Introduction: Power in IO relations
Contemporary scholarly work on international organisations (IOs)Footnote 1 in International Relations (IR) is marked by a shift away from studying individual IOs towards studying relationships and networks in which IOs are embedded. While the focus has been on IOs’ interaction with non-governmental organisations, multinational corporations, and advocacy networks, scholars have also begun to study the relationships among ‘peers’, that is, among two or more intergovernmental organisations in a broader organisational environment or ‘field’.Footnote 2 By analogy with scholarly work on global governance in general,Footnote 3 pertinent strands of these emerging research agendas have been heavily influenced by agentic rationalist perspectives on power.Footnote 4 Within this conceptual imaginary, power becomes relevant when actors – be it IOs, IO units, individual diplomats, or states working with or through IOs – compete for material resources, strategic advantages, institutional mandates, and other sources deemed to generate the capacity to coerce and control others in ways that contradict their presumed preferences or interests.Footnote 5
Put in the language of relational sociology,Footnote 6 IR and global governance scholars working on IOs and inter-organisational relationships in global fields of cooperation tend to be concerned with power within either a self-actional or an inter-actional framework – as a capacity of actors and/or as unfolding in interactions between them.Footnote 7 By contrast, transactional or productive power is often left out of the equation.Footnote 8 In our view, this constriction has profound consequences both for what questions are asked and for what answers are found in said literature. In particular, the narrow view on power has gone along with an often implicit ambition of scholars to contribute to the effectiveness of existing governance arrangements, rather than to uncover or question their power effects. For instance, the breathtaking proliferation and pluralisation of actors, organisations, and programmes that the past two decades have brought about in nearly every field of global cooperationFootnote 9 has been predominantly understood in terms of dangerous, ‘ineffective’ fragmentation of rules and institutions. The ensuing weakening of coercive hierarchy and centralisation has been connected to an alleged emergence of conflicting ‘spheres of authority’, to transformations in the distribution of power and heightened competition between actors, and hence to compliance and coordination problems.Footnote 10
In this article, we make a theoretical intervention in the above literature by putting forward an alternative understanding of power as productive in and of relations among organisations. Specifically, we argue that productive power becomes observable in reflexive IO discourses that encompass norms on how IO relations and the organisational fields in which IOs are embedded should be governed. We conceptualise such historically grown perceptions of the proper ‘governance of governance’Footnote 11 as ‘metagovernance norms’.Footnote 12 Further, we contend that power in IO relations with peers and other actors is reflected both in the (temporary) fixation of meaning(s) in discourses among IOs and in the constitutive inscription of dominant norms and interpretations in inter-organisational practices and institutional set-ups. While our article focuses on norms as relatively stable yet malleable social expectations, our understanding of productive power also extends to moments of contestation and processes of meaning-negotiation in order to account for the emergence and transformation of these norms. Drawing on discourse-analytical concepts and methodological strategies, we identify and apply two corresponding analytical axes to study metagovernance norms and their productive effects empirically: (i) discursive regularities and transformations, and (ii) constitutive inscriptions. Analysing IO relations from such a perspective, we claim, can give us a different, fuller picture of the diverse semantic, normative, institutional orders that IOs in contemporary global governance are embedded in and (re)produce. Crucially, making the discursive (re)production of such orders the object of study promises to problematise historically specific notions of governance (in)effectiveness, to interrogate their constitutive effects and hence their entanglements with power. Notwithstanding our article's emphasis on the effects of normative order(s) in global health, our theoretical framework incorporates instances of normative instability and ambiguity as well as the possibility of contending, contemporaneous discourses, and visions. These instances are reflected in changing vocabularies and truth claims on good global health governance and may eventually not only overhaul pre-existing norms but also redefine what constitutes global health governance. Our relational approach to the norms shaping global health governance thus builds on the co-constitution of inscriptions of dominant global norms on the one hand and contentious politics and meaning-struggles targeting and transforming these inscriptions on the other.
To illustrate the applicability of this perspective, we present findings from an analysis of metagovernance norms, practices, and institutions among eight prominent health IOsFootnote 13 since the late 1990s. The field of global health governance often figures as a prime example for the much-researched trend towards proliferation and pluralisation of institutional actors. Accordingly, scholarly engagement frequently focuses on fragmentation, competition, and increasing complexity, and hence diagnoses a risk for conflicts and competition fuelled by diverging motivations and rationalities held by the diverse actors who occupy the field.Footnote 14 This makes the latter a particularly interesting case for studying the operation of discursive and productive rather than interactional and repressive power in IO relations. Our empirical discussion will show how the contemporary discourse among global health IOs is marked by a very similar imaginary to that of scholars of the field as plagued by detrimental complexity, dysfunctionality, and fragmentation that is discursively intertwined with strong normative beliefs in the necessity of order and harmony in governance.
The post-Cold War period did indeed bring about a broad array of issue-specific organisations such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) and a host of public-private partnerships in global health.Footnote 15 Yet in more recent years, a wide range of new initiatives, mechanisms, and institutions with the stated goal of constructing novel, more harmonic and aligned kinds of inter-organisational relations have emerged. Rather than a neutral scholarly description detached from the empirical reality of IO relations, this suggests that norms stipulating the desirability to order and harmonise have made an imprint and productively reshaped IO relations in global health. Tracing discourses back in time, we find that these causal beliefs and normative predicates were preceded by a markedly different set of discursive regularities around the turn of the millennium that revolved around the virtues of partnerships, pluralisation, innovation, and market- and network-like arrangements. Moreover, we seek to show how these contingent regularities unfolded productive, constitutive effects by reshaping practices and institutions in the field. Here, we point to the proliferation of institutional experimentation, privatisation, and small-scale disease-specific partnerships in the post-Cold War years and the proliferation of reflexive, more institutionalised attempts to coordinate, orchestrate, harmonise, and order the field at the global level from 2003 onwards.
