02 Oct 2012

ASEAN’s member states’ reluctance to adhere to a highly institutionalised regional entity has hampered regional health governance. Civil society can and must step in to meet oppressing needs, writes Marie Nodzenski.

ASEAN’s member states’ reluctance to adhere to a highly institutionalised regional entity has hampered regional health governance. Civil society can and must step in to meet oppressing needs, writes Marie Nodzenski.

In the wake of globalisation, new health threats have emerged which are transboundary in nature and which can no longer be dealt with by states alone. Definitions of health now encompass cross-sectoral determinants of health (such as access to education, housing, work condition, etc), which are transnational. Addressing health issues therefore encompasses various actors and stakeholders. A new governance structure for health is needed.

Tremendous potential exists for regional organisations in the wider Global Health Governance framework, acting as bridge organisations between global initiatives and national health policy implementation.

The Southeast Asian region, home to about 600 million people, is particularly vulnerable to health threats. The populace represents almost 9 per cent of the world’s population, and yet lives on 3 percent of the planet’s land surface. The trauma of the SARS (Severe Acute Respiratory Syndrome) outbreak of 2003 and influenza A (H1N1) of 2009 is fresh in peoples’ minds. It is of particular interest to look into the potential of the Association of Southeast Asian Nations (ASEAN) to support an inclusive framework for Global Health Governance by building on its existing mechanisms for health cooperation. Yet implementing such highly institutionalised mechanisms is hampered by its founding principle of non-interference and conservative interpretations of what constitutes violating state sovereignty.

As such principles still impede on the effective implementation of regional health policies at the national level, it may be more pragmatic to look at the potential of civil society to overcome such constraints and to improve regional health governance in ASEAN.

The ultimate objective is to identify the optimum combination of actors and processes to translate regional policy into local action and change, as Marie Lamy and Dr. Phua discuss in “Regional Health Governance: A comparative perspective on EU and ASEAN”, (EU Centre Policy Brief No 4, June 2012).

ASEAN does not yet benefit from a high degree of integration and has not reached a stable institutional profile. It might therefore be useful to draw comparisons between ASEAN and the EU to scrutinise which mechanisms and legal instruments can further regional health governance.

Regional health governance in the EU

The EU benefits from a high degree of integration, and a large number of institutions working on health and financial resources, enabling it to develop an inclusive framework for health governance.

Regional health governance in the EU is supported by a European Health Strategy which provides member-states with a common approach to health issues. The Statement on Fundamental Health Values and the Together for Health Strategy 2008-2013 which contains a “Health in All Policies” principle as well as the Lisbon Treaty’s Article 9 (TEU 2009) are proof of the EU’s commitment to develop a coherent policy framework for health.

To support such a strategy, the EU operates within a wide framework of cooperation. The EUC’s specific body for health, the Directorate General Health and Consumers (DG SANCO), works in close collaboration with both the World Health Organisation (WHO) EURO and World Health Organisation (WHO) Headquarters in Geneva. Such collaboration limits cases of duplication of health policies and programmes.

Finally, the EU benefits from a supportive network of Civil Society Organisations (CSOs), which are fully integrated in the governance framework for health (through the European Public Health Alliance and the Civil Society Contact Group).

The EU provides a fully inclusive framework for regional health governance by adopting a cross-sectoral approach to health issues and by fostering cooperation between various actors and stakeholders. Can ASEAN adopt and develop such mechanisms pertaining to health to be relevant to our regional context?

Regional health governance in ASEAN

As opposed to the EU, ASEAN holds a low degree of political integration mainly due to political diversity and economic disparities within the region, and longstanding regional conflicts. ASEAN is characterised by a very slow and complex decision-making process, known as “The ASEAN Way”, which works by consensus. Critics call it an ineffective way of governance in a modern world. This is especially so in the area of health governance, in a densely populated area of a populous world, where pandemics would thrive. More crucially, longstanding diseases with known cures and preventions can be better constrained with improved governance.

ASEAN’s potential as a global health actor expanded in 2007 with the adoption of an ASEAN Charter and the birth of an ASEAN Health Division which establishes a Strategic Framework on Health and Development (2010- 2015). Under the same Charter was established the ASEAN Socio Cultural Community Pillar and its ASCC Blueprint which paved the way towards more social integration within ASEAN.

Beyond form, ASEAN is unable to deliver on the substance as it faces numerous structural challenges that limit institutionalised cooperation and which impede on the creation of a fully integrated health governance framework. ASEAN needs both an integrated health strategy that would approach health as a cross-sectoral priority and a wider matrix of cooperation both with WHO and with CSOs to more efficiently bridge global, regional and governmental bodies.

