These institutional and discursive changes in the environment are refected in the IOs' organizational discourses. All three IOs have embraced inclusive growth, along with elements of the ILO's decent work discourse. All three have come to recognize the importance of women's unequal share of unpaid domestic work. At the same time, each translates these into terms that modify its pre-existing organizational discourse.

The crisis provided an opening for the ILO to get other IOs to recognize that informality and precarious work were making it more diffcult for families to earn suffcient incomes. Prior to the crisis, the ILO had also begun to elaborate an additional strategy—a global social protection foor6—to address this. More specifcally, the foor meant national commitments to address important family needs: essential health care, including maternity care, that meets the criteria of availability, accessibility, acceptability and quality; basic income security for all children, including

6For a detailed analysis of the development and dissemination of this idea, see Deacon (2013).

access to nutrition, education, care and any other necessary goods and services; income security for active age adults unable to earn adequate incomes due to maternity, illness, unemployment or disability; and basic income security for older persons. If implemented, the foors would help families currently excluded from social insurance schemes by informality or precarity to provide for their needs across the life cycle.

Elsewhere I have described the broader changes to the OECD's dominant organizational discourse (Mahon 2019). A key change was the adoption of the New Approaches to Economic Challenges (NAEC), which posed a direct challenge to the orthodox ideas of the hitherto dominant Economic Department. NAEC's inclusive growth can be seen as enhancing the centrality of DELSA's organizational discourse within the OECD as a whole, as social investment remains central to the NAEC's conception: "a reorientation away from a risk-only approach to welfare provision, towards a life-long enabling platform that furnishes individuals with capacity enhancing assets in the form of human and social capital, good health and active support in labour markets…that builds on strong foundations for learning and adaptation for life and through life" (OECD 2017a, 5).

This does not mean that the OECD failed to incorporate new ideas into its organizational discourse. Inequality has received considerable attention since the publication of *Growing Unequal*, and this concern has been institutionalized through the creation of the OECD's Centre for Equality and Opportunity. At the same time, the latter's work refects the OECD's continued commitment to the adult earner family. For instance, *Under Pressure: The Squeezed Middle Class* (2018a) reiterates the lessons learned through *Babies and Bosses.* It calls for measures to promote women's fulltime employment, noting that in contrast to dual-income families, one and a half earner families make up a growing share of lower-middle-income families.

The OECD's conception of the gender-equal family now includes recognition of women's unpaid labor. The OECD has also taken on elements of the ILO's decent work agenda, most notably through its renewed Jobs Strategy, *Good Jobs for All in a Changing World of Work* (2018b). This shift is also refected in its ongoing studies of child policy (OECD 2015, 2016). While continuing to stress encouraging parental employment (preferably full-time) through the provision of appropriate supports (paid leave, quality childcare), measures to support "the creation of stable, high quality jobs that are both suffcient and accessible to the lower-skilled parents" have been added onto this (Thévenon and Manfredi 2018, 11). In other words, it is not suffcient to enable adult family members to work; they also need to be able to fnd and secure good jobs.

While the family discourse that built on the Babies and Bosses foundation focused on families with children, the OECD has come to recognize that eldercare is also an important issue that families, especially women, have to deal with. Here again, socio-economic and gender inequality are of concern. Thus, the background documents prepared for its high-level conference on policies for equal aging noted that countries with higher levels of social protection for long-term care had lower rates of informal care and thus less gender inequality (2018c). The main message, however, remained the importance of supporting the adult earner family: "While many countries need to improve long-term care supports and continue pension reforms to make retirement income systems fnancially and socially sustainable, policy efforts to limit old-age inequalities cannot rely only on measures targeted to older people. It is more effcient to address socioeconomic inequalities when they arise rather than remedy their consequences, including gender inequalities, which tend to widen with old age" (OECD 2018c, 6).7

The changing environment was also refected in the Bank's discourse and the Bank, in turn, contributed to those changes. The Growth Commission (2006–2008) played a role both in the adoption—and the wider dissemination—of inclusive growth. The Commission's report differed, however, in important ways from the way the Bank came to translate inclusive growth. For instance, while the adoption of inclusive growth meant for the Bank the addition of 'shared prosperity' defned as improving the incomes of the bottom 40 percent, the Commission had also proposed dealing with those at the top by sharing the wealth through the tax system (Commission 2008, 62). Although both versions emphasized investment in human capital, the Commission noted that such investment would not bear fruit without complementary development of the demand for quality labor (Commission 2008, 37).

More specifcally, the Bank's conception of inclusive growth continued the earlier focus on investment in human capital, with a particular emphasis on the early years. One whole chapter of *The Changing Nature of Work* focuses on lifelong learning, in which early child development is assigned a foundational role: "The most effective way to acquire the skills demanded by the changing nature of work is to start early. Early investment in

7 See also Preventing Ageing Unequally (2017).

nutrition, health, social protection, and education lay strong foundations for the future acquisition of cognitive and socio-behavioral skills. They also make future skills acquisition more resilient to uncertainty. Early childhood investments are an important way to improve equality of opportunity" (World Bank 2019, 73). Early child development programs continue to be given pride of place in the report's 'new social contract'.

Like the OECD, the Bank has had to deal with the issue of demand for labor. Its 2013 World Development Report, *Jobs*, discussed the ILO's concept of "decent work" (World Bank 2013, 15–17). However, while it agreed that those in the informal sector needed a voice, it did not see collective bargaining as the way to achieve this and cautioned against too stringent labor market regulations. Its later report, *The World of Work,* however, nods in the direction of the ILO's social protection foor where it appears under the rubric of 'progressive universalism' (2019, 106). Progressive universalism would involve extending coverage to all in the form of a basic level of social assistance, to be complemented by basic social insurance covering 'contingencies' like maternity. A somewhat more generous social insurance system would be mandated for formal sector workers, supplemented by a 'nudged' or third-tier voluntary system.

Women also feature as more than just mothers and girls in the Bank's inclusive growth discourse. The Bank's 2012 World Development Report, *Gender Equality and Development*, portrayed investment in gender equality as 'smart economics'. The Bank's 2016–2023 Gender strategy, *Gender Equality, Poverty Reduction and Inclusive Growth*, reiterated the 2012 report's arguments for investing in women and girls as smart development policy: "increased women's labor force participation and earnings are associated with reducing poverty and faster growth; income, employment and assets empower women, which benefts men, children and society as a whole" (World Bank 2016, 12). Now programs like center-based childcare are presented as a 'double win', helping increase girls and women's engagement in education and productive activities while promoting early development and lifelong learning for young children (World Bank 2016, 38). Women's unequal share of unpaid domestic work is also recognized and warrants redistribution by including men and boys and through the provision of care services, including eldercare. The 2019 World Development Report recognizes that women's informal caregiving interferes with their engagement in the labor market and goes on to note that "Effective social care entails reimagining a role for the state in reducing involuntary unemployment by providing services in several areas. These include childcare, disability and old-age care, psychological support for the long-term unemployed, support for social kitchens, and rehabilitation…" (World Bank 2019, 126).

This raises the broader question of the 'care economy', a concept which the ILO and UN Women have helped to put on the agenda. As Ilkkaracan notes, the care economy "entails the production and consumption of goods and services necessary for the physical, social, mental and emotional well-being of care-dependent groups, such as children, the elderly, the ill and people with disabilities, as well as healthy, prime working age adults" (2018, 8). UNRISD's pioneering study, the Political and Social Economy of Care (2006–09), can be credited for going beyond the 'care crisis' in the North to show that care is also an issue for the South. Much of that care continues to be carried out in the home as unpaid labor by family members or the low-paid labor of domestic workers. Its conclusions presaged the 3Rs, arguing for (1) recognition and guaranteed rights of caregivers and receivers; (2) distribution of the costs more evenly across society; (3) the support of professional, decently paid and compassionate forms of care (UNRISD 2016). Investing in the development of quality care services provided by workers who receive fair wages can offer both direct supports to families and generate a substantial number of new 'decent' jobs if, as the ILO argues, the high road to the care economy is taken. To this the ILO would add voice (or representation) for care workers, care recipients and unpaid caregivers (ILO 2018, xliii). Moreover, as the ILO report, *Care Work and Care Jobs for the Future of Decent Work*, notes, such jobs are not likely to be replaced by robots given the relational nature of care work (ILO 2018, xxvii). In other words, the care economy holds the potential for generating decent work while providing families with the supports they need.

In the *WDR 2019* report, the Bank seems to recognize this potential, but in other documents, it is clearly looking to the market to create these jobs. Thus, its gender strategy notes, "Governments can establish supportive business practices to foster the development of care services and intervene to encourage greater involvement of fathers in childcare and men in care for sick and elderly dependents. The private sector can invest in care services for better business outcomes and promote approaches that help workers of both sexes balance their work and family responsibilities" (2016, 44). Through the International Finance Corporation, the Bank has developed the 'business case' for such employer-supported childcare (IFC 2017).

The very labor-intensive character of much of care work, however, means that it is diffcult to combine private, for-proft provision with decent work and decent care. The 'gold standard' is most closely approximated in the Nordic countries, where such services are typically both publicly fnanced and publicly provided (Esping-Andersen 1999). To be sure, not all states currently possess the capacity to provide quality care with decent working conditions nor are they likely to do so in the near future. Nevertheless "if NGOs, social enterprises or businesses are to act as the primary institutional framework for social provisioning, the infrastructure still needs to be fnanced by the state" (Ilkkaracan 2018, 38). To this might be added the need for "fscal space which would mean abandoning austerity-oriented macro-economic policies and investing in human capabilities while relieving women of unpaid work in the family and generating (decent) employment" (UN Women 2019, chapter 5).

#### Conclusions

This chapter has traced shifts in global social policy discourses directed at families, from the ILO's post-war conventions that supported the development of social security for the male breadwinner family through to the current family as it appears in the inclusive growth and care economy discourses. The original split in the global family policy environment refected the post-war division between the North and the South. The crises of the Keynesian-welfare and developmental state forms opened the way for neoliberalism. Although neoliberalism may have become dominant, it was challenged and subject to change. The OECD developed a concept of social policy focused on investing in the adult earner family. In response to UNICEF's arguments and inspired by US research on policies to help poor families, the World Bank, in turn, rediscovered poverty and investment in human capital, especially that of the child, as a solution in the 1990s.

The ILO and UNRISD began to challenge these two variants of social investment as the new millennium dawned. The ILO's concept of decent work highlighted an important lacuna: investment in developing human capital requires an environment favorable to the creation of good jobs, yet labor and commodity market deregulation were generating the opposite. The ILO's idea of a global social protection foor addressed another aspect of the same phenomenon—the growth of non-standard and informal economy jobs excluded a growing number of families from traditional social protections. In the meantime, feminists were pushing for the recognition of women's unpaid domestic labor. At the same time, research within the key IOs was beginning to document the growth of inequality within as well as between countries. The food crisis of 2007 and the fnancial crisis of 2008 opened the way for these ideas to be incorporated in the discourses of the OECD and the World Bank and to do so in ways that blurred the old North-South division. The seeds of a conception of a care economy, an idea that calls for a more radical rethinking of how to support families, were planted by UNRISD and the ILO and UN Women have become its champions

There are a few important issues that this chapter has not been able to deal with. First, while the nuclear, adult earner family may be the new norm, it is by no means the only form. In some parts of the world, the extended family remains important (UN Women 2019, chapter 2). This is important to bear in mind, especially given the increase in transnational families and the transnational care chains to which these have given rise, as mothers and/or fathers migrate to secure family livelihoods, leaving children in the care of others, often other family members. IOs like the OECD, the World Bank and the International Organization for Migration (IOM) have grasped aspects of these care chains, albeit in a fragmented manner (Mahon, 2020). With its focus on decent work and the care economy, the ILO has done better and UN Women's (2019) most recent report devotes a whole chapter to families on the move. The chapter has also neglected the heteronormative assumptions that often lie at the heart of global family policy discourses. In this context, it is worth noting the 2018 OECD Ministerial Policy Statement, Social Policy for Shared Prosperity, which recognized "the continued challenges faced by historically disadvantaged groups in our countries, including racial and ethnic minorities; indigenous communities; migrants, refugees, and other displaced persons; lesbian, gay, bisexual, transgender, and intersex (LGBTI) people; older persons; and people with disabilities" (OECD 2018d, 3).