As we will argue in our conclusion, our analysis underlines the benefits of expanding the current understanding of power among IOs towards a productive, transactional perspective inasmuch as health IOs’ discourses on governance undergo profound transformations over time that have reshaped practices and institutions in the field. Our analysis is not only meant to exemplify a different route towards the study of power and IO relations in global (health) governance, but also to challenge a prevailing perception of global health governance as an apolitical, technical domain of international cooperation in which power effects are minimal.
Productive power of metagovernance norms in IO discourses on institutional order
How can we study power in the formation and transformation of IO relations? This begs the question of how IR has looked at IOs and their relations.Footnote 16 While for a long time, interest centred on individual formal IOs, a range of recently emerging research programmes have shifted attention from single IOs towards IO relationships. One side of this spectrum features research programmes with a broadly rationalist-institutionalist theoretical outlook, with regime complexesFootnote 17 and inter-organisationalismFootnote 18 among their most visible representatives.Footnote 19 On the other side of the spectrum, there are a number of contributions that adopt more relational, constructivist approaches that situate IOs in their sociological environment and highlight its constitutive role for IO relations.Footnote 20 However, it would appear premature to speak of one or several clearly identifiable strands of literature that present coherent alternatives to the rationalist core of the emerging literature on IO relations.
Power through and between IOs: Extant literatures on regime complexes and inter-organisationalism
Power is most explicitly discussed in the literature strand of regime complexes and regime complexity.Footnote 21 Yet, even these strands of literature, in our view, suffer from two conceptual limitations that apply to research on IO relations at large. First, power is mostly attributed to states or private actors and understood to be exerted through, rather than (re)produced by IOs. To illustrate this point, the recent literature on regime complexes, institutional fragmentation, and overlap in international politics is most pertinent when considering the structural conditions that influence the position and authority of formal IOs in larger organisational fields. However, it has so far treated IOs as passive objects of study and attributed power only to the member states of IOs or non-state actors inside and outside of IOs that may be empowered by complex systems of rules.Footnote 22 Here, the power of (networked) non-state and state actors lies primarily in their capacity for ‘forum linking’ (that is, integration of rule-systems) or ‘forum shopping/shifting’ (that is, fragmentation/disintegration of rule-systems)Footnote 23 by means of their material, ideational, and organisational resources. Cooperative or conflictive IO-IO relationships are thus the outcome of strategic choices of state and non-state actors operating across IOs, wielding their material and non-material resources so as to steer IOs towards cooperation or competition.
Second, even in cases where assumptions about IOs as arenas rather than co-producers of social order are relaxed, scholars have tended to adopt a rationalist-functionalist perspective on the role of institutions in international politics. As a consequence, they have privileged agentic, repressive understandings of power in their quest to explain IO behaviour, including the conditions under which IOs cooperate or compete with each other (for example, consider the concept of orchestration).Footnote 24 Contemporary theories of inter-organisationalism see strategic interplays or power asymmetries between IOs in terms of resources, knowledge, or legitimacy as the principal driving-force behind IO-IO relations, but do not search for power outside of IOs and their inter-relations. Forging cooperative relationships with other IOs is thus seen as a rational strategy for IOs that are confronted, for example, with resource scarcity following technological specialisation and innovation, or the broadening of the IO's mandate.Footnote 25 In cases of conflict between IOs, power is instead (often implicitly) understood as a capacity that IOs can draw upon in their pursuit to dominate others, protect their own autonomy or alternatively as emanating from strategic (dis)advantages in interactions between organisations.Footnote 26
Power in IO relations: Towards a productive, transactional understanding
We believe that the study of IOs’ relationships and embeddedness in fields of global cooperation has much to gain from an alternative understanding of power as productive in and of social relations among IOs. This perspective departs both from the focus on states and other actors outside of IOs as the ‘actual’ loci of power and from the repressive, agentic conceptualisations that have so far dominated scholarly engagement with IO relations and inter-relations. In order to grasp how productive power unfolds, we must study discursive configurations through which such relations become discernible, are constituted and reproduced.Footnote 27 In our understanding, productive power refers to the very emergence and (re)constitution of social relations, objects, and identities – at the expense of other possibilities. Thereby, we link in with political and sociological theorising that sees power as distinctly relational and as located in the constitutive (re)production of social realities.Footnote 28 In the terminology of relational sociology,Footnote 29 we therefore advocate for a ‘transactional’ understanding of power. While ‘self-actional’ accounts conceptualise power as a resource or characteristic of actors, ‘inter-actional’ accounts locate it in the interactions or interplay among actors. A transactional view goes a step further in untying power from the notion of externally given, already-constituted actors by conceiving of its operation as productive and constitutive of actors themselves, their subjectivities and relations, as well as other social realities.Footnote 30 The following sections draw on critical norms research, metagovernance literature, and anti-essentialist discourse analysis to develop a set of analytical proposals for how the workings of productive power in relations among IOs can be grasped, both conceptually and empirically. Notably, we suggest turning attention to the constitutive effects of norms on ‘good’ global governance in discourses among IOs.
