上海合作组织参与全球卫生治理：优势、挑战及路径选择

李雪威 王璐

The Shanghai Cooperation Organization （SCO）， as a steadily growing inter-governmental organization which takes the building of a community with a shared future for mankind as its own responsibility， has been attaching great importance to public health security and actively participating in global health governance. As the COVID-19 pandemic continues， the importance of health issues on the SCO’s agenda is continuously on the rise. Therefore， it is of great significance to make a comprehensive review of the SCO’s participation in global health governance and analyze the advantages it enjoys as well as the challenges it faces， which will help it play a greater role with more effective approaches.

Specific Measures of SCO Participation in Global Health Governance

Global health governance is manifested in multi-layered activities at national， regional and global levels. As a regional international organization， the SCO focuses on health governance at the regional level and also works hard to play a role in global health governance.

Participating in regional health governance

Global health governance is basically performed through health cooperation. The SCO has been advancing health governance at the regional level through promoting and strengthening regional health cooperation， which has roughly gone through three stages.

From 2004 to 2007， the SCO began to pay attention to regional health governance. The joint communiqué at the third meeting of the SCO Council of Heads of Government （Prime Ministers） on September 23， 2004 pointed out that “it has been recognized expedient to strengthen the SCO cooperation in the field of culture， education， health， sports， and thus further build friendly relations between the peoples of the member states of the Organization.” This was the first time that the SCO explicitly proposed health cooperation. Since regional health governance is an important part of global health governance， the SCO’s initial participation in regional health governance also marked the start of its engagement in global health governance. At its Shanghai summit on June 15， 2006， the SCO issued the Declaration on the Fifth Anniversary of the Shanghai Cooperation Organization， clearly indicating that it would endeavor to actively participate in international campaigns against communicable diseases. Afterwards， the organization， at its fifth and sixth meetings of heads of government， also stated that it was timely to launch SCO cooperation in healthcare， and that the SCO Secretariat， in collaboration with the Council of National Coordinators， was instructed to review the issue of establishing an expert working group， develop a plan of cooperation between ministries and agencies responsible for public health issues， and identify priority areas for such cooperation.

From 2008 to 2014， the SCO regional health governance witnessed steady progress. In June 2008， the SCO Secretariat in Beijing held its first meeting of senior officials from health departments of member states. At the meeting， the member states agreed to establish an expert working group on health cooperation and identify priority areas for such cooperation， thus setting up a basic mechanism and structure for SCO health governance. The eighth meeting of SCO heads of government on October 14， 2009 adopted a joint statement on combating communicable diseases within the region. In November 2010， the SCO member states held their first health ministers’ meeting， which marked the institutionalization of regional health governance. In June 2011， the SCO member states， at the 11th summit， signed the Agreement between the Governments of SCO Member States on Cooperation in Healthcare， thus upgrading regional health cooperation to a higher level. In 2013 and 2014， officials in charge of health and disease prevention departments had their third and fourth meetings respectively， which steadily promoted new regional cooperation in joint prevention and control of infectious diseases.

Since 2015， the SCO’s mechanisms and practices for health cooperation have gradually become mature， resulting in the comprehensive deepening of their health governance. The second meeting of SCO health ministers in July 2015 paid more attention to ensuring the health security of regional residents by joint prevention and control of infectious diseases. In June 2018， the SCO Qingdao summit issued the Statement on Joint Efforts Against the Threat of Epidemics in the SCO Space. This statement becomes a guiding document for SCO regional health governance in the new era， and a guideline for the organization to fully participate in global health governance. Amid the novel coronavirus pandemic， which broke out in late 2019 and has spread to all its member states， observer countries and dialogue partners， the SCO foreign ministers released in May 2020 the Statement Concerning the Spread of the Novel Coronavirus （COVID-19）， making an important contribution to global pandemic response. At the third meeting of SCO health ministers on July 24 of the same year， an overview of best practices of SCO member states to counter the spread of the virus was adopted， and the need to combine efforts of SCO member states in the fight against the pandemic was highlighted. On September 18， the SCO published The Member States of the Shanghai Cooperation Organization （SCO） Measures Taken in the Field of Healthcare to Counter the Spread of the Novel Coronavirus （COVID-19）， summarizing the good experience in pandemic response and promoting information exchange and sharing in SCO health governance.

