Institutional innovation in global health: Changing roles of state and non-state actors in governance of vaccine preventable diseases

摘要

This dissertation examines the changes in global governance of vaccine preventable diseases precipitated by the transformations of national infrastructures and international institutions since the 1990s. Neoliberal policies promoted by the transnational elites prompted privatization of healthcare and decline in public healthcare expenditures and resulted in concentration of economic and political power, crumbling of the welfare state, and deepening inequalities. Emergence in public health of a new institutional form -- Public-Private Partnership (PPP), signals a reconfiguration of the governance space. I focus on one such PPP -- the Global Alliance for Vaccines and Immunization (GAVI). GAVI's philanthropic goals are balanced against accountability to its partners. Collaborating with the pharmaceutical industry to further its philanthropic objectives, GAVI mediates the market's pull by effecting state policies. I document the vectors of power that GAVI both exerts and is subjected to in its institutional entanglement with the states, multilateral agencies, and the industry. These mechanisms of influence are functionally different from market pressures or 'soft' rules of traditional multilateral organizations and forge new paths for exercising power within PPPs. Finally, I examine the networks of vaccine trade between countries from 1996 to 2010. Trade networks retain a pronounced core-periphery structure, and the majority of countries lack capacity for vaccine production. Over time some traditionally strong vaccine producers scale down, and some export-oriented developing countries, -- scale up their vaccine production. Congruent with the industrial convergence hypothesis, I find that industry late-comers no longer accrue significant returns and that some of the formerly dominant vaccine-exporting countries engage in innovative funding ventures, such as GAVI's Advanced Market Commitment (AMC). AMC creates stable demand for new patent-protected and expensive vaccines, subsidizing the industry. I also find that industrial growth does not always reduce inequality for populations most affected by endemic diseases. I take a closer look at India as a country which houses both a thriving vaccine-producing industry and a third of the world's un-immunized children, and examine the rift between capital accumulation and state decision making.