Metagovernance norms as relational discursive objects
To account for the unfolding of productive power effects in IO relations, we argue for an analytical focus on discursive perceptions that define what counts as ‘good’ and ‘effective’ governance in a given organisational field, at a given moment in time.Footnote 31 That is, we suggest studying how reflexive beliefs about ‘good’ governance emerge and evolve over time and how they are enacted among IOs, hence bringing forth regularities in practices and institutional arrangements. This framework combines the notion of metagovernance as denoting ‘second-order’, reflexive kinds of governance practices,Footnote 32 with critical, discursive approaches in IR norms research that conceptualise norms as enacted, contingent meanings, rather than as fixed containers thereof.Footnote 33 Whereas early constructivist theorising on norms employed a less dynamic conceptualisation of norms as relatively stable ‘standards of appropriate behaviour for actors within a given identity’,Footnote 34 these newer theories emphasise that norms ‘do not speak for themselves’ but are only attributed with meaning through enactments in practices as they unfold in historically, politically, geographically, and institutionally specific social contexts.Footnote 35 At the same time, contemporary theories on norms as dynamic processes rather than ‘things’ point to practices of contestation as the major explanatory factor for shifts and ruptures in social expectations and thus as drivers of potential norm transformation. Therefore, while our empirical analysis emphasises the ordering effects of productive power in the area of global health, it will also expose instances of normative instability and contestation indicating normative transformation. In that sense, IOs’ collaborative practices in global health are not only reflective of larger metagovernance norms, but IOs themselves emerge as sites for the formation and transformation of norms on good global governance and as co-producers of social order.
In order to get at how productive power unfolds through constitutive meaning (re)production we propose to focus on a specific kind of reflexive norm that is concerned with how governance itself ought to be governed – that is, with the ‘governance of governance’.Footnote 36 We therefore use the term ‘metagovernance norms’ to denote historically grown perceptions about how governance ought to be pursued that are (re)produced in discursive practices among IOs.Footnote 37 Thereby, we offer two distinct conceptual contributions that advance critical, discursive approaches to international norms. First, we introduce an analytical focus on reflexive perceptions that are related to the proper conduct of governance as such. Second, we argue for situating the analysis of norm (re)production and effects within a discourse-analytical framework that is concerned with how productive power unfolds among organisations who occupy a given governance field. Analysing norms from a decidedly discourse-analytical perspective, we argue, is pivotal to addressing the delicate relationship between norms and power. It has three interconnected advantages: firstly, it allows for consideration of how norms are attributed with meaning through their relations with other discursive entities; secondly, it highlights how meaning-making is inevitably premised on discursive exclusion; and thirdly, it emphasises how the attribution of a sense of naturalness to a given norm in a given social context is underpinned by specific knowledge formations. In other words, our framework aims to shed light on how metagovernance norms are entangled in the unfolding of constitutive power effects that inscribe themselves and bring forth regularities in social relations.
Siding with an anti-essentialist perspective that understands social realities as emerging from contingent processes of (re)production,Footnote 38 we take ‘discourse’ to denote a formation of knowledge that delineates the borders of what is reasonably speakable in a given historical, sociopolitical context.Footnote 39 As a consequence, we understand identities and institutions of the social world as outcomes of contingent, yet productive discursive constitution and inscription, as contingent on the exclusion of other possibilities and as being constantly reproduced in meaning-endowed practices.Footnote 40 In our view, this approach is well suited to investigating the constitutive effects of power. It goes beyond the Weberian imaginary of power as competition and coercion between given actors, instead shedding light on the very emergence of sociodiscursive objects, subjects, practices, and institutions.
The discourse-analytical approach advocated here underlines the necessity of considering how the productive power of metagovernance norms is made possible through the discursive context in which they emerge, to inquire into their relationship with other discursive objects and causal beliefs on governance. More specifically, the working of productive power can be located in the temporal, partial fixation of meaning(s)Footnote 41 in IO discourses, as well as in the inscription of dominant norms and interpretations in inter-organisational practices and institutional set-ups.Footnote 42 In order to concretise this theoretical perspective, the next two sections develop conceptual tools along two analytical axes: (i) discursive regularities and transformations and (ii) constitutive inscriptions. Rather than constituting separate ontological phenomena, these axes can be understood as complementary analytical strategies. As a more fine-grained guide for the interpretation of empirical materials, they help to shed light on how metagovernance norms unfold productive power effects in inter-organisational relations.
Discursive regularities and transformations
To grasp the historico-political specificity of metagovernance norms, our first analytical axis addresses regularities and transformations in the discursive field. Devoting attention to how taken-for-granted assumptions about governance have evolved over time is useful in studying productive power in IO relations as it helps us unearth how meanings have been fixed and what alternative conceptions were excluded as a result. As normative propositions in reflexive discourses on governance, metagovernance norms are particularly entangled with ‘problems’ that governance needs to solve and perceptions about how governance can be effectively pursued and organised. In other words, we can study how prevalent terms in IO discourses, such as policy ‘harmonisation’, inter-agency ‘coordination’ or ‘alignment’ are attributed with meaning and emerge as understandable propositions through discursive patterns that relate them to other terms. Against such a backdrop, our empirical analysis of metagovernance norms maps juxtapositions, equations, contrastations, and groupings of discursive elements within their concrete context of interest.Footnote 43 Moreover, empirical analysis can and ought to move beyond the synchronic identification of metagovernance norms and their discursive relations by engaging in diachronic comparisons of discursive regularities and ruptures. By bringing to light discursive transformations and discontinuities, our diachronic analysis identifies the emergence of new normatively connoted notions and the forgetting, demise, and exclusion of previously powerful ones.Footnote 44
Constitutive inscriptions
As a second analytical axis, we analyse how productive power unfolds as dominant metagovernance norms and interpretations inscribe themselves into organisational fields that IOs populate. We therefore ask: how do perceptions about how governance can and ought to be pursued shape concrete policies and practices among organisations, as well as the institutional constellation of the field? At the same time, we seek to identify moments of contestation and ambiguity over what constitutes ‘good’ global health governance as reflected in changing or co-existing practices and policies. From our perspective, contestation at the level of cooperative practices between IOs therefore becomes crucial in order to account for transformations in these powerful patterns: it forms the quicksand that eventually might lead to shifts in perspective and crystallise into yet another powerful social convention. This can occur in different ways: firstly, through the shifting prominence of existing practices and institutional arrangements among organisations; secondly, by means of the establishment of new (kinds of) organisations and inter-organisational fora; and thirdly through the redefinition or dissolution of existing organisations.
