Vote buying in the UN Security Council.

In an increasingly globalised world, health is ever more affected by international institutions. Over the past 25 years, the World Bank, the International Monetary Fund (IMF), and the World Trade Organization (WTO) have increasingly dominated policymaking in developing countries, leading to substantial effects on health. Furthermore, global threats to health, such as HIV/AIDS, severe acute respiratory syndrome, avian influenza, and climate change, need effective collective action at the international level. Therefore the system of global governance is of central, and growing, importance to health.

However, global governance is becoming increasingly controversial, particularly in the case of global economic institutions. Controversies have included: the World Bank's and IMF's undemocratic weighted-voting structures; the so-called tradition by which the USA and European Union (EU) effectively appoint the respective heads of these organisations; and the abuse of economic and political power by the USA and EU to pressurise developing countries to accept potentially damaging concessions in WTO negotiations.3, 4

By comparison, the UN has tended to be seen as relatively democratic, neither sharing the IMF's and World Bank's weighted-voting system nor showing the routine circumvention of democratic and transparent processes that characterise the WTO. The UN and its specialist agencies have been criticised as being: starved of resources; increasingly dependent on discretionary funding; compromised in their neutrality; and sidelined by the major powers in favour of the World Bank, over which these powers exert greater control. However, criticism of the UN's democratic processes has been more limited, and has focused mainly on the selection processes for agency heads, notably those of WHO.5, 6

Ilyana Kuziemko and Eric Werker recently highlighted systematic use of aid from the USA and resources from UN agencies (mainly UNICEF) to “buy” the votes of countries on the UN Security Council. These researchers reported that countries receive about 59% more US aid and about 8% more UN aid during the time that they are on the UN Security Council than at other times. These figures increase to 170% and 53%, respectively, when important issues are at stake. Overall, US$17 million in aid is diverted in a typical year, and $53 million in an important year, for each of seven or eight countries. Aid is at normal levels in the years immediately before and after UN Security Council membership. The additional UN aid is almost entirely attributable to UNICEF, an agency with close links to the US administration and which is (by another consistently observed tradition) headed by a US citizen (currently, former US Agriculture Secretary, Ann Veneman). Kuziemko and Werker's conclusion that these findings are evidence of an attempt by the USA to buy votes on the UN Security Council seems compelling. However, they have not analysed votes to assess how effective such efforts are, citing problems in the methods for trying to doing so, and they have not assessed how the flow of aid from other donors is affected.

Kuziemko and Werker's findings complement other studies that have found a significant correlation between lending by the IMF (in which the USA casts 17% of votes and wields a de-facto veto on major policy decisions) and recipient governments' proximity to, or movement towards, US positions on votes in the UN General Assembly.8, 9 Furthermore, qualitative and quantitative evidence suggests that lending by the World Bank (in which the USA enjoys a proportion of votes similar to that in the IMF and appoints the President) is used to reward countries in the Middle East that conform to US policy there. The latest, and particularly controversial, US appointee as World Bank President—former US Deputy Defense Secretary Paul Wolfowitz—stands accused of using his position to channel World Bank funds to support the US-backed administration in Iraq, setting aside the standards on corruption he is seeking to apply in other countries and the normal World Bank policies on countries in conflict.

If these analyses and events indeed reflect an attempt by the USA to influence international decision-making, it is a matter for serious concern. If successful, such attempts skew international decision-making away from the common good, resulting in outcomes that will be less favourable for those in greatest need. The credibility and legitimacy, and thus the effectiveness, of international bodies will be undermined, making it still more problematic to find effective solutions to global challenges such as poverty, health, and climate change. Decisions of the UN Security Council, whose remit extends to the legitimate use of military force and economic sanctions, may have profound effects on health, as exemplified by the experience in Iraq.12, 13, 14

Moreover, even if voting patterns are unaffected, allocation of scarce aid resources according to donors' geopolitical agendas rather than to need or potential effect reduces the effectiveness of aid in achieving objectives such as poverty reduction and health. In few cases can the health implications be greater than in UNICEF, whose programmes are targeted strongly at health-related activities, such as immunisation and girls' education.

The growing criticism of the system of global governance is unsurprising. This system was established in the 1940s, and has changed little. Since then, not only have the world and the roles of international institutions changed fundamentally, but so too have political standards and culture. It would be more surprising if a system of governance (developed while much of the developing world remained under colonial rule) did conform to the standards of democracy, accountability, and transparency of the early 21st century.

That governments which enjoy a privileged position in international organisations and dominant economic, political, or military power use these advantages to promote their self-interest and to protect their political privileges is unsurprising. Predictably, when a country's leader has the wealth and power to act at will, in a national governance system that lacks effective mechanisms to ensure accountability, power will be abused and jealously guarded. There is little reason to expect a different outcome at the global level. However, that abuse of power is predictable does not make it acceptable or justifiable, and it does not exonerate the culprits. Rather, it creates an overwhelming case for fundamental reform of governance structures to prevent such abuse.