii

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List of Tables 6.1 The China CCM 2004 (Country Coordinating Mechanism in China 2004) 135 6.2 The China CCM in 2006 (Country Coordinating Mechanism in China 2006) 136

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Author s Note My motivation for writing this book goes back a long way. A physician by training, I worked in tropical medicine research for a brief period of my life, conducting biomedical research on malaria at the Albert Schweitzer Hospital in Lambaréné, Gabon. The work provided me, for a short time, with the humbling opportunity to be part of an entirely different world. I was struck by the contrast between the daily reality of my malaria patients, mostly primary school children, who lacked the most basic things including clean water and basic pediatric services, and the reality of a European biomedical researcher, contributing to a global body of knowledge about malaria, who could step into that world, and out again, at her own discretion. A number of questions stirred my interest, which form the underlying structure of this book. Whose problems get the world s attention, and why? How do policy issues come to be regarded as global? How do new approaches to solving them gain currency and become accepted, financed, and implemented? And do new ways of framing things really lead to different ways of engagement? My search for intellectual tools to help me grapple with these questions led me to pursue a PhD at Harvard University s John F. Kennedy School of Government. Drawing on the multiple disciplinary perspectives inhabiting the School, I found myself drawn to study the emergence of the global, or the transnational; to observe its taking form as a set of rules and institutions; to follow its deployment into the real world; and to study its engagement with the local. In this book I explore these themes through a focus on the Global Fund to Fight Aids, Tuberculosis and Malaria and its interaction with one of its largest grant recipients, China. In order to accomplish this task, I needed to follow a wide range of diverse threads, such as the emergence of HIV/AIDS as a global issue, changing paradigms driving international health cooperation, the evolution of ethical norms for global clinical trials, the emergence of trade and intellectual property regimes in the context of global pharmaceutical policy, the controversies around AIDS denialism, the emergence of

x Author s Note the Global Fund as a new form of governance, the simultaneous emergence of several different HIV/AIDS epidemics in China, the changing image of HIV/AIDS in Chinese public perception and policy design, and, finally, the interaction between the Global Fund and China. To make visible, trace, and connect these different themes, I relied on a wide array of materials scientific literature, policy documents, newspaper articles, interviews, and first-hand testimonies of individuals in China and elsewhere. At the end of the book, the reader will find a long list of sources that were indispensable for the completion of this work. In addition to that, however, I would like to place on record my debt to three sources on which I relied especially heavily. Barton Gellman s excellent account of the political struggles surrounding the international community s approach to HIV/AIDS and the trade disputes surrounding the prices of antiretroviral medicines at the end of the 1990s, described in a series of articles in The Washington Post in 2000, was instrumental to me in understanding the changes in international norms trade, intellectual property, and science that preceded the creation of the Global Fund. I build on his work in large parts of Chapter 4. Edmund Settle s report Aids in China: An Annotated Chronology 1985 2003 was tremendously helpful in gaining an overview of the major threads and milestones I needed to trace in order to understand how HIV/AIDS emerged and was conceptualized in China. One of these threads was that of the emergence of a so-called plasma economy in central China a blood donation industry through which the HIV/AIDS virus was systematically spread to thousands of China s poorest citizens in Central China during the early 1990s. Direct testimony from these regions is hard to come by. Here, Zhang Ke s Report on AIDS in Henan After a 5-Year Investigation allowed me to understand the extent to which this entirely preventable epidemic was a direct consequence of local economic policy, and how government repression contributed to its severity and spread. I draw on his testimony on multiple occasions in chapters 5 and 6. In discussing the formative interactions between the Global Fund and China, this book focuses on the period between 2002 and 2006. It is during this period that China submitted six HIV/AIDS grant applications to the Fund. Tracing these submissions allows us to witness an astonishing paradigm change from an approach that essentially proposed circumscribed, targeted prevention efforts in select subpopulations to a broad and inclusive national HIV/AIDS policy offering access to antiretroviral therapy to patients in need and proposing to actively engage grassroots civil society organizations. As I lay out in Chapter 7, the relationship between China and the Fund during that period shaped not only China s HIV/AIDS policy but also the Fund itself, and the broader concept of global health. Both the Fund and the idea of global

Author s Note xi health have, of course, continued to evolve since then, but the fundamentals have not changed. Many people have supported me in writing this book. First and foremost, I thank my thesis advisors, Sheila Jasanoff, William Clark, and Anthony Saich, who led me through the process of researching and writing this work. It is with their intellectual guidance and continued support that I was able to assemble and connect the different threads that make up its substance. I also thank the Center for International Development and the Sustainability Science Program at Harvard for providing me with the resources and intellectual space that I needed to pursue this project. Finally, I thank many teachers and colleagues who helped me in multiple ways by being thought partners in the design and implementation of this research, introducing me to interviewees, pointing me to valuable resources, and critiquing my writing Lorrae van Kerkhoff, Suerie Moon, Joan Kaufmann, Arnold Howitt, Michael Hsu, and Kathrine Meyers. Finally, I thank my family and my friends, without whom I could not have completed this work. Special thanks go to my friend Avi Kremer, whose courage and determination in the face of ALS continue to inspire me. Nicole A. Szlezák

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Abbreviations and Acronyms 3-TC AIDS ARV AZT BCG CBD CCM CDC China CARES CNY CPT CSW D4T ddi DFID DOTs FPD GAVI GDEP GFATM GONGOs GPA GPSTB GPT HIV 2,3 -dideoxy-3 -thiacytidine, an antiretroviral drug also called Lamivudine (brand name Epivir) Acquired Immune Deficiency Syndrome Antiretroviral Azidothymidine Bacille Calmette Guerin Commercial Blood Donors Country Coordinating Mechanism Centers for Disease Control China Comprehensive Aids RESponse Chinese Yuan Consumer Project on Technology Commercial Sex Workers Didehydro-deoxythymidine, an antiretroviral drug also called stavudine (brand name Zerit) Didanosine UK Department for International Development Directly Observed Tuberculosis Therapy, short course Former Plasma Donors Global Alliance for Vaccines and Immunization Global DOTS Expansion Plan The Global Fund to Fight Aids, Tuberculosis and Malaria Government-organized NGOs WHO s Global Program on AIDS Global Plan to Stop TB Global Program on Tuberculosis at WHO Human Immune Deficiency Virus

xiv Abbreviations and Acronyms IUATLD LFA MDR-TB MSF MSM MTCT PR STDs STIs TB The Global Fund TRIPS TRP TWG UNAIDS UNDP UNFPA UNICEF VCT WTO International Union Against Tuberculosis and Lung Disease Local Fund Agent Multi-drug-resistant Tuberculosis Medecins sans Frontieres Men Who Have Sex with Men Mother-to-Child Transmission of HIV Principal Recipient Sexually Transmitted Diseases Sexually Transmitted Infections Tuberculosis The Global Fund to Fight Aids, Tuberculosis and Malaria Trade-Related Aspects of Intellectual Property Rights The Global Fund s Technical Review Panel Transitional Working Group United Nations Programme on HIV/AIDS United Nations Development Program United Nations Population Fund United Nations Children s Fund Voluntary Counseling and Testing World Trade Organization