Selection of empirical materials: IO annual reports and policy documents
Our results are derived from a synchronic and diachronic discourse analysis that followed the analytical axes outlined above as an interpretative lens for studying changing discursive patterns, IO practices, and institutional settings across time. We originally collected and studied a corpus of all available annual reports published by eight health IOsFootnote 45 since the 1970s. For the purpose of this article, we zoom in on a shorter period from the mid 1990s to the mid 2010s to leave space for an in-depth examination of our findings. The selected IOs span different types and generations: they include older and younger inter-governmental bodies from within and outside the United Nations, as well as so-called hybrid IOs that were formed more recently, typically by coalitions of public and private founders. We choose to study annual reports as they constitute a rich, comprehensive account of IOs’ activities and institutional entanglements during the preceding year(s), while also providing for comparability across time. Drawing on well-established conventions in discourse-analytical methodology, we also extended this core corpus of materials inductively by including further policy documents that annual reports referred to (‘inter-textuality’) and we chose to collect additional material on selected examples to illustrate our theoretical points more aptly and in more depth (for instance on the Health Systems Funding Platform).
In the following, we make use of the above framework and methods to inquire into changing metagovernance norms, their discursive embeddedness and productive power effects in global health since the 1990s. While our theoretical proposals can be applied to the relations of any set of actors/speakers that engage in reflexive discourses on ‘good’ (global) governance, in the following, we focus on discourses among global health IOs in seeking to illustrate the proposals’ empirical fruitfulness.
Metagovernance norms, institutional practices, and changing constellations in global health governance
Pertinent scholarly engagement with global health governance typically paints a picture of actor proliferation and pluralisation, fragmentation and complexity, associating the latter with harmful conflict and competition among the diverse actors who occupy the field.Footnote 46 The gist of these most widely told narratives on global health governance is that health has evolved from a slim governance cosmos with the WHO at its centre into a colourful, bedazzling mosaic of actors, rules, institutions, and networks.Footnote 47 Not only has the substance of health politics changed dramatically – with the WHO covering a wide range of issues beyond traditional medicine from eHealth to the migration of health workers and beyond – but the number of intergovernmental and non-governmental agencies concerned with matters of global health has increased exponentially since the 1990s and the adoption of the Millennium Development Goals (MDGs) in the year 2000.Footnote 48 As a consequence of this plurality, the field appears to be plagued by competition between neatly separable IOs, states, private donors, and hybrid issue-specific partnerships who seek to extend their capacity to dictate others’ behaviour. Power among IOs in global health therefore seems to play out in protracted strategic combats between organisations – over divisions of labour, resources, agenda setting, etc. – that result in duplication of operational activities, parallel funding streams, and normative incoherence, hence first and foremost constituting a problem for governance effectiveness.
This second part of our article tells a different story of power in global health governance by focusing on the emergence and effects of contemporary metagovernance norms in reflexive discourses among IOs. In particular, we show how such perceptions have evolved over time and crystallised into powerful inscriptions that become observable in contemporary inter-organisational practices and institutions. Our diachronic analysis of IO-IO relations in global health also allows us to identify processes of contestation and normative instability and, thus, to trace major transformations in global health governance. We first show how metagovernance norms in current discourses among health IOs are marked by a presumed need for harmonisation, order, and alignment. Thereafter, we trace these discourses back in time, showing how they were preceded by contrasting discursive regularities that revolved around the virtues of competition, pluralisation, partnerships, and innovation. Moreover, we illustrate how these discourses and normative beliefs inscribed themselves and shaped the organisational field. Our conceptual and analytical framework of discourses of metagovernance also allows us to embed observed transformations in interorganisational practices and institutional set-ups in larger transitions towards changing normative orders.