A second set of issues has to deal with the resources needed to realize the promises of 'inclusive growth' and the care economy. Clearly, this involves challenging the austerity policies adopted by many countries, often with the support of the IMF and the World Bank. It would also involve dealing with the issue of tax avoidance, especially by large corporations like Amazon and Google as well as the very wealthy. In this respect, the OECD/G20 Multilateral Convention to Implement Tax Treaty Related Measures to Prevent Base Erosion and Proft Sharing (BEPS), which has garnered offcial support from over 125 countries, is potentially important.8

#### References

International Financial Corporation/World Bank Group. 2017. *Tackling Child Care: The Business Case for Employer Supported Child Care.* Washington: International Financial Corporation/World Bank Group.

Jenson, Jane. 1986. "Gender and Reproduction or Babies and the State". *Studies in Political Economy* 20 (9): 9–46.

8 http://www.oecd.org/tax/treaties/multilateral-convention-to-implement-tax-treatyrelated-measures-to-prevent-beps.htm. Accessed February 25, 2020.

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# Disability as a 'New' Global Social Theme: The Role of International Organizations in an Expanding Global Policy Field

*Johannes Schuster and Nina Kolleck*

#### Introduction

Disability as a global social policy issue has gained increasing importance during recent decades. Largely responsible for this development has been a shift in the general conceptualization of disability—from a medical perspective that views disability as a person's limitations to the perception of disability as limitations imposed by society. After many years of struggle for recognition, the adoption in 2006 of the Convention on the Rights of Persons with Disabilities (CRPD) by the United Nations (UN) represented a seminal step in establishing disability as a human rights issue. Due to this new acknowledgment of disability as a global social policy issue, a

J. Schuster (\*) • N. Kolleck

Institute of Political Science, Leipzig University, Leipzig, Germany e-mail<EMAIL_ADDRESS><EMAIL_ADDRESS>
© The Author(s) 2021 207

K. Martens et al. (eds.), *International Organizations in Global Social Governance*, Global Dynamics of Social Policy, https://doi.org/10.1007/978-3-030-65439-9\_9

global organizational feld1 with a variety of different international actors has emerged around the topic, with strong involvement by International Organizations (IOs).

Today, global policy is no longer made by nation states alone but includes a heterogeneous set of different public and private stakeholders, such as IOs and non-governmental organizations (NGOs) (Jakobi 2009). The concept of global governance underlines the infuence of non-state actors in the interplay with state actors in relation to a specifc policy (Rosenau 1995; Zürn 2018). Moreover, the diverse actors of an organizational feld are interdependent, which means that they build networks to form alliances and disseminate information in order to strengthen their positions (Adam and Kriesi 2007). IOs often have a particular mandate that allows them to act in a frame predefned by their member states. However, public administration scholars have agreed that IOs and their administrations exert additional political infuence by shaping discourses and setting agendas for specifc topics (Barnett and Finnemore 1999; Bauer et al. 2017). This means that the traditional principal-agent model with leading nation states as *principals* creating international regimes as their *agents* that work on predefned problems—is outdated in some felds of social policy, making it particularly interesting to investigate the role of IOs.

An investigation of the population of IOs in a specifc social policy feld needs to consider two approaches: the organizational environment and the intrinsic features (Abbott et al. 2016). Whereas the organizational environment encompasses the general characteristics of a policy feld (i.e., the beliefs and norms) as well as the involved actors and their relationships (i.e., the social networks), the intrinsic features relate to the inherent characteristics of organizations (such as membership rules and thematic orientation) and the way these defne an organization's scope of action (Niemann et al. in this volume). As there is still only limited knowledge about the population of IOs in disability policy, the aim of this chapter is to introduce disability as a global social policy theme and to identify important actors, with a particular focus on IOs.2 First, we give an overview

1We refer to the concept of *organizational feld* as 'the aggregate of actors' of a policy feld, which further includes the rules and belief systems, as well as the relational networks that arise in the broader societal context (see Niemann et al. in this volume).

2Most studies on the topic of global disability policy and the CRPD, which will also be discussed in this chapter, either focus on the historical development or describe the content and *status quo* of the CRPD (e.g., Della Fina et al. 2017; Arnardóttir and Quinn 2009; of the policy feld and its development from a global perspective and present the main IOs in terms of their involvement in disability policy. In order to approach a mapping of the organizational feld of global disability policy, we identify the most central actors and their connections based on Twitter data. We then present the main topics discussed in the feld, followed by a short conclusion of the chapter.

## Background of (Global) Disability Policy Discourse and Involvement of IOs

In general, disability policy is a comparably novel topic of social policy. Before the twentieth century, persons with disabilities were mostly hidden from society, and it took governments until the end of the Second World War to explicitly address the needs and rights of disabled persons through policies. According to Drake (1999, 36–41), domestic disability policies can be evaluated along a spectrum from policymaking that denies disability rights, to an approach that seeks to identify individual disadvantages in order to provide necessary services for adjustment, to a social approach where disabled people are accorded the rights to participate in society as equal citizens. For a better understanding of disability in both national and global context, two main concepts can be distinguished: the medical model3 and the social model of disability (Kayess and French 2008; Harpur 2012). In this section, the two models are explained and related to IOs, thereby partly describing the intrinsic features of these IOs. Subsequently, an additional model—the economic model—is presented and the role of regional organizations is briefy discussed.

#### *The Medical Model and WHO*

The medical model of disability conceives of disability as "a personal tragedy" and focuses on the "affiction caused by the particular condition or impairment and the provision of cure, treatment, care and protection to change the person so that they may be assimilated to the social norm" (Kayess and French 2008, 5). Thus, in this model the limitations are

Kayess and French 2008) and disability policy (e.g., Barnes and Mercer 2004; Oliver 1996), but lack more detailed information about actors and processes in global disability governance.

3Other scholars, such as Oliver (1996) or Priestley (1998), refer to the medical model as the "individual model", but describe the same concept.

caused by the impairment itself, neglecting the role of the social environment and the barriers it builds. In social policymaking, this conception has led to disability policies that categorized persons with disabilities according to their disadvantages and that urged them to adjust according to their unique and individual needs, for example, the Chronically Sick and Disabled Person's Act (1970) and the Disability Discrimination Act (1995) in the UK (Priestley 2000) or the Rehabilitation Act (1973) in the USA (Barnes 2011). This model enhanced welfare policies to support the disabled individuals in their adjustment, such as accommodating them in separate houses or providing fnancial support and care (Priestley 2000). Inherent in such an approach is an increased expenditure on health care and research (Jeon and Haider-Markel 2001). These attempts created a whole new professional system of welfare that aimed to rehabilitate persons with disabilities. This, in turn, exempted persons with disabilities from (labor-related) duties and established and institutionalized a climate of societal segregation (Drake 1999).

The one IO that is closely intertwined with the medical model is the World Health Organization (WHO). In order to establish universal defnitions for different forms of disability and impairment, WHO published the *International Classifcation of Impairments, Disabilities, and Handicaps* (ICIDH) in 1980. The document was divided into three categories, impairments, disabilities, and handicaps, with concise defnitions for each (WHO 1980, 27–29). The classifcation system was used for the assignment and provision of services and benefts. This focus of WHO on the medical model lasted until the beginning of the twenty-frst century. The organization then replaced the ICIDH with its *International Classifcation of Functioning Disability and Health* (ICF) and thereby adopted—at least to some extent—the social model (Barnes 2011). Other activities of WHO include the community-based rehabilitation guidelines—published in close cooperation with other inter-governmental and non-governmental actors (e.g., the International Labour Organization (ILO), UNESCO, or the International Disability and Development Consortium (IDDC)) which mainly cover the provision of medical support (Lang et al. 2011), or the World Report on Disability, published together with the World Bank, which provides a comprehensive outline of the *status quo* around persons with disabilities and provides suggestions for all sorts of different stakeholders (WHO 2011).

#### *The Social Model and the UN*

In contrast to the individual model, the social model of disability states that "contingent social conditions rather than inherent biological limitations constrain individuals' abilities and create a disability category" (Stein 2007, 85). This concept—which was promoted by a growing disability rights movement that started to emerge in the 1960s, particularly in the US and the UK—shifts the focus from the impairment itself to the society as the cause of barriers (Kayess and French 2008). The movement was substantially led by the British disability rights network known as the Union of Physically Impaired Against Segregation, which rejected more mainstream ideas in order to enforce the acknowledgment of the social model (Shakespeare 2010). This sociopolitical or rights-based approach to disability policymaking implied that the adjustment of the physical environments of disabled persons to their needs was what was necessary, rather than a "medical repair" of the concerned persons themselves (Jeon and Haider-Markel 2001, 216).

In tracing the development of the disability rights movement and thus the emergence and acceptance of the social model, we can see that they are closely interlinked with the UN (Degener and Begg 2017; Stein 2007). The frst non-binding declarations, such as the Declaration on the Rights of Mentally Retarded Persons in 1971 and the Declaration on the Rights of Disabled Persons in 1975, still tended to emphasize individuals' medical needs. In contrast, by declaring the year 1981 the offcial International Year of Disabled Persons—which was succeeded by the International Decade of Disabled Persons (from 1983 to 1992)—the UN gave particular attention to the rights and interests of persons with disabilities (Stein 2007). A seminal step was then made with the adoption of the Standard Rules on the Equalization of Opportunities for Persons with Disabilities in 1993, which although only "soft law and legally unenforceable" (Stein 2007, 89) nevertheless represented an initial UN instrument that exhorted member states "to ensure the equalization of opportunities for disabled persons" (Stein 2007, 89). Until today, the Standard Rules are conceived as a leading watershed in the development of global disability rights. Finally, at the beginning of the new millennium, disability rights successively became a human rights issue worthy of their own convention, having been promoted by individual states (such as Mexico and New Zealand) as well as scientifc studies which looked at the neglect of disabled persons in the core human rights conventions beyond the medical perspective. The convention itself was discussed and drafted by an Ad Hoc Committee which was established in December 2001 and included signifcant involvement by civil society organizations. After a process of eight sessions, the fnal document was adopted in December 2006 and came into force in May 2007 (Degener and Begg 2017).

Today, the UN is the driving force in global disability policy. The implementation of the Convention is monitored by the Committee on the Rights of Persons with Disabilities, which is located at the Offce of the High Commissioner for Human Rights in Geneva. Signatories are obliged to submit reports on the progress of the implementation of the CRPD every four years. The Committee then evaluates the reports and returns general observations, including recommendations for further implementation. Moreover, the main tasks of the Committee comprise the preparation of General Comments on specifc issues of the Convention as well as the examination of individual complaints (Uerpmann-Wittzack 2018). It should be noted that as well as the Committee's other tasks, the development of the reports is exercised in close consultation with different nonstate actors, foremost disabled persons' organizations (DPOs).