After 16 years of development， the SCO has made positive progress in agenda-setting for regional health security governance， in promoting health governance reform， and in providing regional health public goods.

The importance of health issues in regional governance has been elevated. Looking from the SCO’s successive summit declarations and communiqués of heads of government， we can tell that health issues have evolved from being juxtaposed with issues of education and sports to being mentioned in separate paragraph and then elaborated in multiple paragraphs， gradually becoming the organization’s priority area. It has also evolved from being subordinate to the overall framework of SCO summits and meetings of heads of government to being discussed at special meetings.

Reform of the health governance system has witnessed substantial advance. According to changing threats and challenges to health in the region， the SCO has put forward adaptive measures in a timely manner， and institutionalized health governance and cooperation with greater efforts by establishing mechanisms including meetings of health ministers and officials in charge of disease prevention and control. In the face of new and sudden public health problems， the SCO has launched corresponding measures in time to improve and reform the regional health governance system.

Public health goods have been provided to the region energetically. In February 2020， the SCO issued the Statement on Supporting China’s Fight against COVID-19. As a gesture of their utmost support， the other SCO member states donated medicines， equipment， protective supplies and medical experts to China where the epidemic first broke out. When the coronavirus spread to other countries in the region， the SCO moved quickly to provide medical， financial and food assistance to the Central Asian countries， and made big contributions to putting COVID-19 under control in the region.

Engaging in health governance at the global level

With regional health governance being developed and governance awareness constantly improved， the SCO has also been engaging in global health governance， which is mainly reflected in the following four aspects：

First， supporting the central role of the United Nations and the World Health Organization in global health governance. The SCO prioritizes cooperation with the United Nations and UN agencies， and actively carries out public health cooperation with the UN and the WHO. In the Statement Concerning the Spread of COVID-19 in May 2020， the SCO foreign ministers pointed out the necessity of seeking common solutions on the basis of global solidarity and inclusiveness， supporting the central role of the UN system and carrying out effective cooperation with the WHO. Close cooperation has been conducted between the SCO and the WHO in the prevention， control and publicity of infectious diseases such as HIV/AIDS， measles， tuberculosis， influenza and COVID-19， as well as in vaccine development and medical assistance.

Second， conducting cooperation with other international organizations on global health governance. The SCO has been cooperating with comprehensive inter-governmental international organizations such as the Commonwealth of Independent States （CIS） and the Organization for Security and Cooperation in Europe （OSCE） on health governance. In April 2005， the SCO signed a memorandum of understanding with the CIS， and the two sides reached consensus on cooperation in various fields， including health. In September 2016， then SCO Secretary-General Rashid Alimov attended the CIS Bishkek anniversary summit and discussed the prospects for further cooperation with CIS member states in the fields of politics， culture and health. The SCO has kept sound exchanges and cooperation with the OSCE. Since COVID-19 broke out， the two organizations have been working together to cope with the pandemic through regular communication. Based on a memorandum of understanding in 2005， the SCO and ASEAN reached consensus on strengthening all-round cooperation including in the field of health in 2015. The SCO has also stepped up cooperation with the International Red Cross and other NGOs in the field of health assistance. In June 2017， the SCO Secretariat signed a memorandum of understanding with the International Committee of the Red Cross to launch cooperation in humanitarian relief.

Third， pushing forward reforms in global health governance system. The global health governance system， with the WHO as the center， is dominated by the Western and developed countries. As the Trump administration announced the United States’ withdrawal from the WHO and Western powers such as Europe became less willing to provide public health goods， global health governance faced the risk of deficit. The SCO highly recognizes the central role of the UN and the WHO and stands ready to contribute to global health governance to the greatest possible extent， promote diversification of the main bodies of global health governance and， to a certain extent， make up for the deficit in global health governance. In addition， as an organization established by and representing the interests of emerging market and developing countries， the SCO’s participation in global health governance helps correct the imbalance of power in the global health governance system and increase the representation and voice of emerging market and developing countries.