Contemporary taken-for-granted truth claims on governance: Detrimental complexity and the need for order
Looking at the discussion on the challenges for global health governance as it has been led among academics and practitioners for the last decade, three regularities become obvious: first, the landscape of global health is routinely portrayed as excessively fragmented and tremendously complex. As one prominent global health scholar puts it ‘today's global health landscape is increasingly complex, populated by more than one hundred organisations, often with competing programs and priorities’.Footnote 49 Secondly, this complexity is associated with collective ineffectiveness, that is, underperformance and dysfunctionality of the global health governance complex. And thirdly, this underperformance justifies the ritualistic call for restoration of order and the creation of some sort of identifiable institutional architecture.Footnote 50 The contemporary discourse on how global health should be governed and by whom, thus, is marked by a strong unity among IOs, policy analysts and public health experts in the search for an appropriate ‘architecture’ that embeds the actions of individual organisations in a more coherent set of rules and oversight, while at the same time promising better collective outcomes. The international debate in the wake of the Ebola outbreaks in 2014 is a case in point, as it was marked by unanimous calls for more order and large-scale coordination rather than further experimentation with small, punctuated, issue-specific initiatives and partnerships.Footnote 51 A systematic analysis of policy documents and annual reports issued by influential IOs in the field of healthFootnote 52 reveals a remarkably homogenous perception of complexity as detrimental.Footnote 53 This causal belief that differentiation and fragmentation – of actors and the rule-systems defining the field of ‘global health’ – are ineffective and dysfunctional is used to support calls for centralisation, and integration in which typically already powerful agencies are presented as the logical candidates for governing coordination and harmonisation.Footnote 54 In the contemporary discourse among health IOs, there are also references to health in general and specific health issues (especially HIV) as being of a complex nature. Such issue complexity is typically seen to require functional differentiation and harmonisation among organisations at the same time.Footnote 55 Complexity is also used to justify demands for effective solutions based on evidence and the generation, processing, and sharing of ever-greater amounts of health data.Footnote 56 Complexity as a discursive object emerges also in the context of increasing demands for expertise from a wide variety of professional backgrounds.Footnote 57
These widely shared causal beliefs thus support visions of good global health governance as complicated, overcrowded, and ineffective. Such narratives in turn serve to justify normative beliefs in the need for synchronisation, harmonisation, and coordination of a range of actors and agencies geared towards efficient use of resources and effective collective solutions and outcomes.Footnote 58 By way of juxtaposition and contrast, the interactions between different spheres of social and political life and the inevitable frictions resulting from the encounter between different social orders and rule systems are typically presented as ‘dysfunctional’ rather than productive, thus calling for more expertise and enhanced efforts to coordinate and harmonise interactions, for instance by creating institutional arrangements between IOs. Taken together, these contemporary discursive regularities unfold productive power effects, as they circumscribe what counts and what makes sense as a reasonable proposal for improving and (re)ordering the global health field – and what does not. Moreover, as we seek to illustrate in the next two sections, a look into the recent archives of inter-organisational discourse and practice in global health governance reveals, first, a relative novelty and hence non-necessity of these contemporary truth claims and, second, points to shifting institutional arrangements and practices in congruence with these normative transformations.
Historical emergence and contingencies: From plural, networked, and competitive to orderly, coherent, and synchronised
The contingency and borders of contemporary discursive regularities become understandable only by tracing their historical emergence. Our diachronic perspective on discourses among health IOs reveals the contemporary search for a global institutional master design to be a relatively novel phenomenon that marks a departure from earlier phases of consolidated and patterned inter-organisational discourses and practices. From the beginning, the WHO had organisational ties predominantly with the UN, its specialised agencies, funds,Footnote 59 and programmes, but also with bilateral agencies and the private sector (such as the Rockefeller Foundation).Footnote 60 In the Cold War era, inter-organisational relations consisted largely of joint committees for specific purposes, integrated personnel management, information exchange, or the coordination of statistical services.Footnote 61 While inter-organisational relationships between IOs were thus always part and parcel of international health politics, an increasing focus on institutional experimentation, privatisation, and small-scale disease-specific partnership prevailed in the post-Cold War years. Since the 1990s, but particularly around the turn of the last millennium, a new spirit of ‘innovation’ characterised global health governance, with a move from system-wide approaches (or sector-wide approaches in World Bank terminology) to disease-specific, targeted interventions, mostly in collaboration with the private sector (for example, business, private foundations, and civil society at large). Numerous public-private partnerships for health and other global initiatives involving governmental and non-governmental actors emerged in this period, among them well-known partnerships such as the Roll Back Malaria Initiative or the Drugs for Neglected Diseases Initiative (DNDi).Footnote 62 As other studies have shown, over time health became embedded into new discursive patterns. While there is some divergence among scholars, they agree that understandings of health based in security, economics and public health or biomedicine have been particularly influential, next to more marginal ones such as (human) rights-based and charity-based understandings.Footnote 63 These observably changing discourses on good global health governance also affected the substance of policymaking and the emergence of new issues and agendas. Most importantly, they underpinned a perceived need to broaden the range of actors considered indispensable for global health governance – from military actors to private enterprises, consultancy firms and philanthropies, to human rights activists and communities and individuals affected by specific health issues and diseases.
Adding to these findings, our discourse-analytical survey of IO policy documents and annual reports points to historical transformation not only in the framing of health as such, but also in the reflexive causal and normative beliefs on how to properly govern the global health field – that is, in dominant metagovernance norms. In the 1990s and around the turn of the millennium, we found that discourses among health IOs were marked by beliefs in the effectiveness of market-like exchange, networks, and the inclusion of private actors in governance mechanisms and arrangements.Footnote 64 Crucially, markets, networks, and public-private partnerships were discursively constituted as effective and normatively desirable ways of governing through juxtaposition with hierarchical and intentional modes of steering, such as state regulation and bureaucracies, which were deemed inefficient and outdated. To illustrate, the WHO 1999 Annual Report bespeaks the need to ‘recognize the limits of government’,Footnote 65 ‘harness the energies and resources of the private sector and civil society’,Footnote 66 and ‘be more innovative in creating influential partnerships’.Footnote 67 As we will show in the next section, such beliefs informed the creation of new organisations with market-shaping ambitions, such as GAVI, and made the partnership model of newly emerging health IOs, including GAVI and the Global Fund, appear as logical, effective, state-of-the-art set-ups. The proliferating number of public-private partnerships and hybrid IOs in global health at the time can therefore be conceived of as a product of IO discourses that constituted privatisation as a metagovernance norm. At the same time, once established, these hybrid IOs rearticulate the same beliefs on governance that underpinned their own coming into existence, hence becoming co-producers of such regularities.