Besides the Committee and its administration, the main focal point of the CRPD and disability rights at the UN is the CRPD secretariat, which is located at the UN headquarters in New York. The secretariat falls within the Division for Inclusive Social Development (DISD) of the UN Department of Economic and Social Affairs (UNDESA). The secretariat is established to promote the international normative framework on disability, to support other inter-governmental bodies concerning disability rights issues and to service the annual Conference of States Parties (COSP) (UN Enable 2020). The COSP represents—for human rights treaties in particular—an innovative mandate and provides a forum for constant exchange and discussion between member states, IOs, and civil society organizations (de Búrca et al. 2013).

However, the promotion of disability rights in the UN is not limited to the main bodies, but also brings together other UN divisions and specialized agencies, such as the UN Educational, Scientifc and Cultural Organization (UNESCO), the UN Children's Fund (UNICEF), and the World Bank. UNESCO is an offcial supporter of the CRPD and has adopted an action plan including "research and evidence-based data collection, development of policies and strategies on inclusion of persons with disabilities, building an enabling environment and raising awareness, development of appropriate tools for instruction and capacity building" (UNESCO 2020). In doing so, UNESCO places a strong emphasis on the promotion of inclusive information and communication technologies (ICTs), as can be seen from the publication of model policies for inclusive ICTs to support UNESCO member states in the implementation of specifc issues concerning disability policy (Watkins 2014). Whereas the focus of UNESCO is linked strongly to the CRPD, UNICEF's concern with disability rights has been an integral part of their work since the Convention on the Rights of the Child (CRC) (see also Holzscheiter in this volume). Predominantly focusing on the rights of children with disabilities as "one of the most marginalized and excluded groups in society" (UNICEF 2020), UNICEF follows three disability goals. First, it commits itself to being "an inclusive organization for all" (UNICEF 2020), stating that the organizational staff includes an adequate number of persons with disabilities, but also undertakes efforts to raise awareness on disability issues. Second, it aims to "develop leadership on the rights of children with disabilities and build capacity among [its] staff and [its] partners" (UNICEF 2020). This means engaging in collaborative relationships with other UN stakeholders as well as actors from civil society, academia, or the private sector. The third goal is to "mainstream disability across all of our policies and programs, both in development and humanitarian action" (UNICEF 2020). UNICEF mostly implements programs in different countries, predominantly in the Global South, in order to support them in the implementation of the CRPD.

As one of the leading IOs in the global social policy feld, the World Bank is also considering disability. Its goal is to "integrate disability into development through its analytical work, data and good-practice policies" and to include disability-related issues in its operations (World Bank 2020). Besides the *World Report on Disability* (WHO 2011) that has been published together with WHO to give a comprehensive image of the global *status quo* in disability policy, the World Bank has a focus on the inclusion of disability and disabled persons in its own work. As mentioned in its *Disability Inclusion and Accountability Framework*, the guiding principles in the World Bank's disability-inclusive work are based on the CRPD and encompass nondiscrimination and equality, accessibility, inclusion and participation, as well as partnership and collaboration (McClain-Nhlapo et al. 2018). This suggests a rights-based perspective of the organization that is in slight contrast to its previous collaboration on this issue with WHO.

#### *The Economic Model*

A third dimension of disability policy that can be found in the literature has emerged in close relation to the shift from the medical to the social model and, therefore, has implications for the understanding and setup of the global disability policy feld: an economic defnition. From this perspective, disability is understood as a "health-related inability or a person's functional limitations on the amount or kind of work that disabled people can perform", with associated calls for policy solutions to remove these barriers (Jeon and Haider-Markel 2001, 216). Consequently, disability policymaking is supposed to aim at an inclusion of persons with disability into the labor market in order to have them contribute to the economic success of a country. Moving toward the establishment of such inclusive environments—even if most of them have not yet been implemented successfully—implies a shift from a welfare system for disabled people to a 'workfare' system (Peck 2001). The underlying assumption of this approach is that citizens who beneft from the welfare system need to contribute by participating in the labor market—a system of conditionality that is increasingly implemented by Western welfare states (Geiger 2017; Soldatic and Chapman 2010). The IO that exerts a particular infuence on the development of such a model is the Organisation for Economic Co-operation and Development (OECD). In a collection of country reports from 2003, the OECD discusses opportunities to integrate disabled people into society in general as well as ways to secure their income by building inclusive structures in the labor market (OECD 2003). Another series of books published between 2007 and 2010 called *Sickness, Disability and Work: Breaking the Barriers* also examined different country case studies according to the inclusiveness of their employment structure for persons with disabilities (OECD 2010). A similar agenda is set by the ILO, which has continuously extended its instruments in regard to the rights of persons with disabilities. The ILO adopted a frst recommendation concerning Vocational Rehabilitation of the Disabled (R099) in 1955 in order to "meet the employment needs of the individual disabled person and to use manpower resources to the best advantage" (ILO 1955). The recommendation was then renewed in 1983 (R168) and led to the technical Vocational Rehabilitation and Employment (Disabled Persons) Convention (C159), which entered into force in 1985.

#### *Regional Organizations*

The global disability policy feld not only consists of IOs but also of regional organizations. As the frst-ever supranational organization to sign an international human rights treaty, namely the CRPD, the European Union (EU) has a disability strategy that addresses eight priority areas: accessibility, participation, equality, employment, education and training, social protection, health, and external action (European Commission 2010). One main objective of the EU is the collection of comprehensive information and data on the implementation status of the CRPD in its member states. For instance, it has launched the European Agency for Special Needs and Inclusive Education, an independent organization that provides information about the schooling of persons with special needs in the member states. Even broader thematically is the Academic Network of European Disability Experts, which offers a database summarizing the implementation status of the Convention in regard to the most important topics, such as accessibility, education, or employment.

There is signifcant variation in the ways in which other regional IOs address disability rights. Two examples stand out because of their explicit strategies and policies. The African Union introduced two African Decades of Disabled Persons (2000–2009 and 2010–2019), which led to the recent adoption in January 2018 of an additional Protocol to the African Charter on Human and People's Rights on the Rights of Persons with Disabilities. The main purpose of the Protocol is "to promote, protect and ensure the full and equal enjoyment of all human and people's rights by all persons with disabilities, and to ensure respect for their inherent dignity" (African Union 2018, 5). Similarly, the Association of Southeast Asian Nations (ASEAN) adopted the Enabling Masterplan 2025 in November 2018 to mainstream the rights of persons with disabilities. This is conceived as an additional framework in support of the implementation of the CRPD in ASEAN member states (ASEAN 2018).

# Mapping the Global Disability Policy Field Based on Twitter Data

As we have already shown in this chapter, the population of IOs in the feld of disability policy is diverse and contains many different organizations. Besides these international and supranational actors, the global disability policy sphere also comprises a variety of NGOs, mostly DPOs, that are engaged in the advocacy of disability rights. During the disability rights movements in the late twentieth century, these organizations played a crucial role in achieving self-advocacy, using international advocacy networks to share ideas and information (Priestley 2007). Moreover, in the context of the CRPD, DPOs have had an infuential role since the drafting process, with signifcant involvement in the meetings of the Ad Hoc Committee (Degener and Begg 2017; Stein and Lord 2009). The close interaction between the member states of the Convention with stakeholders from civil society is also explicitly mentioned in Article 32 (United Nations 2006) and is further considered in the monitoring process of the Committee. Moreover, despite the differences in disability concepts and policies, the UN endeavors to establish programs that combine forces for the promotion of disability rights outside and inside the organization. For instance, the Inter-Agency Support Group for the CRPD was established in 2006 in order to integrate disability into the UN system, and the UN Partnership on the Rights of Persons with Disabilities brings together different stakeholders—including the ILO, UNESCO, or WHO as well as civil society organizations, such as the International Disability Alliance or the IDDC—to advance disability rights on a global scale.

Consequently, it can be assumed that IOs and DPOs use means of soft governance—that is, institutional and discursive resources—to diffuse and implement the standards set in the CRPD (see Niemann et al. in this volume). We argue that in order to do so, they build networks to collectively shape discourses around disability rights. This makes an analysis of such networks a promising approach to better understand the global disability policy feld. However, mapping global networks that comprise a diverse set of global actors is challenging (Dicken et al. 2001). In order to address this challenge and to acknowledge the increasing relevance of new ICTs for the exchange of information, we draw on Twitter data.

The social media platform Twitter is used for real-time information and discussion and has gained increasing importance in politics over recent years (Weller 2014). Different political actors contribute to the platform to promote their ideas, for mobilization or organization (Dubois and Gaffney 2014; Guo and Saxton 2014; Conover et al. 2012). Users can participate in issue-specifc discussions by adding a so-called hashtag ('#') to a word (e.g., #crpd or #disability). Moreover, users can interact with other users by mentioning them (i.e., placing the @-symbol in front of a username so that the user in question receives a notifcation), replying to them (a mention at the beginning of a tweet), or retweeting them (republishing another user's tweet). By collecting tweets on a specifc topic and extracting the interactions made in these tweets, issue-specifc Twitter networks can be mapped.

For the present analysis, we obtained Twitter data that were published during the COSPs to the CRPD in the years 2013 to 2017. To identify references to the CRPD and to disability policy, we fltered for specifc hashtags such as #crpd, #cosp, or #disability. In total, we identifed 44,545 tweets, which led to an overall network consisting of 16,712 accounts (socalled nodes) and 38,737 interactions (edges). We used techniques of social network analysis (SNA) to map the network and the relations between the different actors and to identify central actors (Borgatti et al. 2013). SNA is particularly suited to exploring the 'hidden infuence' that actors exert in a given organizational feld because it shifts the unit of analysis from individual attributes of actors to their embeddedness in social relations (Jörgens et al. 2016; Kolleck et al. 2017).

In order to present an overall impression of the network, Fig. 9.1 shows the network with labels for the 20 most central actors according to eigenvector centrality. This measure represents the centrality of a node in relation to the centrality of the nodes it is directly connected to. It can therefore be seen as an indicator of an actor's popularity in a network (Borgatti et al. 2013). The size of the labels is proportional to the eigenvector centrality value. The fgure indicates that the most central nodes belong to the UN, namely the offcial UN account, the UN entity for the empowerment of women, the account of the secretariat of the CRPD (UN Enable) and UNICEF. Other UN accounts that appear among the top 20 are directly linked to the division and department to which the CRPD is assigned (i.e., the Division for Social Policy and Development (DSPD)4 in the UNDESA) or represent the offcial Special Rapporteur on the rights of persons with disabilities. In addition, the International Disability Alliance and the Ecuadorian president, Lenín Moreno, show high centrality values. Other central actors are mostly NGOs and DPOs or their representatives, such as the IDDC, Lumos, the European Disability Forum (EDF), or Catherine Naughton (EDF Director). The clustering of these nodes in the network suggests that they are closely interconnected. Aside from that, the lack of other IOs in this list is quite remarkable, even though for the most part they are not explicitly concerned with disability

4Today, the DSPD is part of the DISD.

#### 218 J. SCHUSTER AND N. KOLLECK

**Fig. 9.1** The overall twitter network of the COSPs 2013–2017

rights (see Section "Background of (Global) Disability Policy Discourse and Involvement of IOs").

Figure 9.2 provides a reduced network containing only the interactions between IO-related accounts. In this network, the size of the nodes represents the eigenvector centrality. As could be observed in the overall network, the most central nodes in the IO-IO interaction network belong to the aforementioned UN agencies. According to the graph, one particularly prominent organization is the UN International Telecommunication Union (ITU), a specialized agency that is established to facilitate global

**Fig. 9.2** Twitter network of the most central IOs during the COSPs 2013–2017

connectivity. This is not surprising given that the organization is concerned with ICTs and the analyzed data were created using ICTs. Hence, it can be assumed that the ITU has a particular interest in appearing prominently in online social media. Rather remarkable is the position of WHO and the OECD. Though among the most infuential actors in global disability policy, they seem to be excluded from the Twitter network. However, the extent to which this is due to an actual lack of interaction with other relevant actors or rather a general reluctance to engage in social media activity cannot be ascertained from this data.