Fourth， providing public health goods for the international community and building up international exchange platforms. In the event of infectious disease outbreaks， the SCO provides timely financial and medical assistance to the world and fully supports the fight against epidemics. In April 2015， three SCO member states， Russia， China and Kazakhstan， contributed US$60 million to fighting Ebola in Africa and provided medical and technical assistance to African countries. As the coronavirus raged worldwide， the SCO， based on the experience of its member countries in traditional medicine， held the 2020 SCO Forum on Traditional Medicine via video conference， inviting WHO representatives and traditional medical experts from SCO observer countries and dialogue partners to share ideas on the unique role of traditional medicine in epidemic prevention and control.

Motivations for Participation

The SCO participation in global health governance is driven not only by the need to deal with regional public health security threats， expand the organization’s functions and consolidate its foundation， but also by practical considerations such as addressing global public health threats， alleviating the dysfunction of global health governance mechanisms， and enhancing the international standing of the SCO and its member states.

Motivations at the regional level

First， there are problems in regional public health security that the SCO has to deal with. According to the International Health Regulations （2005）， global public health security involves health problems caused by infectious diseases， human behavior， climate change， man-made destructive events， natural disasters and other factors. Most SCO member states are densely-populated emerging market and developing countries with limited access to health care， and therefore face the threat of serious communicable diseases. Besides， to tackle the abrupt outbreak and fast transmission of infectious diseases and put them under control require concerted efforts from SCO member states. In addition， cooperation among the SCO member states is all the more necessary to address the threat to the health of residents in these countries from respiratory diseases related to more frequent forest fires caused by global warming and a deterioration of air quality due to unregulated industrial development.

Second， the SCO has to expand its organizational functions and consolidate its foundations. The SCO is a regional organization founded with the purpose of combating the “three forces” of terrorism， separatism and extremism， and maintaining regional security. After nearly 20 years of development， the SCO has established relatively mature organizational mechanisms with rich cooperation practices， and has become an important force in global governance. In this context， the SCO needs to explore and expand new areas of cooperation， constantly improve its organizational functions， and make greater contributions to regional development. In this context， cooperation in the field of health has received more and more attention， and the SCO has also stressed the contribution it can make to global health governance. At the fifth meeting of heads of SCO member states’ services responsible for the maintenance of the population’s sanitary and epidemiological wellbeing in 2017， SCO Deputy Secretary-General Aziz Nosirov pointed out that “efforts to maintain the population’s sanitary and epidemiological wellbeing is an important SCO task.” More importantly， the solidarity and friendship of member states in health cooperation can not only strengthen the ties among governments of member states， but also be conducive to the mutual trust and friendship among the peoples in the region.

Motivations at the global level

First， the SCO has to deal with global public health threats. Public health threats are cross-national and cross-regional. The deepening of regionalization and globalization has resulted in substantial progress of trade liberalization and significant increase of cross-border population flow， which makes no country or international organization able to stay detached from global changes. Given their complicated and diversified nature， addressing public health threats requires huge financial support， necessary medical techniques， control technologies as well as joint efforts of the international community. As the world’s largest and most populous international organization， the SCO is profoundly affected by global health threats and needs to respond to them. At the same time， as a responsible international organization， the SCO has an obligation to participate in global health governance out of the responsibility and humanitarian principle of providing public health goods.

Second， the SCO tries to alleviate the dysfunction of global health governance mechanisms. The major actors of global health governance include sovereign states， inter-governmental organizations and non-governmental organizations， but these entities have gradually exposed their failure to play an effective role in global health governance. On the one hand， even though sovereign countries have some advantages in putting epidemics within their territories under control， the prevention and control of emergent global health problems requires joint efforts of the international community. The US greatly reduced its contribution of international public goods under the Donald Trump administration， while major countries in Europe have become less willing to participate in global governance. The prevalent nationalist sentiment has formed a huge resistance to the advancement of global health governance. On the other hand， although global international organizations are the main organizers in global health governance， their role is limited at the regional level. At the same time， growing deficiencies have been exposed in their management of global health threats. In recent years， the WHO has become increasingly incompetent in responding to global health challenges， with some experts even declaring that the WHO is becoming irrelevant in global public health governance， or arguing that “the WHO’s management of the 2009 H1N1 pandemic and of the 2014 outbreak of Ebola Virus Disease （EVD） in West Africa has been perceived as inept， dysfunctional， even shambolic.” Some experts pointed out that “the WHO must reform for its own health.” Given this， regional international organizations are playing an increasingly important role in global health governance. They not only carry out health governance in specific regions， but also cooperate with other international actors to deal with global issues， effectively alleviating the dysfunction predicament in which global health governance mechanisms are bogged down.