Such a discourse on governance contrasts quite sharply with the period from the early 2000s to the 2010s – a period in which IOs increasingly articulated a perceived need for new initiatives for high-level harmonisation and comprehensive institutional attempts at ordering relations among actors. The emergence of such novel articulations in our corpus allows us to depict this period as one of normative instability and ambiguity, with continuous support for large-scale privatisation of global health governance on the one hand and, on the other, the growing influence of a discourse marked by a vocabulary of harmonisation, coordination, coherence, and inter-agency collaboration.Footnote 68 We thus observe the proliferation of references to harmonisation as a core value in global health governance – harmonisation understood as large-scale initiatives that seek to span all international and transnational actors and networks relevant to a specific issue or cluster of issues. The emergence of harmonisation as a metagovernance norm is, for example, reflected in core policy documents and working papers of the most important IOs in the field of HIV/AIDS (UNAIDS, World Bank, Global Fund, and WHO), in which they outline their individual or collective perspective on inter-organisational coherence and coordination.Footnote 69 As an illustration, a report issued by the Global Fund in 2005 recorded ‘potentials’, ‘challenges’, appropriate ‘instruments’ and ‘support’ for ‘harmonization’, understood as ‘refer[ing] to efforts to streamline and coordinate approaches between multilateral institutions’.Footnote 70 In a similar vein, a UNAIDS report from the same year sought to evaluate the ‘progress’ achieved among global health IOs and to identify further ‘efforts’ that were required to ‘enhance harmonization of policies, procedures and practices’ in various areas of shared activity (for example, at ‘the country level’, in ‘procurement policies and procedures’, and in ‘joint monitoring and evaluation’).Footnote 71 Since then, calls for more coherence, architecture, and ‘harmony’ in global health governance became commonplace among global health agencies and influential commentators.Footnote 72 Yet, these contemporary truth claims emerged quite recently as the product of a reorientation towards visions of good global health governance as orderly, coherent, and synchronised, rather than plural, competitive, and differentiated.
Our empirical analysis of core policy documents and annual reports of eight influential health IOs evidences how the growing influence of harmonisation as a metagovernance norm in global health was intertwined with transformations in more encompassing international standards, before the 2005 Paris Declaration on Aid Effectiveness (PD). The PD includes harmonisation among its five principles for improved foreign aid, requesting that ‘donor countries coordinate, simplify procedures and share information to avoid duplication’.Footnote 73 It was supported, among others, by the eight IOs we researched. The principles are meant to serve as the normative basis for good development cooperation. Studying metagovernance norms by looking at how health IOs have responded to the Paris Declaration in their discursive practices permits us to draw two important conclusions: firstly, that all major IOs in health have subscribed and continue to subscribe to the normative demands of the Paris Declaration. Secondly, they have also changed their organisational policies and practices accordingly (see next section). The strategies and visions for effective global health governance articulated by these major health IOs show that they value coordination and coherence between IOs as the backbone of more legitimate and effective global governance.Footnote 74
As these research findings suggest, a look at the emergence, effects and transformation of metagovernance norms in the field of global health helps us identify the strings that hold the many pieces of a seemingly cacophonous orchestra together. Studying discourses on good global health governance allows us to capture historically specific regularities in the discursive field that IOs reproduce and inhabit. Our findings thus allow us to break with a powerful contemporary narrative of global health governance as a fragmented and incoherent array of actors, rules, and institution. While a look at the number of global partnerships and initiatives that have emerged in the past 25 years certainly allures one to diagnose that global health is out of control, upon closer inspection we are able to detect shared discursive imaginaries among presumable adversaries of how the field should be governed and rendered more effective, in spite of the plurality of actors, rules, and perspectives. Rather than constituting a space of competition and exchange of different epistemic or political horizons, the plethora of large global networks, partnerships, and inter-organisational initiatives in global health – that make up the contemporary landscape in which IOs and their relations are embedded – displays a homogeneity in a mixture of technocratic and managerial vocabularies revolving around evidence, performance, efficiency, and historically variable ‘governance effectiveness’ terminologies that are shared across IOs and other actors. These discursive regularities point to the productive power that metagovernance norms unfold as temporal fixations of what ‘good’ governance of global health means and how it can be pursued.