When looking at the IO-NGO interactions (see Fig. 9.3), we fnd similar results to the overall network. Aside from UN accounts directly related to disability rights, the DPOs hold the most central positions in the network (in regard to both the centrality value and the actual position). Overall, it can be observed from this analysis of Twitter data that both IOs and NGOs use Twitter to exchange information. The most central actors in the network are UN agencies directly related to disability policy as well as DPOs. This suggests that those actors with an explicit agenda for disability policy use the available channels—including online platforms—to promote disability rights, whereas the topic is less important to others. However, it must frst be noted that the data was collected in the context of a UN event, making it more likely for UN actors to participate, and second, that social media platforms are still used to different extents by offcial political actors. For this reason, inferences from these results must be made with caution.

**Fig. 9.3** Twitter network of central IOs and NGOs

#### Main Topics in Global Disability Policy

The presentation of IOs in the feld has already shown that disability is often discussed in conjunction with other forms of discrimination and can hardly be discussed separately from other social and development policy issues. Hence, in the context of disability rights, a specifc focus is placed on other marginalized groups who need more immediate consideration when they also have a form of disability. Most commonly, children (or youth) and women (and girls) with disabilities are discussed—often in combination—in the global disability discourse as groups prone to multiple marginalization. First of all, women with disabilities (Article 6) and children with disabilities (Article 7) are addressed with specifc articles in the Convention. Moreover, a closer look at the thematic setup of the COSPs to the CRPD shows that the specifc consideration of children and youth (main theme 2012, sub-themes 2014 and 2015) as well as women and girls (main theme 2012, sub-themes 2015 and 2018) is important in discussions about the implementation of the Convention. Also, the General Comment No. 3 by the CPRD Committee pays particular attention to women and children, stating that they "face barriers in most areas of life" (United Nations 2016a, 1). According to the UN, the main dangers for women and children with disabilities are poverty, lack of health care, the general degree of social inclusion and participation, and lack of employment and equal education (United Nations 2014; United Nations 2016a). However, it must also be noted that children and women with disabilities in the Global North face different challenges to those in the Global South and that the focus of politicians and advocates can differ in light of this. Being at the intersection of several forms of marginalization and discrimination, the topic of children and women with disabilities is dealt with in close cooperation between the respective units of the CRPD, the CRC and the Convention on the Elimination of All Forms of Discrimination Against Women (Watson 2012; Kayess et al. 2014; see also Holzscheiter in this volume).

One of the most controversially discussed topics during the meetings of the Ad Hoc Committee to the CRPD was that of education (Biermann and Powell 2014; de Beco 2018). The main argument involved the position on whether the Convention text should exclusively demand inclusive education or whether schooling in separated special schools or classes should still be maintained as an option. Although member states are asked in the fnal version in Article 24 to "ensure an inclusive education system at all levels" (United Nations 2006, 16), the schooling of persons with disabilities still differs widely across the world. The CRPD Committee has emphasized the importance of education as a disability rights issue by publishing the General Comment No. 4 on inclusive education (United Nations 2016b). At the same time, WHO's ICF is still used to justify special education systems. From a medicalized perspective, the classifcation can be useful for the allocation of resources (Schiemer 2017). As is the case for children and women with disabilities, education for persons with disabilities on a broader, more global level also needs to address different issues depending on the region. In countries of the Global North such as Germany, the main argument is between supporters of a traditional segregation system with special schools and proponents of a comprehensive, inclusive system. In contrast, countries in the Global South (e.g., Nigeria) are still struggling to provide any sort of education for disabled children (Biermann 2016). Hence, DPOs emphasize the importance of assuring general access of persons with disabilities to the education system, frst and foremost, though they also support the inclusive approach.

In an increasingly digitalized world, another crucial topic for disability policy is technology. As different scholars point out, the provision of assistive and accessible technology is mandatory for the inclusion of people with disabilities in policymaking processes. For instance, Trevisan and Cogburn (2019) emphasize that offcial UN conferences lack accessibility and thereby exclude disability rights advocates from participation. Only the COSPs to the CRPD meet the needs of disabled persons, making it diffcult to represent persons with disabilities in events that do not explicitly address disability policy. Moreover, Alper and Raharinirina (2006) have shown through their systematic review that assistive technologies for individuals are also still rare. This topic is also taken into account by different IOs in the context of disability policy. Just recently, "technology, digitalization and ICTs for the empowerment and inclusion of persons with disabilities" was announced as a sub-theme for the CRPD COSP 2019, making technology a sub-theme at the conference for the third time (after 2012 and 2016). A UN specialized agency that directly addresses the intersection of ICTs and disability—and that appeared prominently in the CRPD Twitter network—is the ITU. In order to meet the needs of persons with disabilities in using ICTs, as is required by Article 9 of the CRPD, the ITU provides policymakers with reports and guidelines as well as trainings and capacity-building programs. This material is published to enable member states of the ITU to make their ICTs accessible. Discussing accessible and assistive technology in the context of global disability policy is particularly interesting as it represents the part of the feld that is most proftable for private business actors. Hence, new partnerships between public (inter-)governmental actors, civil society and businesses are already forming at the global level and can infuence future disability policymaking (Goggin and Newell 2007; Stienstra et al. 2007).

#### Conclusion

The main objective of this chapter was to examine disability as a 'new' global social policy theme. Both the development of global disability policy and the involvement of different IOs in that organizational feld were examined. In order to approach a mapping of the global disability policy network and to identify particularly central actors as well as their interactions, social network analysis was used to map the Twitter network surrounding the UN CRPD. Finally, the main discourses of the feld were identifed.

The development of disability policy, both at national and global levels, was mainly infuenced by a shift from the general conceptualization of disability as a negative condition of individuals that needed to be reacted to with care and welfare in order to assimilate them to the social norm (the medical model), toward a perception of disability as barriers and limitations imposed by society that disabled persons have to face (the social model). The two main IOs in the feld—the UN agencies assigned to the CRPD on the one hand and WHO on the other—stand divided by this discourse. While the UN tends to promote the right of persons with disabilities to a society and environment without barriers, WHO tends to maintain the medicalization of disability. However, since the adoption of the CRPD, the UN has undoubtedly been the dominant actor, driven by its monitoring system that obliges its member states to regularly disclose their disability policy. As Búrca, Keohane, and Sabel (2013) note, this rather new mode of governance can best be described as 'experimentalist governance' (see also Sabel and Zeitlin 2010). Experimentalist governance is characterized by "a set of practices involving open participation by a variety of entities (public or private), lack of formal hierarchy within governance arrangements, and extensive deliberation throughout the process of decision making and implementation" (de Búrca et al. 2013, 16). In an iterative process, it is left to the member states of an international treaty to establish ways of incorporating the goals of the treaty into their domestic policy framework and, in return, their performance is regularly assessed by IO bodies. This iterative process can create a dynamic of peer pressure that often leads to a continuous strengthening of policy targets accompanied by a gradually evolving institutionalization and formalization of the procedural rules.

This structure offers diverse opportunities for IOs to engage in global disability policy. However, as the Convention is still rather new, there is currently not much research on the involvement and especially the interplay of different actors, such as the UN and WHO. To date, only the important role played by civil society organizations and their robust relationship with the UN bodies have been emphasized by different authors (Lord and Stein 2008; Degener and Begg 2017; de Búrca et al. 2013). Our empirical mapping of the CRPD Twitter network also suggests that the CRPD-related accounts are well connected to other UN agencies and to crucial civil society actors, while WHO is rather excluded from these discursive networking activities (see also Schuster et al. 2019). It will be interesting to see how the organizational feld around global disability policy will develop in the future and what role WHO will play. Moreover, the increasing focus on persons with disabilities as 'human capital'—with the OECD as a driving force behind an economic model—has the potential to steer global disability policies toward the creation of workfare states. In theory, this is in line with the social model and the focus on the right to inclusion. Consequently, critics of the social model state that a mere focus on the social barriers neglects the bodily impairments, and that this in turn can deny the necessity of medicalization (Thomas 2004). Hence, scholars have recently made attempts to synthesize the medical and the social model in order to take into account "the complete background of an individual's life and living", including environmental and personal factors (Barnes 2011, 66). Adding the economic model, future disability policy both at global and national levels—will have to be made within this area of tension between the different conceptualizations, thereby leaving space for IOs to exert their infuence.

#### References

Abbott, Kenneth W., Jessica F. Green, and Robert O. Keohane. 2016. "Organizational Ecology and Institutional Change in Global Governance." *International Organization* 70 (2): 247–277. doi:https://doi.org/10.1017/ S0020818315000338.

**Open Access** This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/ by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence and indicate if changes were made.

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# Health and Environment

# Characterizing Global Health Governance by International Organizations: Is There an Ante- and Post-COVID-19 Architecture?

# *Alexandra Kaasch*

#### Introduction

Health is commonly considered as one of the most fundamental, but also highly challenging needs in individual and societal life. As a policy feld, it extends and connects to an incredibly broad and complex set of issues such as different notions of well-being, different types of illnesses (e.g. infectious and non-infectious), different groups of people, the various functions and elements of public and private health care systems and diverse service providers. Part of these issues extend beyond national spheres of social problems or policymaking—most clearly communicable diseases do not stop at national borders. Furthermore, migration leads to national systems of social and health protection being confronted with constantly new categories of people as well as new health challenges; health care professionals, pharmaceutical companies and other providers

A. Kaasch (\*)

Faculty of Sociology, Bielefeld University, Bielefeld, Germany e-mail<EMAIL_ADDRESS>
© The Author(s) 2021 233

K. Martens et al. (eds.), *International Organizations in Global Social Governance*, Global Dynamics of Social Policy, https://doi.org/10.1007/978-3-030-65439-9\_10

have long crossed national borders in their provision of health care, medical goods and insurance plans.

This has led to some conceptual tension, as health care systems (here understood as institutions of social protection responsible for the provision and fnancing of health care) are established and organized as distinctly national (or sub-national) institutions. Nevertheless, at transnational policy levels there is signifcant activity on various health care systemrelated issues which entails the emergence and involvement of a high number of global policy actors. Better yet, there is a clear trend toward an increasing number of global actors, as for example Youde (2015, 130) puts it "the global health governance architecture has become far more encompassing and wide-ranging in recent years".

The focus of this chapter is on global actors (*population*) of and ideas (*arguments*) on health care systems, for the purpose of producing a characterization of the current global health governance architecture in the feld. This frst requires an illustration of global health governance in general so as to understand its specifc actor set. The positions and constellation of key International Organizations (IOs) are then illustrated by a mapping of four central IOs: the World Health Organization (WHO), the World Bank, the International Labor Organization (ILO) and the Organisation for Economic Co-operation and Development (OECD). The main ideas of these four IOs regarding health care systems are presented in relation to each other and by taking into account their discourses. This is then taken further to characterize the global health governance architecture based on contestational and collaborative relationships between these IOs. While fnalizing this chapter, the world has come under threat from a massive global health crisis. Thus, in an additional paragraph, this chapter also discusses the preliminary implications of the Corona Virus Disease 2019 (COVID-19) pandemic for altering that architecture. The concluding section refects upon the implications of the ante- and emerging post-COVID-19 situation for global social governance in the feld of health care systems.

# Global Health Governance

The population of IOs in the feld of health is subject to a very large body of literature under the frame of global health governance. For the purpose of this book on global *social* governance, I combine such approaches with those of the global social policy and governance literature.

