© 2013 ANNA DA SILVA ALL RIGHTS RESERVED INSTITUTIONAL INNOVATION IN GLOBAL HEALTH: CHANGING ROLES OF STATE AND NON-STATE ACTORS IN GOVERNANCE OF VACCINE PREVENTABLE DISEASES by ANNA DA SILVA A Dissertation submitted to the Graduate School-New Brunswick Rutgers, The State University of New Jersey in partial fulfillment of the requirements for the degree of Doctor of Philosophy Graduate Program in Sociology written under direction of József Böröcz and approved by ___________________________ ___________________________ ___________________________ ___________________________ New Brunswick, New Jersey October 2013 ABSTRACT OF THE DISSERTATION INSTITUTIONAL INNOVATION IN GLOBAL HEALTH: CHANGING ROLES OF STATE AND NON-STATE ACTORS IN GOVERNANCE OF VACCINE PREVENTABLE DISEASES By ANNA DA SILVA Dissertation Director: József Böröcz 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, ii 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. iii ACKNOWLEDGEMENTS I would like to thank my dissertation chair, József Böröcz, for his guidance and trust. I am very grateful to Paul McLean for his many insights and to David Smith and Catherine Lee for thoughtful readings and probing questions. At earlier stages, I benefitted from many useful suggestions from Philip McMichael, Ted Schrecker and Yildiz Atasoy. Anna Sher, Rachel Askew, Alena Alamgir, Eric Kaldor and A. Aneesh each played a crucial role in my journey. I am thankful to Larissa Kolesnikova and Nikolai Kolesnikov for teaching by example and for all they have done for me. And finally, I could not have completed this dissertation without unwavering support from Mark da Silva, for which I am immensely grateful. iv For my mom, Larissa Kolesnikova. Thank you for setting the bar high v TABLE OF CONTENTS Abstract ………………………………………………………………………………….. ii Acknowledgements …………………………………………………..…………………. iv Chapters I. Introduction Neoliberal Globalization and Its Discontents …………………….1 Global Governance and the State …………………………………8 Neoliberal Globalization and the World System ………………..12 Neoliberal Globalization and Inequality ………………………...14 Global Commodity Chains and Production Networks …………..23 Global Health ……………………………………………………27 Global Governance of Vaccine Preventable Diseases …………..38 Double Movement……………………………………………….46 II. Hybridization of Global Health Governance and GAVI Public-Private Partnerships………………………………………53 GAVI…………………………………………………………….58 Strategic Alignments: the Pharmaceutical Industry……………..63 Advanced Market Commitment………………………………….77 III. GAVI and Health Governance Mechanisms Wielding Power: Influencing the Recipient Countries………….85 Mission Drift: Health System Strengthening…………………105 IV. Geopolitical Changes in Vaccine Trade vi Trade Related Aspects of Intellectual Property Rights Agreement………………………………………………………114 Network Structure: Persisting Hierarchy……………………….118 Regional Patterns……………………………………………….128 V. Industrial Convergence and Health Inequality Centrality and Mobility…………………………………………139 India…………………………………………………………….147 VI. Conclusion……………………………………………………………...156 Appendix ………………………………………………………………………..……. 166 Bibliography ……………………………………………………………………..…… 173 List of Tables Table 4.1 Changes in number of importing partners for top vaccine exporters 1996-2004-2010. ……………………………………………………………. 122 Table 4.2 Percent changes in number of pharmaceutical exports and vaccine exports between 1996 and 2010. ……………………………………………………... 124 Table 4.3 Vaccine trade and pharmaceutical trade network density changes. ………....129 Table 4.4 Inter/Intra-regional vaccine and pharmaceutical exports, 1996. …………….133 Table 4.5 Inter/Intra-regional vaccine and pharmaceutical exports, 2004. …………….134 Table 4.6 Inter/Intra-regional vaccine and pharmaceutical exports, 2010. …………….135 Table 5.1 Changes in degree centrality for top vaccine exporters 1996-2004-2010. .…141 vii List of Figures Figure 5.1. Changes in centrality as vaccine exporters for countries exporting to more than one partner, 1996-2010. …………………………………………………. 143 viii 1 CHAPTER I INTRODUCTION Neoliberal Globalization and Its Discontents One of the more contentious areas of debates in various literatures on globalization centers around questions of broad societal changes that globalization has wrought and its consequences that reverberate through political, economic, social and cultural spheres of modern existence. Globalization is often conceptualized as increasing economic integration, which results in and is further fueled by ever-increasing cross- border flows of money, goods and services, information, people and culture (Held et al. 1999), and the accompanying expansion and intensification of cross-border and large- scale networks (Tilly 1995). Mainstream perspectives on globalization that focus on what Susanne Soederberg (2006) called “the harmony of difference” tend to optimistically portray the new global governance as converging towards cosmopolitan democracy (Held and McGrew 2003; Held 2006), ‘flattening out’ (Friedman 2005), or evolving into a borderless world (Ohmae 2005). These perspectives share a teleological orientation and view globalization processes as essentially progressive, irreversible, and encouraging integration and breaking down of borders to an unprecedented degree. For instance, in his bestselling book, Thomas Friedman (2005) introduces a metaphor of the ‘flat world’ – a vision of the world that has become a level playing field for commerce and competition. Among the ‘flatteners,’ Friedman cites world-historic events like the collapse of the Berlin Wall, technological advances in communication that made internet widely accessible to the public and enabled widespread online collaboration, innovations like workflow software