Changing inter-organisational practices and institutional set-ups: Vertical partnerships, experimentation, and the proliferation of ‘synchronized architectures’
While the above elaborations were centred on identifying regularities in the discursive field, a closer look at changing inter-organisational practices and institutions shows how the latter have not only inscribed themselves but also reshaped and transformed the field. Contemporary global health governance is marked by the creation of super structures and large inter-agency activities geared towards collaboration at all levels of policymaking and with very large mandates such as global health funding in general or partnerships spanning maternal, newborn, and child health. In contrast, for example, the WHO/UNICEF Joint Committee on Health Policy of 1949 limited itself to technical cooperation on selected issues, capacity building, and the sharing of knowledge between the two organisations. This is one of a number of interagency committees with limited mandates that were created with WHO at their centre.Footnote 75 More importantly, in early inter-organisational collaboration among international agencies whose mandate included health, there was little reflection on the broader effects of these selective interactions on the institutional architecture of the United Nations or on international health governance overall. For UNICEF and, to a lesser extent, UNFPA, there seemed to be no need to consider the implications of their collaboration on the mandates and authority of the interacting organisations, with the centrality of WHO taken for granted. The same dynamic has characterised interactions with the private sector for considerable time. In fact, contrary to what the literature on global governance invokes as a ‘new’ paradigm, international cooperation in the field of health was, from the onset, marked by interactions with the private sector, in particular philanthropies but also the pharmaceutical sector.Footnote 76
An early, widely noted example of public-private partnerships for health is the Onchocerciasis Control Program, a partnership to control river blindness established between WHO, World Bank, the Food and Agriculture Organization (FAO), and UNDP in 1974 that also involved large-scale drug donations by pharmaceutical companies such as Merck and Co. During the 1990s and, particularly, under the leadership of WHO Director General Gro Harlem Brundtlandt, though, WHO interactions with civil society and business actors skyrocketed, resulting in a wave of large public-private partnerships to control or eradicate a number of infectious diseases, above all HIV and Malaria.Footnote 77 The enthusiasm for these vertical partnerships and experimentation with institutionalised interactions between IOs and private actors, however, started waning by the mid-2000s. First of all, international health agencies, most notably the WHO, slowly started to perceive of their relationships with private actors as requiring a legal basis – a reasoning that has sparked off a recent trend towards the ‘legalisation’ of partnerships in the form of Memoranda of Understanding between the partner institutions.Footnote 78 Moreover, we can observe how health IOs increasingly subscribe to a re-emerging health systems strengthening agenda, thus being more and more concerned with the systemic effects of disease-specific initiatives and their long-term sustainability.Footnote 79 Since then, therefore, a shift in perspective towards health systems strengthening also serves to justify the deepening of inter-organisational ties and the growing belief in the appropriateness of large-scale harmonisation activities, integrating individual agencies’ and partnership actions into a broader ‘health architecture’.
Our discourse-analytical approach to studying inter-organisational relations in global health rests on the proposition that to trace power in IO-IO relations it is insufficient to study merely regularities and transformations at the level of discourse. Rather, it also emphasises the need to expose the working of norms by looking at the ways in which such articulations are reflected in patterned practices of inter-organisational cooperation. On a most general level, constitutive inscriptions of the contemporary shift towards IO-IO harmonisation as a metagovernance norm are manifested in the creation of numerous global initiatives whose purpose explicitly lies in reducing the duplication of efforts and coordinating the actions of ‘different groups of disease-specialists … under the same programmatic umbrella’.Footnote 80 In 2010, Dina Balabanova and colleagues counted 75 of these coordination-oriented partnerships.Footnote 81 More specifically, we see these inscriptions exemplified in the Partnership for Maternal, Newborn and Child Health launched in 2005 (PMNCH).Footnote 82 The decades prior to the establishment of the PMNCH were characterised by tensions between the maternal and child health policy community, with ‘ideological and programmatic differences’Footnote 83 resulting in an increasing dissociation of these two health policy agendas since the 1980s. As a consequence, advocates and experts for maternal health organised around the Safe Motherhood Initiative established in 1987, thereby becoming insulated from a broadly supported, but selective Primary Health Care agenda of which child health became the most important pillar. The effect of maternal health's divorce from child health was a growing competition between the two policy goals and agendas. It was only the international debate on ‘aid effectiveness’ that intensified in the early 2000s and the growing prominence of a vocabulary of harmonisation, alignment, and order as a new normative horizon for the governance of governance in health that led to the SMI turning to the idea of partnership with the child health community and the formation of a larger, integrated umbrella organisation. As the insights presented by Katerini Storeng and Dominique Béhague reveal, it was particularly the maternal health policy community that felt pressurised by donors to coordinate and reconnect with the child health community for the sake of reducing transaction costs and enhancing efficiency.Footnote 84 Their findings are supported by other studiesFootnote 85 on discourse and power in maternal and child health policy networks.Footnote 86
The Health Systems Funding Platform (HSFP) provides another example of how the contemporary discourse on effective global health governance as ‘harmonized architecture’ continues to inscribe itself into the practices and institutions that make up the global health landscape. Following concerns of a number of important donor countriesFootnote 87 over fragmentation of funding sources and systems related to health-systems strengthening, a High Level Task Force for Innovative Financing for Health Systems was established. Its mandate was to identify a financing mechanism that could complement traditional aid and ‘bridge the financing gaps that compromise attainment of the health-related MDGs’.Footnote 88 Upon recommendation by the task force, a joint Health Systems Funding Platform was established by the Global Fund, GAVI Alliance, World Bank, facilitated by the WHO. The HSFP's primary task was ‘coordinating, mobilizing, and channeling health resources – from both domestic budgets and international aid - to comprehensive, integrated, country-driven health plans and strategies’.Footnote 89 Its creation can be understood as an inscription of the harmonisation discourse, inasmuch as it was justified in line with the Paris Declaration on Aid Effectiveness, with the aim to ‘assure donors that their investments are being used efficiently and effectively – in line with agreed development principles’.Footnote 90 Both the PMNCH and the HSFP are prominent, early examples of a concomitance of disease- or problem-focused initiatives and partnerships, on the one hand, and a systemic perspective on global health governance on the other that stimulated the creation of over-arching, yet relatively slim institutional structures seeking to stabilise large-scale architectures for ‘funding’, ‘data’, and ‘women and children’ from the mid-2000s onwards. The continuous creationFootnote 91 of such organisations has been driven by the health systems strengthening agenda, which demands a slimmer funding architecture and places the oversight and management of huge funds into the hands of only a handful of powerful global agencies. Rather than ‘economies of scale’, therefore, at present the productive inscription of harmonisation as a metagovernance norm manifests itself in the proliferation of such ‘alliances of scale’ as super networks. These material inscriptions of metagovernance norms – embodied in people, buildings, infrastructure, funds, computers, telephone calls, data repositories – are from our theoretical standpoint, an effect of institutionalised meaning-structures that connect agents and organisations in the global health network. The observable trend towards the creation of such super structures binding multiple IOs and public-private institutions together, though, coexists with an ongoing proliferation of small-scale, disease- or problem-specific partnerships and collaborations with for-profit and not-for-profit actors. Contemporary global health governance, thus, is marked by normative instability and ambiguity, reflected in the concomitance of two influential metagovernance norms – privatisation and harmonisation.