With growing complexity and transnational nature of health threats in the region, there is a crucial need for the nations of Southeast Asia to transcend this inertia and look beyond the state to overcome deficiencies in dealing with such issues. What processes can therefore be used to overcome structural constraints within ASEAN and to translate regional health policy into local action?

The potential of civil society

Considering ASEAN’s member states’ reluctance to adhere to a highly institutionalised regional entity, the adoption of mechanisms and legal instruments such as the ones designed in the EU is a non-starter. One could instead look to the involvement of civil society as essential to a fully inclusive Global Health Governance framework.

Civil society is often defined as a ‘third sector’, distinct from government and business. In this view, civil society is defined by Civil Society International as so-called ‘intermediary institutions’ such as professional association, religious groups, labour unions, citizen advocacy organisations.

Civil society therefore encompasses various actors, institutions and networks ranging from NGOs and academia to the media. Antonio Gramsci, the 20th Century Marxist political theorist often considered a highly original thinker within modern European thought, understood civil society as the realm of culture, ideology and political debate. Association in civil society is voluntary and is characterised by individuals coalescing around common ideas, needs or causes to promote collective gain.

Since the 1990’s, International Governmental Organisations (IGOs) have come to recognise the important role of CSOs in health including in governance.

Regional entities should consider too the potential of civil society actors in bridging regional policies and their implementation at the national level. In Southeast Asia, non-state actors are increasingly recognised as participants in the creation of a regional community and identity although their participation to the ASEAN’s processes remains limited.

Traditionally, civil society steps in where the state or markets are failing, and are typically viewed as non-threatening because of limited access to power or finances relative to the other two pillars. With the growing complexity of health issues and the emergence of IGOs and regional organisations, the role of civil society in health has considerably expanded. Civil society actors, through advocacy, are now able to influence policy-making and priority-setting on the global health agenda. They have made global and international processes more publicly accessible by disseminating information, therefore raising public awareness on health issues. Civil society can also greatly contribute to health policy- making by sharing information, exchanging data, technical expertise and through fund mobilisation. Civil society plays a major role in implementing and monitoring global or regional health policies at the national and local levels.

Given that the paralysis within ASEAN has created a gap, civil society has a crucial role—and crucially, room—to play. Indeed, ASEAN’s exclusive nature limits the interaction between the Association and the citizens of member-states. Civil society can act as a bridge between the various levels of health policy-making. Furthermore, civil society actors may become ideal partners for ASEAN member-states both in the arena of health policy formulation, implementation and monitoring. Indeed, the consequences of ASEAN’s reluctance to design enforcing mechanisms for national implementation of health policies might partially be alleviated with the implication of civil society in policy implementation.

Effective participation of civil society

For civil society actors to achieve their potential fully within a regional health governance framework, their legitimacy needs to be legally recognised by states. Enabling factors at the national level are also crucial (such as tax and financial incentives, legal protection, mechanisms for their involvement in decision- making). At the regional level, the scope of civil society actors’ involvement through improved consultation, granting of observer status and the provision of resources to participate in specific functions must be broadened, as Kelley Lee noted in her article, “Civil Society Organisations and the Functions of Global Health Governance: What Role within Intergovernmental Organisations?” (Global Health Governance, Volume 3, No.2, Spring 2010)

Closer collaboration between states and civil society has become necessary to sustain health initiatives.

The pressing needs in the health arena has spawned Public Private Partnerships (PPPs), which can be defined as collaborative relationships that transcends national boundaries and which brings together three or more parties to achieve a shared health goal on the basis of a mutually agreed division of labour. PPPs are based on mutual benefice: public agencies often lack expertise and experience and the private sector brings product development, manufacturing, marketing and distribution. Various forms of partnerships in addition to PPPs, such as collaborative networks (research, knowledge, etc) are emerging, signifying the growing involvement and impact of civil society on regional health governance.

The multitude of actors in health demands new ways of health governance to arrive at the most optimum combination of actors and processes to translate regional or global health policy into local action. Working closely with civil society and designing new processes that fully integrate its components within a regional health governance framework might be a relevant approach to the ASEAN context. Assessing the impact of civil society regional networks within ASEAN will be crucial to the creation of a sustainable regional health governance framework.

Marie Nodzenski is a Research Associate for Professor Phua Kai Hong at the LKY School. Her email is