Global social governance has generally been defned as being comprised of a huge number of different actors. Often, the relationship between these actors has been characterized by competing organizations, some of which claim to be the key and central actors in the game (particularly, Deacon 2007; Kaasch and Martens 2015; Kaasch and Stubbs 2014; Yeates 2008). Apart from other activities, these actors provide social policy prescriptions for different social policy felds, including for health care systems (Kaasch 2015). This involves various activities such as the collection, presentation and interpretation of relevant data, the development of concepts and the prescription of 'appropriate' social policy measures and instruments to meet social problems. IOs present these 'products' as information, recommendations, ideal models, reform suggestions and the like. In the academic literature, these activities by IOs and their outputs have been conceptualized and studied as ideas, discourses or knowledge production (see, e.g. Béland and Orenstein 2013; Stone and Maxwell 2005).

Concerning the population of IOs, global health governance literature draws a picture of a plurality of different sorts of actors. These include public and private actors, collective and individual ones, as well as various sorts of actor networks. Given their nature—that of being set up by governments, granted with mandates and tasks, and intensely observed and covered by worldwide political and media actors—IOs have a very important position and role.

In explaining the emergence of global policies in the feld of health, some characterizations portray global health governance as a response to global health challenges, an expression of international cooperation, and as such a necessity, given current global (health) problems. Part of the argument is that the nature of global health problems and the limitations of national health care systems lead to global health governance (e.g. Fidler 2010; Smith and Lee 2017). Even though the transnational character of these problems may be more than obvious to the researcher, the political reality is that there is no consequential referral of competency to transnational policy levels. As we can see with reactions to the global threat of COVID-19, the measures and responses are strongly national. Therefore, the political and legal realities contradict explanations of the nature of the problem shaping or causing global social and health governance architectures: policymaking competence in the health care system is at national policy levels with very few and minor exceptions.

Another part of the literature characterizes global health governance more qualitatively and often combines this with normative claims on the desired nature of global health governance. This does not contradict other assessments which describe global health governance as the concerted efforts to privatize health services and global health activities, accompanied by "indirect efforts by the same actors that present bona fde social justice and equity-oriented public health approaches" (Birn et al. 2016, 753). For sure, health markets are an important part of the global economy in many ways, and the 'concern' for public health is also strongly shared at a global level, which is refected in the globally constituted communities raising their voices in the name of social justice in health. The notion of 'the global' informing this chapter, however, is the interest and concern of global actors as regards issues of (national) health care systems. This approach does not assume a legal competence in regulating health care systems from transnational policy levels; neither does it assume a relevance of global actors in terms of the nature of contemporary health issues. What it does is observe and study global actors with a (direct or indirect) mandate to 'speak' on health care systems. This implies an analysis of mandates, ideas and inter-actor relationships (for more detail on this approach, see Kaasch 2015; Kaasch and Martens 2015).

For the purpose of this book, this chapter focuses on only one type of actor, namely IOs. IOs have been founded with broad and general aims, usually directed at either a policy feld or a group of (vulnerable) people. As part of such mandates, they intervene within, but also beyond specifc policy felds and react to changing conditions as well as varying and emerging problems and crises. Furthermore, they do not conduct their work in isolation from each other. Inter-actor relationships are dynamic, susceptible to shifts, and are part of what causes changing settings in global health governance (Kaasch and Martens 2015; Fidler 2010; Cooper and Farooq 2015). Furthermore, as Ng and Prah Ruger (2011, 17) argue, such relationships are often characterized by "insuffcient coordination, the pursuit of national and organizational self-interest, inadequate participation by the recipients and targets of aid, and sheer lack of resources". There is also another "concept" used to refer to global health governance: chaotic pluralism (Van Belle et al. 2018, 1). This is where the individual global health actors, including IOs, often appear in a contradictory light and are portrayed as not living up to their responsibilities for various reasons. The contradictory image in the approach used for this chapter, however, is focusing on the secretariats or headquarters of IOs and their ideas on health care systems only. While the concrete ideas developed and communicated may refect national perspectives or experiences, these are usually not systematically interest-driven as to any IO staff member's national background (another issue would be analyses driven by providers of extrabudgetary funding, but the level of analysis and type of documents studied is assumed to be at a level where this is not a strong factor).

The meaning of IOs in the context of this chapter is, therefore, focused on what they express and recommend (*arguments*) with regard to the specifc issue of health care systems. On the one hand, such ideas are being shaped by organizational mandates generating some sort of path dependence. On the other hand, they are also being adjusted and they change in reaction to a number of contextual and historical factors. Ideas might change as concepts of a social or health problem become broader or more diversifed; there might be new actor alliances that let shared terminologies and concepts emerge; better or altered problem descriptions might generate a need for new or adjusted solutions; or there might be strategic reasons (such as more and competing actors in the feld) that might lead to new or different approaches by a single IO. In that sense, the population in terms of number and inter-actor relationships of global actors in the feld of health care systems has an important impact on the architecture of arguments.

#### Mapping IOs in Global Health Governance

Global health governance is characterized by a multiplicity of actors. These actors may be very different in their composition, size, mechanisms or power. Most visible are international organizations (WHO and the World Bank in particular), philanthropic organizations (particularly the Bill and Melinda Gates Foundation), hybrid organizations (particularly the Global Fund to Fight Aids, Tuberculosis and Malaria) and non-governmental organizations (most well-known are perhaps the International Red Cross, Doctors Without Borders and the Cooperative for American Remittances to Europe (CARE)).

Looking at IOs more specifcally, the answer as to which organizations matter and how many populate the feld critically depends on the specifc health feld or issue looked at. Focusing on health care systems, WHO is in the center considering its mandate and role within the United Nations (UN) system. The World Bank is critical, given its power to provide funding for research and projects on health care systems. However, there is more than that: on the one hand, there are other IOs focused on specifc health issues such as the Joint United Nations Program on HIV/AIDS (UNAIDS). On the other hand—and this will be the focus of this chapter there are other more generally social policy-related IOs that include health care systems as an important component in social protection in their work. These are the ILO and the OECD (see also Kaasch 2015).

In the following sections I describe the roles of WHO, the World Bank, the ILO and the OECD in matters of health care systems in more detail, as well as how they collaborate, compete or—more generally—relate to each other.

#### *World Health Organization: Key Mandate, Encompassing Ideas but Multiply Contested Position*

In terms of its mandate and position within the UN system, WHO is the frst and central IO to look at when it comes to global health policies. It is the UN's health agency and by mandate concerned with all kinds of health policies at various levels. This certainly holds true for medical information and where health care systems (as institutions of social protection) are concerned, though neither its mandate nor its actual role are straightforward or uncontested.

More specifcally, WHO's constitution provides the IO with both a norm-setting and coordinative function in the feld of health care systems. In terms of 'policy content' or ideas, the general aim is the "attainment by all people of the highest possible level of health", stipulated in the WHO constitution, which has been specifed into a mandate to assist governments in strengthening their health services (Constitution of WHO, article 2c; see WHO (2020a)). Nevertheless, due to WHO's multi-faceted mandate, the resulting role and position have been changing over time because of fnancial and organizational constraints as well as a changing global architecture. Over the decades, WHO has defned itself as the "health conscience" (World Health Assembly (WHA) 1973) in the 1970s, the "health advocate" (WHO 1998) in the 1990s and the "directing and coordinating authority in international health works" (WHO 2006) in the 2000s. Since the 2010s, there is a tendency to supply broad descriptions of a set of WHO roles. Furthermore, the fact that WHO is not alone and uncontested in the feld, but part of a broader global governance scenarios is much more refected: "WHO is joint lead agency with the ILO in the United Nations initiative to help countries develop a comprehensive Social Protection Floor" (WHO 2010). In its latest (13th) General Program of Work, WHO shows itself as an actor providing public goods, a science- and evidence-based organization setting global norms and standards, an advocate for health as a human right, an organization networking "to build a community to work for the shared future of humankind" (WHO 2019, 3) and an institution to monitor global health developments. It is also active in developing plans together with national governments for better health care systems and for the realization of universal health coverage (UHC). Beyond that, at the global (horizontal) level, WHO assumes a role in "raising global awareness of UHC" (WHO 2019, 19; see also Cook et al. 2020).

Operationalizing its health care system mandate, WHO structures its strategic priorities around three main areas, namely universal health coverage, health emergencies and health promotion (WHO 2019). More specifcally, the concepts under which health care systems have been dealt with have seen a certain dynamic and changes over time, even though most of them did not fully replace each other and have also seen times of 'revival'. Among them are primary health care and health for all (in the 1970s), health care systems strengthening, social determinants of health, UHC and social health protection (as part of the social protection foor initiative and collaboration in the 2010s). Furthermore, the Sustainable Development Goals (and to a lesser extent the prior Millennium Development Goals) have provided a framework within which health care systems have been approached.

Currently, WHO mostly defnes its ideas and strategies on health care systems specifcally in relation to the Sustainable Development Goals (SDGs), particularly in connection to the aim of achieving UHC. This is also combined with the social protection foor framework and initiative that increasingly turned into a UN initiative, including meetings on a regular basis, and which was particularly driven by WHO jointly with the ILO and the World Bank. The core idea being that essential health care should be one of four basic social security guarantees.

In sum, the arguments brought in by WHO have importantly—even if under different headings and buzzwords—centered around what is now called UHC. It stands for the aim of universal access to primary health care, to fnancial risk protection, to people-centered health care systems and to comprehensiveness in service provision and access. This ideational account can be regarded as a somewhat cohesive and coherent approach, promoted with the justifcation of a normative and coordinative mandate of the IO. WHO's position as a global actor more generally, but also the quality of its health care system assessments and recommendations, has been questioned and criticized frequently, however, which limits the IO's power to live up to its tasks (e.g. Youde 2018; Kaasch 2015). The following sections will show how and by whom WHO got challenged in the position of the lead agency in global health governance in the feld of health care systems.

#### *World Bank: Derived Mandate, Changing Ideas and Multiple Powerful Positions*

The World Bank has been founded with a completely different idea from WHO. It is a fnancial institution with funding means, more independent but also linked to the UN system, and it does not have a health mandate in the frst place. However, over the years, it has increasingly considered the health sector as a feld to engage with in aiming to fght poverty (which is part of its mandate according to the Articles of Agreement of the International Bank for Reconstruction and Development (IBRD) and the International Development Association (IDA)). Thus, the World Bank has also evolved into a massive knowledge actor in the feld of health care systems.

The World Bank's engagement in health developed from the 1980s onward in particular. That meant, on the one hand, that the IO increased its interest and activities in the health sector. But, on the other hand, it also led to a more encompassing and thorough understanding and concept of what the meaning and content of health care systems is. Over time, this brought the World Bank away from earlier and pretty much standard economic arguments thrown on the health sector (which were often not really appropriate either, such as the promotion of user fees, or most basic health care) to much more elaborate and comprehensive concepts of health care systems which appreciate the functions of UHC and their meaning as systems of social protection necessary for developmental success. Still, the main focus is on those health care system-related issues and needs that are particularly critical for low- and middle-income countries, as those are the World Bank's main 'clients'.

Apart from developing a health mandate out of poverty reduction, the World Bank has continuously justifed its role in the feld through specifc strategies for the health sector that have become increasingly comprehensive and specifc in terms of its understanding of and role in health care systems. Through these strategies, the World Bank manifests a very broad and very competent role in engaging with national health policymakers, the implementation of projects, and facilitating knowledge exchange. It uses the illustration of comparative advantages to justify its role, such as expertise in health fnancing, governance, accountability in health service delivery and the like.