Third， the SCO aims to enhance the international status of itself and its member states. Given the strong legitimacy and authority of international institutions， countries participating in them can be well recognized by the international community. After years of development， the SCO has created a good international image on the world stage. The SCO member states’ provision of public health goods through the SCO platform ensure their deeper participation in global health governance， which is conducive to enhancing their international discourse in global governance and improving their image in the world. Specifically， for China， Russia， India and Kazakhstan， which have greater influence in global health governance， participating in global health governance through the SCO framework helps further shape their good international image and enhance their international status; for member states with relatively small international influence， such as Uzbekistan， Tajikistan and Pakistan， the participation in global health governance through the SCO mechanisms enables them to contribute to global health governance， thus improving their international image and standing. By providing public goods that are imperative to people’s livelihood， urgent in need and life-saving， the SCO can win more popular support in the international community， build a responsible image， and enhance its international influence.

Advantages and Challenges

Global governance means that countries （regions）， international organizations and citizens of all countries， by partially transferring their rights through consultation and cooperation， establish and develop a set of global rules and systems to safeguard security， peace and development of all mankind and maximize their common interests. Therefore， the advantages and challenges of SCO participation in global health governance can be evaluated in terms of its value objectives， rules， participants and recipients.

Advantages of SCO participation in global health governance

First， SCO member states have shared common value objectives for participating in global health governance. The SCO member states uphold the principle of putting the right to life and health first， and take the protection of people’s life and health as the most important political ethics. With common interests in jointly responding to public health threats， the SCO member states have reached a high degree of consensus on strengthening global health governance， and unanimously supported the SCO’s participation. At the regional level， with various health mechanisms in place and a series of statements and documents signed among its member states， health governance has become an important issue of the SCO. At the global level， the SCO has been supported by its member states to play an active role as a participant in global health governance. From Ebola and Zika to COVID-19， the SCO has been stepping up its response and acting in a much timely manner， playing a bigger role in global health governance.

Second， the gradual establishment of SCO health governance regulations has laid a solid foundation for further participation in global health governance. The SCO has set up special platforms such as meeting mechanisms for health ministers， senior officials of health departments， and leaders in charge of health and epidemic prevention， thus normalizing and institutionalizing health governance cooperation. Through these mechanisms， SCO member states have carried out a variety of actions for regional health governance. The SCO has signed and issued a series of statements and documents to institutionalize health cooperation， including the Agreement on Disaster Relief Mutual Assistance between the Governments of the Member States of the SCO （2005）， the Joint statement on Combating Communicable Diseases within the SCO （2009）， the Regulation for the Working Group of Health Experts of SCO Member States （2009）， the Plan for Key Cooperation in the Field of Health among SCO Member States （2010）， the Intergovernmental Health Cooperation Agreement between the Governments of SCO Member States （2011）， the Notification Program for Infectious Diseases in SCO Member States （2013）， the Proposal on Strengthening the Ability of SCO Member States to Cope with Challenges and Threats of Infectious Disease Outbreak （2014）， the Statement by the Heads of SCO Member States on Joint Efforts Against the Threat of Epidemics in the SCO Space （2018）， and the Statement Concerning the Spread of COVID-19 （2020）.

Third， member states have actively participated in global health governance. The participation of SCO member states， as sovereign states， in global health governance provides basic experience for the organization’s further engagement. As an important leader and participant in global health governance， China provides public health products to the world by means of export and donation of vaccines and medical goods as well as financial assistance. From August 2018 to February 2020， China donated US$4 million to the WHO to fight the Ebola outbreak. In support of the developing countries’ fight against the coronavirus， China has contributed US$50 million to the WHO. India is also an important force in global health governance and has provided high-quality and low-cost vaccines and medicines to the international community. At present， India is one of the major vaccine suppliers in the world， and more than two thirds of the medicines in 150 international organizations are produced in India. Russia has made significant contribution to the prevention and control of tuberculosis in the world. In 2011， Russia and the WHO co-hosted the first Global Ministerial Conference on Healthy Lifestyles and Noncommunicable Disease Control. In 2017， Russia and the WHO jointly launched the program to end TB， and Russia has since been taking active action to terminate the disease. Kazakhstan has taken an active part in the fight against plague， cholera and other diseases， and has gradually participated in epidemic prevention and control. In addition， Kyrgyzstan， Tajikistan， Pakistan and other member states have also made positive efforts to prevent and control transnational infectious diseases.

