Global health. The current scenario and future perspectives

28 2. Governance of the Global Health System. Marta Maurás Pérez, José Sulbrandt Cabezas, Hernán Rosenberg Rubel. Governance in Global Health The need for a global approach to achieve an acceptable state of global health has been recognized for over a century and a half, yet the international system has never established an adequate governance for this purpose, although some conceptual and political advances have been made. The series of pandemics at the end of the 20th century and the beginning of the 21st have had a greater impact than expected (given the experiences of the early 20th century, such as the Spanish flu and subsequent epidemics like HIV/AIDS and Ebola). This has highlighted the need to review and modify the governance system to effectively address the needs of global health, including pandemics, while considering the emergence of new strategic actors (Fidler, 2010). This search to define the organizational parameters of the global health system is supported by relatively systematic work in political science in the 1980s and 1990s on the concepts of governance and governability, applied, among other areas, to health systems in Latin America. Both concepts have a multidimensional and relational character regarding the organization and structure of the State, which, by extension, applies to the United Nations whose membership is solely composed of States (Prats i Catalá, 2001). The use, not only in academic but also in political contexts, of these concepts indicates the relevance of the discussion on a global healthcare system - its objectives, organization and operation- This debate has been going on for years at the World Health Assembly and is becoming more complex as the international situation grows more polarized and fragmented. The multilateral system appears not to be responding to the need for cross- cutting dialogue on common objectives, policy coordination and program agreements. When used to designate the effectiveness, quality and good direction of State intervention, governance has provided much of the State’s legitimacy in the globalization era post-Berlin Wall since 1989. The term relational governance is also used, and it is becoming increasingly clear that governance will tend to be understood as the functioning of networks and multi-level interactions among the public, private and civil sectors, along a local/global axis. Regarding governability, suffice it to cite Michel Coppedge (Camou, 2001) who defines it as “the degree to which the political system becomes institutionalized”, with institutionalization, citing Huntington (1968), as “the