Outlook: From regularities, transformations, and inscriptions towards struggle and translation
In this article, we expanded the current understanding of power in IO relations by looking at discourses surrounding reflexive norms that give meaning to the field of global health. As we have shown, this policy field has undergone a series of remarkable changes with regards to substance (What is global health?), actors (Who governs?), and norms (How should one govern? Who should govern?). On all of these levels, a proliferation of issues, actors, and rule-systems has led observers of the global health landscape to make routine diagnoses of fragmentation, complexity, and competition. These changes thus have also affected the relationships between IOs in this ever more prominent field of international collaboration. However, our qualitative analysis of discourses on ‘good’ global health governance also allowed for identification of regularities in discourse and practices, as well as historical moments and phases in which these patterns are broken and normative orders become unstable and shift. In particular, we found that contemporary visions of good global health governance as orderly, coherent, and synchronised emerged quite recently as a counternarrative to previously dominant beliefs in the virtues of partnerships, pluralisation, and innovation. Furthermore, as we illustrate above, these changes in metagovernance norms and the broader discursive regularities in which they are embedded engraved themselves into the field by shaping inter-organisational practices and giving rise to new institutional set-ups.
Our analysis of health IOs’ reflexive discourses on governance underlines the value of a discursive, productive perspective on power as it illustrates how, the ‘trans-actions of A and B cannot be considered in isolation but rather always as part of wider networks of interdependent relations’.Footnote 92 From such a perspective, the structural ramifications of relationships between two (or several) IOs are of paramount interest inasmuch as these relationships constitute not only the identities of the IOs involved but also affect social relations of other public and private organisations in the wider organisational field. In fact, our findings suggest that the adoption of a productive understanding bears tremendous value for the study of IO-IO relations in global (health) governance and beyond, as it permits conceptualising power in inter-organisational relations as an ‘unfolding, ongoing process’.Footnote 93 Most broadly, it permits us to draw a more comprehensive and differentiated picture of the normative, institutional, and semantic orders that are constitutive of contemporary global health governance in which agents are embedded and to denaturalise dominant contemporary beliefs among both practitioners and scholars about how fields of global (health) governance ought to be governed. In conclusion, this article has sought to show the benefits of a discourse-analytical approach for grasping the productive effects of metagovernance norms. In our diachronic analysis of IO discourses in global health, we sought to disentangle the productive power effects of metagovernance norms and surrounding discourses along two axes: first, by illustrating how metagovernance norms limit the imaginary of what constitutes good ‘governance of governance’ at a particular place and point in time and, second, by showing how discursive regularities underpin the (re)organisation, transformation, and emergence of practices and institutional arrangements that bind IOs together in fields of global cooperation.
We believe that this research agenda could be advanced in several directions in order to draw even more far-reaching conclusions regarding how the (re)production of normative, institutional, and semantic orders of contemporary international relations are imbued with discursive, productive power. In particular, we see the need to study discursive struggles over the meaning of metagovernance norms and resistance against their enactment in domestic, operational, and ‘local’ contexts. Such an extended productive power approach to inter-organisational dynamics would highlight how discursive regularities do not only (re)order organisational fields at large as they transform over time, but that they are also open to contextually situated struggles, translations, and renegotiations. Against the backdrop of the discursive homogeneity and ambiguous coexistence of incongruous metagovernance norms that our findings illustrate among global health IOs, it appears particularly warranted to study struggles over the desirability and practical implications of metagovernance norms in operational settings – including contestation by social actors operating entirely outside of global health IOs’ discursive galaxy, as well as resistance and translations that take place at the domestic, operational level. A 2015 Audit of the Country-Coordinating Mechanisms (CCMs) of the Global Fund, for example, was particularly interested in coordination and alignment of the Global Fund and other international partners, following a clear commitment to the Paris Declaration and the Accra Agenda. The Audit concludes, though, that while the norm of harmonisation is openly endorsed by the Global Fund and its partners as something required and good, practice on the ground shows low compliance with the norm and confusion over what it means for every interaction between agencies in the field.Footnote 94 Examining resistance, translation and local appropriation when metagovernance norms ‘travel’ from the global to the operational, ‘local’ level bears, we think, potential for examining how productive, discursive power unfolds in struggles over the meaning and implications of the powerful global discourse on ‘good’ governance of health governance that this article has sought to interrogate.
Acknowledgements
The research presented in this article was conducted by members of the Research Group ‘Governance for Global Health’, which is jointly funded by WZB Berlin Social Science Center and Freie Universität Berlin through the German Research Council's (DFG) Excellence Initiative. Early drafts of the manuscript were presented at the 5th International Power Conference ‘Power, Institutions & Authority’ in Tampere, 2016 and the 11th Pan-European Conference on International Relations ‘The Politics of International Studies in an Age of Crises’ in Barcelona, 2017. The authors wish to thank Peeter Selg, Tine Hanrieder, and Cornelia Ulbert for valuable comments on earlier versions of our article, as well as the two anonymous RIS reviewers for their insightful comments and helpful suggestions during the review process. We thank Markus Sperl and Martha van Bakel for their excellent editing and research assistance.
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