Challenges for SCO in its global health governance participation

First， threats to regional and global public health are getting diversified. With the deepened development of globalization and the rapid growth of cross-border population flow， abrupt outbreak of new cross-border infectious diseases often catches the international community unprepared. Since the SCO covers a wide range of region with a large population and ethnic groups， it is very difficult to prevent and control cross-border infectious diseases. To deal with the challenges， the SCO needs to take concerted actions with the international community. Meanwhile， with the change of people’s lifestyles， the situation of non-infectious diseases in SCO countries is not optimistic. The incidence and mortality of cancer， cardiovascular and cerebrovascular diseases， as well as lung and bronchial diseases are on the rise， which poses grave challenges to health governance in the SCO region.

Second， free-riding exists in the SCO’s participation in global health governance. The level of contributions made by SCO member states to global health governance is very different. China， India and Russia play a greater role in global health governance， followed by Kazakhstan， while Uzbekistan， Kyrgyzstan， Tajikistan and Pakistan make smaller contributions. The difference in contributions may cause a sense of imbalance among the countries， and result in the problem of free-riding since major contributors have shown some degree of fatigue and small contributors are less enthusiastic to play a greater role.

Third， member states have limited ability to take collective action in compliance with SCO agreements. Since the SCO’s membership enlargement， the differences in political system and economic development among its member states have become more prominent， with intertwined interests getting more complicated， which increases the difficulty of organization-wide collective action. For example， Western countries， headed by the United States， have long held biased attitudes toward the SCO， and believed that the organization， with a strong geopolitical flavor， is the “NATO in the East，” thus keeping vigilant on the SCO. India enjoys a close relationship with the US and is the core country in the quadrilateral security dialogue （QUAD）. This may lead to interferences by US-led Western countries in the SCO agenda through their influence on India， and bring about certain negative impacts on SCO health cooperation. Besides， while member states participate in global health governance under the SCO framework， they still put much consideration on their own national interests， which requires the SCO to conduct more consultations and discussions before consensus on health cooperation， especially in the provision of public health goods， can be reached. This has certainly inconducive to the SCO’s global health governance participation.

Fourth， the SCO’s health governance mechanisms are too rigid and relevant institutions are far from perfect. The SCO adopts the principle of consensus in its decision-making， requiring all decisions made by the organization be approved by all member states. This has resulted in poor efficiency in the SCO’s handling of public health emergencies. At the same time， most of the SCO’s existing health mechanisms stay at the level of annual meetings， with no specialized agencies to manage daily health problems and respond to public health emergencies. The lack of mechanisms on information exchange， fund-raising and technological synergy in the field of health has led to a shortage of public funds and material resources， which will become the weak link in its response to public health emergencies. In addition， the lack of authority in the field of health may lead to insufficient supervision and evaluation of health governance implementation.

And fifth， the SCO’s participation in global health governance is relatively lagging behind. Compared with economics， security and other areas of governance， health governance is still a weak link of global governance. Over the years， the focus of SCO participation in global health governance is mainly at the regional level， while its role at the global level still needs to be improved， especially in the provision of international public health goods and in global health cooperation. In terms of health governance， the SCO has made great breakthroughs in the prevention and control of infectious diseases and major non-communicable diseases， but there is still room for further improvement in emerging areas of health governance.

Future Path Options

Given the above-mentioned advantages and potential challenges it faces in global health governance， the SCO needs more substantial action in deepening cooperation among member states and strengthening its organizational cohesion to build an SCO community with a shared future. Besides， for in-depth participation in regional and global health governance， more efforts are needed to establish and improve its health governance mechanisms， promote health cooperation at both regional and global levels through the Belt and Road Initiative （BRI）， and intensify cooperation with multilateral international health organizations.