Despite a certain degree of contradiction between WHO and World Bank approaches and their claims on necessary action in health care systems, recent years have been remarkably characterized by collaboration between the two (and other) IOs, particularly in the area of UHC and social protection foors. Therefore, the 'struggle on positions' (Deacon 2007; Kaasch 2015) has been sidelined by more or less strategic collaboration and increasingly shared frameworks of reference. UHC is now the key concept used to explain and develop the World Bank's health strategy, as it is said to respond to the World Bank's twin goals (ending extreme poverty and increasing equality and shared prosperity) and is linked to the Sustainable Development Goals as well as other collaborative global health initiatives.

Nevertheless, what provides the World Bank with a clear comparative advantage is the number of staff they have, and that they possess the means to run different sorts of activities and projects related to health care systems. Within its headquarters, there are many health system experts, particularly in its Human Development Network Section on Health, Nutrition and Population, but also in its social protection unit and other units that have an overlap with health care system-related issues. In this way, the World Bank has developed into a key source for policy evidence and policy advice in this social policy feld.

In terms of health care systems support (in the positive sense) or the impact on national health care systems (in a critical sense), the World Bank is certainly much more powerful than WHO, particularly when it concerns low- and middle-income countries, and to some extent also when calling for actions in and through health care systems in crisis response situations. Regarding the shaping of key ideas or arguments, however, WHO's concepts have proven more appealing and are now also refected in many World Bank utterances and guide many World Bank initiatives.

#### *International Labor Organization: Questioned Mandate, Coherent Ideas and Limited Position*

Founded a hundred years ago, the ILO is the UN agency mandated with the promotion of social justice and human and labor rights. As a tripartite organization, it shows quite a different structure compared to WHO and other IOs within the UN system, but in its secretariat (the International Labour Offce), a number of staff also work on health care systems as part of the ILO's social protection framework. In terms of justifying its mandate, the ILO's engagement in social protection and health is, similarly to the World Bank, related to fghting poverty, addressing income security and as such improving access to health services.

However, the ILO's initial concerns were predominantly on the specifc needs of *workers* and that has also informed their initial take on health care issues. That has played out in a twofold way: health issues connected to the workplace and health as dimension of social security related to the lives of workers. Accordingly, and as we can see in the World Labor Report 2000 (International Labour Offce 2000), there are adverse effects of health problems on earning capacity, and there is fnancial risk connected to the inability to work due to health problems. In the meantime (and also in a broader than health care system sense), however, the ILO has adjusted its take on these issues in recognition of the fact that many people work in the informal sector. For example, Scheil-Adlung made this explicit by explaining that "to be meaningful, legal health coverage needs to result in effective access for all residents of a country" (Scheil-Adlung 2014, 6).

This broader perspective on residents, rather than workers, had important implications for how the ILO could position itself as a general global health actor, at least as far as health means social health protection, and in doing so it can be seen as giving voice to health care systems as well. Nowadays, the ILO even relates to the UHC aim and related agendas: it has diagnosed that insuffcient funding is the main problem for providing essential health care, which then increases the risk of fnancial hardship (ILO 2019, vii).

The potential power of the ILO is different to both WHO and the World Bank in the sense that the ILO possesses a function in facilitating international law as a result of its tripartite assembly, which includes the Secretariat (Deacon 2013). Beyond that, the ILO has had a strong role in coordinating (partly with WHO and the World Bank) the Social Protection Floor initiative. In terms of providing specifc ideas, what can be found is only derived from a very small number of staff members able to engage the issue (Kaasch 2015, 67).

Overall, even if the ILO is not considered in most of the global health literature, an account of global social governance in the feld of health care systems must not leave this organization out of the picture. It is the organization providing the frame through which to view health (care systems) as an element of social protection. In this way, the ILO contributes a logic different to the more medical or technical perspectives, but also to perspectives of the most basic provision of health care necessary to lift people out of poverty. Instead, it leans toward being an integral part of a system making societies more equal and improving health in a socially sustainable way. Nevertheless, its potential of positioning itself as a strong global actor in the feld of health care systems is limited, and does not go much beyond one feld within its coherent concept of social protection.

#### *Organisation for Economic Co-operation and Development: Derived Mandate, Expanding Idea and Growing Position*

Much like the ILO, the OECD is not typically considered to be a global health actor in its own right (particularly not in global health governance literature). However, global social policy and governance literature have increasingly focused on this IO (e.g. Mahon 2019; Deeming and Smyth 2019). In the past few years, there has been a signifcant expansion in the OECD's health work, so that my own account from 2015 describing the OECD's involvement in health policies as only just evolving and dependent on "an explicit demand from its member states for specifc activities and engagement in health policies" (Kaasch 2015) now appears to be somewhat outdated.

Originally, the OECD's health work grew out of its statistical work in the second half of the 1970s. Beginning in the 1980s, health has been dealt with as part of the social policy work of the OECD, but still mostly in terms of statistical work. Then, with the 2000s, the OECD's work became more analytical, also in a qualitative sense, particularly in the context of the OECD Health Project (2001–2004). Over the past decades, the OECD's role in health seems to have become the most integral part of its engagement, and no longer accompanied by much of an explicit legitimizing reasoning.

This is the case even in a twofold sense: for its own member states, the OECD has taken on an important role in assessing and comparing their health care systems. In this way, it challenges the competence of WHO in the feld of health care systems. What started with a small number of very careful, country-specifc health care system assessments on demand (Kaasch 2010) has developed into an encompassing role in supporting OECD member states understanding and enhancing their health care systems to become more people-centered. This has provided the basis for the development of new assessment methods, tools and guidance by this IO on health care systems. At the same time, the OECD is increasingly part of the global health (development) community, engaging in development agendas in the feld of health, including the attainment of the SDGs and realizing the UHC agenda (OECD 2017b).

In the past, OECD health work was clearly characterized by dealing with health, on the one hand, as a social service and, on the other hand, as an economic factor. These perspectives have got increasingly balanced over time. Health care systems, according to OECD work, should provide accessible health care (for all citizens), respect equality and equity, provide high-quality health care, be mindful of economic effciency, and also provide for redistribution and income protection (e.g. OECD 2004). Similarly to the other IOs discussed here, the OECD now fully subscribes to the UHC agenda, justifying that by stating that its work could show that "UHC contributes to promoting more inclusive growth; improves health outcomes; and is affordable" (OECD 2017a).

The OECD fulflls its health mandate by providing its highly acknowledged data and expertise, while at the same time joining in collaborative endeavors with WHO, the ILO, the World Bank and others. This mix of approaches makes it an increasingly powerful global voice on health care systems and provides the OECD with a position as a legitimate and credible actor in the feld.

# Characterizing Global Health Governance by Its Architecture or Arguments

Looking at the feld of health care systems in terms of global social governance, we can identify several decades of discourse with an increasing number of major IOs engaging. While it is possible to follow certain traditions and the development and change of concepts, we particularly see the relationships and formation of global actors, specifcally IOs, in processes of alteration. Therefore, the architecture of global social policy in this feld is now signifcantly different from those of the past decades. The centrality of WHO might still be the same (both in terms of its key mandate and in terms of how and why it is challenged and questioned), however, the increasing number of IOs in the feld, each coming with specifc characteristics and resources of power, has challenged this position on a repetitive and increasingly complex basis. At the same time, regarding the content of ideas and character of discourses, we see an increasingly shared, but also broad set of concepts, principles and aims for health care systems among many of those actors. This is in some contrast to characterizations up until the early 2000s when the emphasis was more on different epistemic communities and practices in health care systems.

More concretely, if we trace back the global health history of the past by at least 50 years or so, the Alma-Ata Declaration of the 1970s may be seen as a starting point and point of reference for emerging global health ideas and discourses—though merely for WHO and associated global actors. An important tension of the time was the different interpretations of key concepts between WHO and the United Nations Children's Fund (UNICEF), the latter leaning more toward the World Bank's basic safety net ideas of the time (see, e.g. Koivusalo and Ollila 1997). These frameworks, namely 'primary health care' (PHC) and 'health care for all' (HFA), were introduced at that time and have guided WHO work ever since. In the 1990s, global ideas and discourses on health care systems were increasingly also developed by and within the World Bank. These ideas were connected to its engagement both in the transformation states in Central and Eastern Europe (Kaasch 2015) and in emerging economies such as Indonesia sidelining their economic development with expanding health care systems.

The ILO, in the meantime, has developed a somewhat independent but minor account of health care systems as part of their social protection work. It has, however, gained increasing importance in the context of increasingly collaborative activities in the 2000s (the social protection foor initiative). At the same time, and partly due to shortcomings of WHO, the OECD continuously expanded its health work in terms of ideas and engagement in the feld.

It was partly in the context of the reaction to the global economic and fnancial crises that the IOs discussed in this chapter also provided prescriptions for how to address the crisis through social policy measures. These contributions came rather quickly from 2008 onward and particularly warned not to repeat any cutbacks in health and other social services as had happened in the 1990s in many crisis-affected countries. Given the nature of that crisis though, the initial focus was much more on 'jobs' than on other systems of social protection. Both WHO and the OECD, however, recommended counter-cyclical public spending and stressed the role of health care systems as well as their function as automatic stabilizers (Kaasch 2014).

In sum, the inter-IO discourse has considerably changed through the developments described in the previous sections, and so has the architecture of governance in the feld: previously distinct agendas and activities are increasingly shared and merged, even though to some extent different 'languages' are being used, strongly oppositional epistemic communities cannot be identifed. The UHC agenda and the Social Protection Inter-Agency Collaboration Board (SPIAC-B) are the current settings within which all IOs discussed locate their ideational accounts. Accordingly, global social governance as the architecture of arguments on health care systems can be summarized as having developed into increasingly broad concepts and shared principles among the key IOs working in the feld.

## Global Health Governance in the COVID-19 Context

While fnalizing this chapter, the COVID-19 outbreak has not only paralyzed national and global societies and generated massive political reactions and measures, but even IOs in the feld of health have been on demand and have had to adjust their activities to this new, dramatic situation. In this section, I illustrate their 'reactions' (in terms of their comments on health care systems in the COVID-19 context) and discuss the question of whether or not there is an ante- and post-Corona architecture emerging in global social governance in the feld of health care systems.

Unsurprisingly and in continuity with what has been illustrated in this chapter, WHO appeared as the central, frst, and most signifcant actor from the very beginning—although this was more in terms of its role as the health agency responsible for alerting everyone to the fact that a pandemic disease was spreading, as well as its work on the medical side of things. In terms of its mandate on health care systems, WHO delivered by providing some ideas and guidelines as well. These have been linked to its common framework on health care systems (strengthening) and UHC, the critical points being well-fnanced health care systems following the principles of risk-sharing and UHC. The concept referred to and used here is 'public fnancial management'. In a related document, Barroy et al. (2020) clarify that the COVID-19 response requires suffcient public funding and recommend a turn away from private toward public funding modes. Funding, so the authors claim, needs to be made available and stocked up; furthermore, there is the need for balance between fexibility and accountability. Kutzin (2020) further argues that countries do not need to make a choice between health security and UHC, but rather that the two are dependent on each other. Accordingly, "investing in core health care system-functions is key to both, completed by public policy actions beyond the health care system". In more concrete, technical guiding notes though, WHO's focus appears to be slightly different. Rather than drawing on the broader social protection network, WHO appears to be collaborating with UNICEF, specifcally on ideas regarding health care systems and COVID-19. This also implies placing focus back on Primary Health Care (PHC) and the community level, albeit considered within national multilevel systems. The focus is on select essential services and prevention (WHO and UNICEF 2020). In another document, WHO highlights how, as a consequence of high numbers of COVID-19 cases, the need to limit and consciously direct resources may arise. This is in some inexplicit contrast to more comprehensive social protection recommendations on health care systems; here, WHO is more situated in the older tradition and turns to postponing and suspending routine and elective services, to targeted immediate action, and at reorganization measures (for the recommendations see, e.g. WHO 2020b).

