Regional Health Cooperation in Multi-Layered Health Governance: A Comparative Study of Pandemic Preparedness and Response Efforts in the EU and Asia
Global health governance became fragmented with the growing political divisions and worsened during the COVID-19 pandemic. Consequently, practical health cooperation at the regional and national levels, or among like-minded countries, has increased. Several innovative projects have been launched in Asia and Europe; however, they are standalone programs without any coordination in Asia as they reflect geopolitical movements in the region, while all innovative projects in the EU are linked to each other or at different levels. In this way, health cooperation in the EU has been institutionalized more than in Asia. However, it should be noted that this does not necessarily indicate good performance by the EU, where the numbers of infections and deaths due to COVID-19 have been high; this is also confirmed by the spread of monkeypox in 2022. Based on this recognition, this study aims to clarify the characteristics of regional efforts on pandemic preparedness and response (PPR) in the EU and Asia, compare them, and obtain implications for better PPR. The fundamental question is what institutional efforts or norms are necessary to strengthen PPR within the regions. In sum, this study analyzes the experiences and current situation in both regions, and through interviews, historical research, and intensive discussions, itaims to present lessons to these regions to properly prepare for the next pandemic.
1. Multi-layered structure of global health governance
Global health governance (GHG) is defined as ‘the use of formal and informal institutions, rules, and processes by states, intergovernmental organizations, and non-state actors to deal with challenges to health that require cross-border collective action to address effectively [Fidler2010]. The system has, however, become fragmented with growing political divisions in international society [Kickbuschet al.2015] and has worsened during the coronavirus disease (COVID-19) pandemic. In fact, many rules under the International Health Regulations (IHR 2005) were not observed during the pandemic, and the ongoing revision of the IHR or negotiations of the so-called Pandemic Agreement have not been smooth, all of which area reflection of growing political divisions. In contrast, the need to cooperate with others to tackle viruses has never been greater, given the significant risk posed by infectious diseases, such as monkeypox or even bio-terrorism. However, for most of us the meaning of ‘others’ has changed from indefinite ‘others’ to specific ‘others’. Consequently, practical health cooperation at the regional and national levels, or among like-minded countries, has increased during the pandemic.
Professor Amitav Acharya from American University has argued that the liberal international order based on Western hegemony has declined, and that a ‘multiplex world’ is on the rise instead in which various actors such as international organizations, like-minded groups, emerging countries or private actors with different roles and values cooperate or co-exist with each other [Acharya 2018]. The same is true for the GHG. The so-called vaccine diplomacy over COVID-19 vaccines has emerged among like-minded countries, but discussions on the Intellectual Property waiver have been deadlocked by the World Trade Organization. At the regional level, the European Health Union was launched, and in Africa, regional cooperation on vaccines was observed with the establishment of the African Medicines Agency in 2022. Practical health cooperation at the regional level has increased during the pandemic to compensate for the lack of health cooperation at the global level [Takuma 2022a].
2. Regional health cooperation in Asia
With an interest in regional health cooperation in Asia, Dr. Takuma has researched the subject from a historical and practical perspective [Takuma 2021; Takuma 2022b], and has also discussed the prospects for regional health cooperation with researchers and practitioners in Asian and Quadrilateral Security Dialogue (QUAD) countries [Takuma 2022c]. Three main findings were identified.
First, various innovative projects have been launched in Asia to prevent the next pandemic. Even before the COVID-19 pandemic, various bilateral-based health cooperation agreements existed in Asia—such as between Japan and Vietnam, Thailand or Mongolia, and the US and Vietnam—which have expanded during the pandemic, and new initiatives have also emerged. Some projects have linked different levels of cooperation or different regions, such as the biomanufacturing hub of the World Health Organization (WHO) in South Korea (global and regional levels) and the establishment of a branch of the U.S. Centers for Disease Control and Prevention (CDC) in Tokyo (America and Asia).
Second, such innovative projects are standalone programs without any coordination, reflecting geopolitical movements in Asia. For example, vaccine cooperation among QUAD countries is in direct competition with China’s vaccine diplomacy, which has resulted in excessive donations of vaccines to the Asia-Pacific region [Council on Foreign Relations 2022]. The WHO Hub in South Korea targets Southeast Asian countries; the ASEAN Centre for Public Health Emergencies and Emerging Diseases (ACPHEED), which the Japanese government supports, also targets Southeast Asian countries. However, there is no coordination between the WHO Hub and ACPHEED.
Geopolitical movements have delayed the institutionalization of regional health cooperation in Asia, but this has not necessarily led to poor performance in pandemic preparedness and response (PPR). Taiwan, which is outside any institutional framework, has shown overwhelming performance in terms of its response to the COVID pandemic, and the numbers of infections and deaths have been relatively suppressed in Asian countries. Rather, it may be possible to hypothesize that bilateral or like-minded cooperation that existed before the pandemic contributed to the diffusion of various norms, leading to a convergence of COVID-19 prevention practices within the broader East Asia compared to any other region.