Reinforcing in-depth cooperation among member states

First， SCO member states should strengthen their bilateral and multilateral health cooperation within the SCO framework. Public health involves people’s livelihood and is closely related to the fate of all member states. In deepening their cooperation， the countries should not only pay attention to the provision of public health goods， but also extend the cooperation to all aspects of the health field in line with basic national medical needs， so as to ensure all member states’ participation and elevate their enthusiasm.

Second， SCO member states should intensify health cooperation in newly emerging areas， such as combating medical crime， medical technology， medical device management， medical tourism， maternal and child health care， and bio-safety. Cooperation should also be deepened in strengthening laboratory capacity-building， improving professional skills， conducting joint scientific research， developing vaccines and studying effective treatment methods， so as to jointly prevent and control new-type diseases and address newly emerging health threats.

Finally， the SCO should also combine economic cooperation with health governance. By strengthening the construction of regional cross-border e-commerce platforms and promoting online services， cross-border purchase and transportation of medical goods and daily consumer goods will become possible， thus reducing unnecessary human contact and improving the efficiency of health work.

Improving cohesion to build an SCO community of shared future

The SCO should further strengthen its internal cohesion， work for broader consensus among its member states on health governance， and effectively implement joint actions. It should step up organizational building and push member states to take collective action with clear-cut policies， agreements and norms. At the same time， the SCO should boost the construction of collective identity and create an atmosphere of common value within the organization based on the Shanghai Spirit of mutual trust， mutual benefit， equality， consultation， respect for diverse civilizations and pursuit of common development， to enhance member states’ consciousness of action. In creating common values， the building of an SCO community with a shared future can also be advanced. In his speech at the SCO summit in June 2018， President Xi Jinping said， “We should， guided by the Shanghai Spirit， work closely to build an SCO community with a shared future， and move toward a new type of international relations.” The common vision of building a community for the shared future of humankind was then written into the Qingdao Declaration， and has since become the consensus of all member states and the goal and direction for the SCO’s development in a new era. In the future， the SCO still needs to constantly build consensus， step up collective action and provide more public goods for the international community.

Improving health governance mechanisms and institutions

While further developing existing health governance mechanisms and making them more regular and institutionalized， the SCO should work to improve its internal communication channels， including by building up information exchange and technical platforms. By so doing， in response to public health emergencies， the SCO can increase communication through these mechanisms， make regular briefings on progress in epidemic prevention and control， and improve its working efficiency. At the same time， new institutions should be established in the area of health， especially agencies in dealing with emergencies. As the SCO meetings of heads of state and heads of government are held only once a year and the issues discussed on these occasions are mostly macroscopic， the organization often finds itself incompetent to deal with routine health work and respond to public health emergencies. To address the problem， a health working group， responsible for the command， publicity and coordination in the field of health， can be set up under the SCO Secretariat to improve the organization’s emergency response capacity and working efficiency. The SCO can also set up a health foundation， which can be used for medical and health care work of member states， and also for providing solutions as well as financial and technical support in coping with global health threats.

Giving full play to the BRI in promoting health cooperation

In May 2018， the SCO held the first Forum for Hospital Cooperation and established the SCO Hospital Alliance， learning from the experience of the Belt and Road Hospital Alliance set up in 2017. The SCO Hospital Alliance has since become an important part of the Belt and Road Hospital Alliance. While the BRI provides effective guidance and demonstration for the SCO’s health work， the SCO serves as a platform and provides necessary support to put the BRI into effect. Most of SCO member states are important countries along the Belt and the Road routes. They can carry out Belt and Road medical and health cooperation under the SCO framework， such as cooperation in health infrastructure building， health education and cooperation between medical institutions， while developing international health cooperation with other countries along the Belt and Road routes by actively providing public health goods such as medicines and vaccines.

Developing in-depth health cooperation with multilateral international organizations

In addition to traditional global health governance organizations such as the WHO and the International Red Cross， many international groupings， such as BRICS and G20， have also expanded their health governance functions through proactive participation in global health governance. China， Russia and India are important members in these international organizations. By actively developing health cooperation with these other organizations， the SCO and its member states can make concerted contributions to global health governance. In addition， the SCO should also reinforce communication with ASEAN， the African Union and other regional international organizations， and engage in cooperation and exchange on issues such as the prevention and control of regional epidemics and non-communicable diseases.