In terms of the World Bank, thus far it has not published a comprehensive piece on COVID-19 and health care systems in particular, but instead on social protection more generally in relation to the SPIAC-B (Social Protection Interagency Cooperation Board) (2020). However, it has fnancially supported a number of countries in strengthening their health care systems in the current situation and issued a factsheet on that. According to that factsheet, about \$160 billion will be provided for assisting countries (World Bank 2020). In some contrast to the above, however, the International Finance Cooperation (part of the World Bank Group) is a strong component in this support, as there is belief in the private sector being critical to mastering and overcoming the crisis.

At the same time, some more concrete recommendations come from frst short publications on related issues, namely a brief that highlights the necessity of infection prevention as well as control policies and campaigns to draw attention to necessary hygiene measures (Bedoya and Dolinger 2020); and Gillson and Muramatsu (2020) who recommend allowing cross-border movement of health personnel and goods, and exploration of tele-medicine. Thus, overall, more comprehensive and focused health care system ideas have not yet been established and distributed. That is certainly more due to the complexity of the matter, as well as the urgency and depth of the COVID-19 crisis, than to dismissal of the World Bank from the critical role of health care systems in responding to global pandemic disease outbreaks.

The ILO's COVID-19 contributions thus far reveal its typical focus on the world of work, in that it re-emphasizes the need for social protection systems—including foors—to prevent and meet crisis situations, and stresses that emergency crisis responses should ideally be executed with a longer-term perspective in mind. This would include guaranteed access to good health care by means of additional public funds (both for emergency response, safeguarding and extending coverage) (ILO 2020c). Furthermore, and more specifcally related to its social protection mandate, the ILO has focused on the meaning and role of sickness benefts as part of social health protection systems. This is not particularly an issue of the health care system, but the question of income security in the case of illness for the prevention of impoverishment (ILO 2020b). There are more specifc ideas on entitlements to social sickness protection for this specifc COVID-19 outbreak situation. The ILO paper argues that there is a risk of further disease spread if unprotected people continue working while contagious, and that there is a high risk of impoverishment if they are not covered by health insurance. This results in recommendations to extend coverage to all by mobilizing additional fnancial resources, expanding the scope of sickness benefts (e.g. in cases of quarantine or care obligations), increasing beneft levels and removing any waiting periods or other constraints to speedy delivery of sickness benefts (ILO 2020a).

As for the OECD, their work does address health care systems quite specifcally, though with a common and typical focus on collecting and analyzing data as well as illustrating the variations in the frst place. Their work shows how there are four key measures to respond to the COVID-19 pandemic from the side of health care systems: ensuring access, improving health care system capacity to manage caseload increases, digital solutions and data for care and surveillance, as well as improving research and development for improved diagnostics, treatments and vaccines (OECD 2020). In this case, however, the OECD report also draws rather clear conclusions and recommendations from the data:

The current crisis demonstrates the importance of universal health coverage as a key element for the resilience of health care systems. High levels of out-of-pocket payments may deter people from seeking early diagnosis and treatment, and thus contribute to acceleration in the rate of transmission. However, even in health care systems that have already achieved universal coverage, an epidemic caused by newly discovered pathogens requires an early response to clarify coverage for new diagnostic tests and treatments that were not previously included in the health beneft package. (OECD 2020, 6)

In a forum contribution, Francesca Colombo, Head of the OECD Health Division, additionally highlights the need for health care systems to be adaptable to health crises like this COVID-19 outbreak (Colombo 2020).

Thus, these accounts provide some picture of 'back to the roots' in global health governance as a COVID-19 response. At the point of writing this chapter, each of the organizations is re-focused on original mandates and defning foci of attention within that, rather than on all speaking on the same matter. Nevertheless, joint and collaborative work has also been happening, despite little of it being prominently placed on websites or elsewhere, and this does provide some evidence of continuity at the same time. In terms of the content of policy advice, it is somewhere between scaling up for meeting new health needs and focusing specifcally on COVID-19 at the expense of some non-urgent health services.

#### Conclusion

This chapter aimed at characterizing global social governance in the feld of health care systems. It focused on IOs and illustrated their key ideas, as well as their relationships with each other. Given the specifc timing of writing this chapter, the more general account of global health governance has since extended beyond, and to some extent contrasted with, the frst moves related to the 2020 COVID-19 crisis.

The important characteristics of global health governance as dealt with in this chapter are not to do with the global nature of social or health issues as such. Instead, the interest has been in global activities and on the subject of national competencies: the ideas of health care systems. IOs have been studied as knowledge and norm providers, not as potential regulators with legal power. So, what do these characterizations mean for the architecture of global social governance in the feld of health? Due to the high number of actors, the complexities of their relationships and a frustrating degree of failing multilateralism and global solidarity when it concerns addressing global health issues, some would claim "there is 'no architecture of global health'" (Garrett 2007, 246). Others would put the World Bank and WHO in the center and others loosely around, or in concentric circles of actors (Ng and Prah Ruger 2011, 2–3). The picture gets clearer though when more carefully defning the specifc meaning and focus of a health issue (though in the case of this chapter, it's still a very broad one).

The population of IOs in this feld has been characterized as multiactored, even when it concerns the selection of the most important global actors. The presentation and discussion of WHO, the World Bank, the ILO and the OECD have revealed that the ongoing relationships have been increasingly marked by collaboration. However, the architecture of arguments is also shaped by a certain duplication of work, which demands a constant effort to justify such a role (with reference to, but also clearly beyond, original mandates) (see also, Kaasch 2015). While in the 1970s–1990s the relationships were characterized more by competition and only short spots of collaboration on a non-stable basis, from the 2000s onward it has become much more common to join forces under specifc global initiatives (particularly the UHC agenda and the social protection foor initiative). Global crises have also marked interruptions in the activities of IOs, but while following the global economic and fnancial crisis we saw a quick and rather concerted reaction, whereas the 'initial reactions' to the current COVID-19 crisis hint at more IO-mandate oriented, individual approaches on ideas regarding health care systems.

#### References

Mahon, Rianne. 2019. "Broadening the Social Investment Agenda: The OECD, the World Bank and Inclusive Growth." *Global Social Policy* 19 (1–2): 121–138.

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# IOs and Climate Change: Toward Global Eco-Social Policy

#### *Silvana Lakeman*

#### Introduction

The introduction to this book stated that International Organizations (IOs) "provide forums for exchange, guide and supervise international treaties, which states sign and adhere to," as well as "direct, fnance and implement projects which affect people's lives" (see Niemann et al. in this volume). This is undoubtedly the case for the plethora of IOs engaging with climate change as a cross-cutting concern. Although climate change has perhaps only taken off as a clear global problem in the last 50 years (and social policy framings of the issue even later), it is evident that we now live in an age where "self-suffciency in social policy is no longer a realistic option" (George and Wilding 2002, 187).

Environmental changes and social policies are linked in several ways. On the one hand, climate change is a cause of social risk for individuals with specifc vulnerabilities (health, social and others), and for populations

S. Lakeman (\*)

Bremen International Graduate School of Social Science (BIGSSS), University of Bremen, Bremen, Germany e-mail<EMAIL_ADDRESS>
© The Author(s) 2021 255

K. Martens et al. (eds.), *International Organizations in Global Social Governance*, Global Dynamics of Social Policy, https://doi.org/10.1007/978-3-030-65439-9\_11

based in regions already affected by the more damaging consequences of climate change (such as rising sea levels or desertifcation). On the other hand, the typical measures and policies undertaken to tackle social and environmental problems are to a signifcant degree contradictory to one another; while social policy advancements are usually linked to economic development and growth, protecting the environment is better achieved by zero or even degrowth (Buch-Hansen and Koch 2019; Koch 2020). Furthermore, in the discussion of social policy and climate change, challenges converge in relation to social inequality and injustice. Questions abound regarding who is responsible for climate change and associated inequalities, especially as those countries and people causing the problem are typically the least affected. At the same time, global solidarity with respect to compensation for social problems related to climate change is of concern. This chapter discusses the role of international organizations in shaping global social policies in the feld of climate change, also known as eco-social policies more broadly, and studies IOs in their function as forums for exchange and potential facilitators of international treaties, as laid out in the introduction to this volume.

This chapter proceeds in three steps. It frst briefy highlights the temporal shift in discourse on climate change and the subsequent expansion of IOs engaging with the issue as a global social policy concern. For a long time, climate change was conceptualized in a narrow manner; however, in the twenty-frst century context it is understood as an underlying issue for global social policy writ large, especially as it relates to the global concept of sustainable development. As outlined in a second section, this has led to a wide variety of IOs from various policy felds engaging with climate change as a determinant of social well-being and as an issue to be addressed through social policies, with rapid historical developments in this area challenging the traditional roles and mandates of IOs. To illustrate this point, a third section explores the position of IOs in relation to climate insurance as a global social policy tool. This chapter argues that IOs occupy an important space as conveners and for exerting infuence—particularly 'soft' governance—when it comes to social policy dimensions of climate change, even if many IOs are not yet explicitly framing their work in such terms. A shift in global discourse on climate change—which has both given rise to the creation of IOs and been directly infuenced by IO behavior—is illustrative of this point.

#### Shifting Discourse and Expanding IO Engagement

In the feld of climate change, there are numerous IOs exerting soft governance, opening spaces for discussion, and dealing with the issue as a cross-cutting concern for social policy. Certain IOs have clearly demarcated authority on climate change, such as the United Nations Framework Convention on Climate Change (UNFCCC) and the Intergovernmental Panel on Climate Change (IPCC). At the same time, a wider population of IOs with diverse mandates and functions—especially those in the United Nations (UN) family—now see climate change as an omnipresent threat, understanding it as an intersecting issue that needs to be addressed if original mandates are to be responsibly fulflled.

From a historical perspective, the global discourse on climate change has undergone considerable transformation, of which IOs have been part and parcel. In the post-World War II context, major IOs addressed environmental change under the auspices of environmental conservation or climate science. In 1948, the UN established the International Union for the Protection of Nature and Human Resources (now the International Union Conservation of Nature and Human Resources, or IUCN) for environmental conservation, and in 1951 the World Meteorological Organization (WMO) to focus on climatic change. However, it was not until the 1960s and 1970s that a broader understanding of the global consequences of environmental degradation took hold in the international community, with climate change identifed as a clear problem arising from industrialization in the Global North (Clapp and Dauvergne 2005, 48–82). This conceptualization was central to the UN's frst global Conference on the Human Environment in Stockholm in 1972, which sparked the creation of the United Nations Environment Programme (UNEP) (Brisman 2011, 1039–1040). Given the rhetoric at the time, UNEP was mandated to contribute toward the development and implementation of policies which strike a balance between economic development and overcoming environmental degradation (Clapp and Dauvergne 2005, 57–58).

