Global health governance: international, national, subnational

I think it is useful to discuss political economy of development in three broader contexts: subnational, national, and international. As Reimagining Global Health outlines, much of the policy-making and agenda-setting in global health starts at the top, the international sphere, with the IMF and the World Bank. It is worthwhile to consider how international institutions interact with not only national governments they donate to (i.e. the ‘developing’ world) but how their rules and agendas are set by powerful nations (namely the United States and, to a lesser extent, the United Kingdom in the Washington Consensus). The next bit is how national governments must adapt to these rules and agendas while juggling sometimes drastically different sub national realities.

Are both the IMF and the World Bank really at this agenda-setting “top?” One would think that multinational organizations which draw upon the standpoints and needs of all of its member states reflect a consensus, a World Consensus. This is debunked with the Washington Consensus and the driving need for the Western world (United States) to bring other nations in line with its own neoliberal system. As fun (or exhausting) as it may be to get into Marxist and Anti-Marxist critiques, there is truth that the IMF and World Bank reflect the Washington Consensus and 1980s neoliberal aspirations. Included here is the long road of privatization initiatives and other rules tied to loans which countries must implement, oftentimes including the commodification of health care. Nations which rely on types of care that differ from Western biomedicine have trouble introducing (Western) private-sector medicine to their citizens. In the end, many of these newly privatized markets end up benefitting mostly powerful nations making money investing rather than local populations outside of the new systems.

An integral part of the Washington Consensus is cost-effectiveness and the rise of certain initiatives because they are cheap and have a widespread and immediate effect. However, these initiatives are not necessarily a "fit" for different countries and more specifically, different parts of a country. In nations that are as large or diverse as Brazil and India, certain public health initiatives are simply either irrelevant or not as desperately needed as in other parts of the country. A great example is a disparity between different states in India in regards to institutional birthrates. Kerala, a southern Dravidian state, has a 100% hospital birth rate. The national average is about 41%, with some states in the 20s or even lower. In this example, funding going towards bringing women of childbearing age into hospitals is almost irrelevant in Kerala but desperately needed in other parts of the country. I am curious about how a nation as large as India handles these differing disparities and fund allocation. On the other hand, which health issues are ignored in favor of more cost-effective initiatives or ones which align more with international institutions’ goals?