3. Multi-layered health cooperation in the EU
Similar to Asia, various innovative projects have been launched in the EU during the pandemic, although the difference is that projects in the EU are linked to each other or at different levels. For example, the WHO office in Lyon has played a role at the local, national, and regional levels as well as at the global level.
This is largely due to the presence of the EU, a supranational organization, as well as to the role of non-state actors, such as the international network built by the Pasteur Institute. Previously, Dr. Takuma argued that the Pasteur network in Asia and Africa played an essential role in France’s health diplomacy [Takuma 2020]. This view also resonates with the present study, which hypothesizes that non-governmental actors such as research institutes or companies can play practical roles in health projects, and that they can ensure that the projects are free from the influence of politics and can make role-sharing between them and governments possible.
In this way, health cooperation in the EU has been institutionalized more than in Asia. However, it should be noted that this does not necessarily imply good performance by the EU. The numbers of infections and deaths due to COVID-19 are high in the EU, and this is also confirmed by the spread of monkeypox in 2022.
4. Research Plan
Based on the above recognition, this study aims to clarify the characteristics of regional efforts on PPR in Europe—especially in the EU—and Asia, compare them, and obtain implications for better PPR. The fundamental question of this research is what institutional efforts or norms are necessary to strengthen PPR within the region. This study aims to answer this question by comparing the experiences of the EU and Asia.
This study also focuses on the role of various actors in regional cooperation and the interaction between the local, regional, and global levels. Further, it aims to draw the implications for favorable role-sharing between governmental and nongovernmental actors in post-COVID-19 health governance as well as for norm sharing or institutionalization.
Much research on GHG has incentivized this study and is worth describing, one of which is the comparative research that has taken place between Europe and Asia in the field of health [Greer, King, Massard da Fonseca, and Peralta-Santos eds., 2021]. Although their historical and institutional backgrounds differ, a comparison of both continents can provide useful suggestions for other regions. In his examination of Asia’s response to the COVID-19 pandemic, Tiberghien argued that the success of each country was driven by its high institutional capacity, social cohesion, and regional economic cooperation [Tiberghien 2021]. A similar perspective is necessary for regional cooperation.
Another research finding which has incentivised this study is a change in the approach of GHG. The necessity for social innovation in GHG has been pointed out even before the COVID-19 pandemic [Normand and Scheffler 2011; Cooper and Kirton 2016], but the outbreak has pushed forward this need [Gates 2022]. While conventional approaches in response to the COVID-19 pandemic did not work in both developed and developing countries, unconventional approaches—such as South-South cooperation, public-private partnership, or even South-to-North cooperation—had, on the other hand, been observed to work [Gaudillière et al. 2022]. This is the main reason why this study is focussed on the role of non-governmental actors in the global health arena.
This study had three goals. The firstgoal was to examine the nature of regional health cooperation in the EU by focusing on the European Health Union. As mentioned above, the EU has institutionalized a cooperative framework compared to Asia; however, this does not necessarily imply good performance. The number of COVID-19 infections remains relatively high, and the EU has been plagued by the monkeypox epidemic in 2022. What worked and did not work in the EU under high institutionalization? The question of why this is so is clarified by focusing on the EU’s historical background and role of various actors, including non-state actors.
The study also clarifies the historical background of regional health cooperation in the EU, since the origin of international health cooperation in the continent is traced to the mid-nineteenth century [Howard-Jones 1975] and non-governmental actors such as the Pasteur Network have played a crucial role [Owhadi-Richardson 2012].
In addition, this study focuses on the multi-layered nature of governance. It is interesting that health cooperation in the EU is linked with efforts at different levels, such as the WHO Hub for Pandemic and Epidemic Intelligence in Berlin or the WHO office in Lyon. As the name indicates, WHO hubs are positioned as part of the WHO in form, but are practically supported by governmental or nongovernmental actors in their host countries. Likewise, in Asia, the WHO biomanufacturing hub in South Korea was established in 2022, and the WHO hub for Universal Health Coverage is planned by Japan. However, unlike Asia, WHO hubs in the EU play a crucial role in local, regional, or global health cooperation, and even in linking different levels of cooperation. Based on these observations, this study aims to clarify the role of WHO hubs in multi-layered governance structures through interviews and an examination of documents and historical archives.
The second goal of this study is to clarify the dynamism of regional health cooperation in Asia. Reflecting the diversity and political tensions in Asia, the framework for regional health cooperation has not been institutionalized while developing fragmented cooperation—such as between Japan and ASEAN, Japan and the US, or the US and Southeast Asian countries. On the other hand, even if the system has not been institutionalized, it can be hypothesized that the sharing of certain norms has progressed since before the pandemic, leading to good performance in the region. The second goal is to test this hypothesis.
The final goal of this study is to compare health cooperation between Asia and the EU and provide useful suggestions to each other, specifically concerning the share of norms, institutionalization, and favorable role-sharing between governmental and nongovernmental actors in post-pandemic health governance. In sum, this study analyzes the experiences and current situation in both regions and aims to present lessons to both regions to properly prepare for the next pandemic through interviews, historical research, and intensive discussions.
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