Further developments and events in the 1970s cemented both the recognition of climate change as a global issue, and the importance of IOs as collaborators and conveners in this domain. These included WMO's frst international assessment of the state of the ozone layer in 1976, which was associated with growing global health concerns and triggered a range of studies over the following decades between WMO and UNEP (Social Learning Group 2001, 13), and the watershed World Climate Conference in 1979, which was a collaborative effort between WMO, the United Nations Educational, Scientifc and Cultural Organization (UNESCO), the Food and Agriculture Organization of the United Nations (FAO), the World Health Organization (WHO), UNEP, the International Council for Science (ICSU), and other partners (Zillman 2009). The World Climate Conference resulted in WMO and UNEP together establishing the IPCC—now one of the most trusted sources for scientifc consensus on climate change. Subsequent watershed successes for global climate change policy, especially the Montreal Protocol, were at least in part due to the involvement of IOs in assisting and including developing countries in the discussion on the environment, especially via the Multilateral Fund for the Implementation of the Montreal Protocol, which is managed by an Executive Committee comprising UNEP, the United Nations Development Programme (UNDP), the United Nations Industrial Development Organization (UNIDO), and the World Bank (Luken and Grof 2006).

In the 1980s, seeds were sown for current IO discourse and partnership on climate change with a focus on sustainable development. In 1980, IUCN partnered with UNEP, the World Wildlife Fund (WWF), FAO, and UNESCO (IUCN et al. 1980) to create the "World conservation strategy: living resource conservation for sustainable development." Although sustainability in that report focused more on the environment itself than (economic) development, by 1984, the UN General Assembly had established the World Commission on Environment and Development (WCED) (Clapp and Dauvergne 2005, 59–60). Providing a new defnition for economic development with the environment at its core, the Brundtland Commission's 1987 report "Our Common Future" proposed a global development and environment strategy designed to be acceptable to all, popularizing the mainstream term 'sustainable development' as we know it today—development that "meets the needs of the present without compromising the ability of future generations to meet their own needs" (World Commission on Environment and Development 1987).

Following this report, multiple keystone conferences took place which have ultimately shaped current discourse on social policy and climate change. In 1990, a second World Climate Conference took place, and while its predecessor had led to the creation of the IPCC, the second presented the IPCC's frst assessment report, which highlighted the risks of global climate change (IPCC and Houghton 1990). This event, coupled with the UN Conference on the Environment and Development (UNCED) in 1992 in Rio de Janeiro (the Earth Summit), led to the establishment of the UNFCCC. The UNFCCC would go on to dominate global discourse and act as the primary convening body for states looking to address climate change (Kuyper et al. 2018), as well as to play a direct role in the exploration of how to address some of the social consequences of climate change via social policy. More importantly, the Earth Summit cemented the notion of sustainable development as a vector for social policy, combined with the promotion of environmental protection (Clapp and Dauvergne 2005, 64).

Discursive focus on sustainable development dominated at the turn of the twenty-frst century, as all UN Member States and a variety of associated IOs committed to eight Millennium Development Goals (MDGs) measured by targets in a variety of social issue areas. Although only the seventh goal explicitly relates to climate change ("to ensure environmental sustainability"), the 17 Sustainable Development Goals (SDGs) as a whole are considered far more interdependent, bringing together socioeconomic, political, and environmental sectors (Nilsson et al. 2016). Climate change and social policies both belong to the objectives to be achieved through the collective action model of the SDGs, and following decades of incremental developments, IOs now view climate change as a social policy concern. IOs which may not have originally or directly addressed climate change now do so anyway, with a common set of terms comprising the new discourse on IO involvement in this area; this notably includes the identifcation of vulnerable groups in the context of climate change and enhancing global resilience via mitigation, disaster risk reduction, and adaptation.

#### Interconnected Policy and Action at the IO Level

Following on from these developments, global social governance as the intersecting feld of climate change and social policy (or eco-social policy) has evolved from a body of core IOs working on climate change and the environment (such as IUCN, UNEP, WMO, the IPCC, and the UNFCCC) to a wide variety of IOs with diverse mandates in the felds of migration, urbanization and population dynamics, livelihoods, health, WASH (water, sanitation, and hygiene), and poverty reduction, to name but a few. Nowadays, many UN specialized agencies, the World Bank, regional IOs, and the OECD may be considered global eco-social policy actors since they recognize climate change either as a direct or compounding issue for global social policy and integrate it into their work portfolios. In this section, a 'chain of connection' between climate change and various social policy areas is outlined as visible in the activities of major IOs; the starting and reference point being climate-change-induced migration.

Climate change has been recognized as early as the 1990s (including by the IPCC) as not only directly contributing toward migration and displacement (Martin 2010, 397), but also as a contributing factor in major conficts where migration and displacement are an outcome (Perch-Nielsen et al. 2008). Climate change is therefore of major concern for well-established and authoritative IOs in this area, such as the International Organization for Migration (IOM) and the United Nations High Commissioner for Refugees (UNHCR). In recent decades, IOM and UNHCR have lobbied for the inclusion of language that recognizes the link between climate change and human mobility in policy, including: the Hyogo Framework for Action and its successor, the Sendai Framework for Disaster Risk Reduction (UNDRR 2019); the state-led Nansen Initiative and its successor, the Platform on Disaster Displacement (McAdam 2016); and the UNFCCC Task Force on Displacement, established following the UNFCCC's twenty-frst Conference of the Parties (COP21) meeting in Paris in 2015 "to develop recommendations to avert, minimize and address displacement in the context of the adverse effects of climate change" (UNFCCC 2020b). More recently, these agencies have also played a direct role in the formation and early implementation of the nonbinding Global Compact for Safe, Orderly and Regular Migration (GCM) and the Global Compact on Refugees (GCR), which include direct recognition of the impacts of climate change on global human mobility (UNHCR 2020; UNHCR and IOM 2019; United Nations 2019).

Such increased movements of people due to environmental stress and disaster may place strain on several other intersecting social policy areas. Climate-related factors such as increased drought and fooding speed up the process of urbanization, as community centers shift from rural to urban spaces. This in turn affects livelihoods, as people shift from agrarian practices in search of new types of work in urban centers. Although such shifts may represent opportunity, they can also equate to exacerbated societal inequality if poorly managed. Several IOs are working to address climate change in this context. The United Nations Population Fund (UNFPA), the International Institute for Environment and Development (IIED), and the United Nations Human Settlements Programme (UN-Habitat) regularly partner in a research and advisory capacity, for example, to support the implementation of the New Urban Agenda (NUA), which was adopted in 2016 (UN Habitat 2020; UNFPA 2020b). Likewise, the World Food Programme (WFP) has placed an emphasis on the need for sustainable livelihoods and ecosystems, as "every new drought or food further depletes people's assets, trapping them in a spiral of diminishing resilience and environmental misery" (World Food Programme 2020b). This has also resulted in climate change having ultimately contributed to WFP's overwhelming spending on emergency and recovery operations following climate-related disasters in recent years (World Food Programme 2020a). Further at the heart of addressing threats to livelihoods, IOs exert infuence via policy recommendations, as the International Labour Organization (ILO) has done in relation to promoting the use of social protection schemes to tackle unemployment in industries where activity must necessarily be reduced or phased out in the face of climate change, such as forestry and fossil fuel industries (Montt et al. 2018, 27). Meanwhile, other IOs have worked directly with local authorities to introduce schemes for improving livelihood opportunities for vulnerable groups. One example of this has been the introduction of hydroponic farming in food prone areas as part of the trend toward community-based adaptation projects; in Bangladesh, pilot farming projects have been supported by UNDP (UNDP 2019), and farms for Bangladeshi returnee migrants have been supported by IOM alongside national authorities as part of a sustainable economic reintegration project (IOM 2018).

Shifting dynamics among populations and means of work in turn place a strain on urban capacities and housing as more people inhabit smaller spaces and strain existing services. UN-Habitat fnds itself working at the intersection of these concerns, as it seeks to address bottle-neck issues affecting resilience and risk reduction, sustainable cities, and human mobility issues, among others (UN-Habitat 2020). Similarly, UNFPA has worked on hazard mapping in populated areas for climate change adaptation policy (POPClimate 2020), and has promoted policy practices for sustainable development and planning that set those most vulnerable to climate change on the path to a better life without contributing further to emissions and worsening climate change (UNFPA 2020a). Population shifts and ensuing challenges are in turn of direct concern for the domains of WASH, as well as health more generally, as they place societies at greater risk for a range of health implications often directly attributable to climate change, such as increased heat stress (Harlan et al. 2006), the spread of infectious disease such as malaria and cholera, malnutrition, and lack of access to clean drinking water, not to mention the mental health risks associated with livelihood and migratory-related stress. WHO has to that end emphasized the need for a continual fow of information between science, research, and policy, with their language emphasizing sustainability and measures for adaptation and reducing vulnerability (McMichael et al. 2003). Although a core authority on health, WHO is not the only viable IO considering health in the context of climate change and exerting soft governance—the aforementioned Sendai Framework for Disaster Risk Reduction 2015–2030 has included health as a key outcome, with actions for public health outlined and prioritized by the United Nations Offce for Disaster Risk Reduction (UNDRR), WHO, and others in the UN system (Aitsi-Selmi and Murray 2016). Health is also a key area under the UNFCCC's Nairobi Work Programme, established at COP11 to convene "knowledge for action" for climate adaptation and resilience (UNFCCC 2020c), and WHO was contributing to health aspects of the Inter-Agency Committee on the Climate Agenda (IACCA)—in partnership with WMO, UNESCO, the International Olympic Committee (IOC), FAO, and ICSU—as early as 1998 (WMO et al. 1998).

In considering how interconnected such issues are, other IOs are in turn forced to address climate change in their policy work regarding vulnerable groups—such as women and children—who have been identifed as disproportionately affected, particularly in areas such as health and livelihoods (Huyer et al. 2015, 4; Preet et al. 2010, 5). IOs such as UN Women (created in 2010) are addressing climate change and exerting soft power in this area by facilitating platforms for the participation of women in decision-making, with the goal to achieve more gender-sensitive policy outcomes. This is clear in their disaster risk reduction work, where they have been active in supporting disaster management bodies at the national level in countries such as Nepal, Myanmar, Vanuatu, Bangladesh, and Kenya, and at the regional and global level alongside IO partners such as UNDRR as well as Member States to develop 'gender responsive' implementation plans and programs for the Sendai Framework (UN Women 2020b). More broadly, UN Women also focuses on economic empowerment for women within the UN's Sustainable Development Agenda, specifcally seeking combatant or adaptive solutions to climate change (UN Women 2020c). A directly observable outcome of this is the IO's facilitation of training seminars for those looking to diversify their livelihoods as part of adaptation measures (UN Women 2020a). Similarly, the United Nations Children's Fund (UNICEF) has restructured its climate change policy around children as central actors, visible through their facilitation of projects in Bolivia and Papua New Guinea for youth leadership in water resources management and disaster response plans for schools, and more broadly in their provision of a platform for children and young people at United Nations events (UNICEF 2020). As part of efforts to enhance resilience in the face of climatic and environmental shocks, UNICEF and FAO have for many years engaged in and evaluated the potential for social policy schemes such as cash transfer programs to enhance the resilience of vulnerable groups in the face of climate change (Davis et al. 2016; FAO 2018; Lawlor et al. 2015).

The notion of global social governance as developed in this chapter suggests an increasing contextualization of global social policies in relation to the global threat of climate change. In other words, in the description of the causes or determinants of social problems and challenges, climate change takes an increasingly prominent role. Furthermore, as climate change plays out in multiple ways for the well-being and livelihoods of people, IOs that previously had clearly assigned mandates, roles, and responsibilities are crossing (social) policy felds in response to the global threat of climate change. In this sense, global social policy is increasingly evolving into global eco-social policy, with actors forming interconnected governance structures that merge social policy with environmental policy agendas and prescriptions. To illustrate this argument, the following section will describe climate change/risk insurance as one potential option for merging traditional social policy tools with climate change policies, highlighting the activity of and between various IOs in this area.

## 'Climate Risk Insurance' for Global Eco-Social Policy? A Case Study