While the ‘each wealthy nation’s dilemma’ highlights state autonomy and health sovereignty, a multilateral model underscores relationships among diverse global actors up and down the vaccine supply chain that impact vaccine distribution. These relationships are no longer demarcated by geographical spaces and boundaries, but by overlapping interests and shared stakes. Part of what is required to shift toward a multilateral model of global health justice is challenging the background philosophy and narrative that identifies global actors and frames the kinds of choices they make.

Just as the ‘each wealthy nation’s dilemma’ represents a background narrative in the geopolitical sphere, it also holds sway in prevailing philosophical accounts of global health justice, which bear the imprimatur of Western philosophy. Standardly, these views extend the model of individual consent to state authority to the global sphere, requiring states’ consent to any exercise of global authority. Westphalian sovereignty, a principle in international law enshrined in the 1945 UN Charter, demonstrates this approach, granting each state exclusive sovereignty and concomitant responsibility over what occurs within its territory. Historically, Westphalian sovereignty traces to two treaties, collectively known as the Peace of Westphalia, which brought an end to the Thirty Years’ War (1618–1648) between Catholic and Protestant estates within the Holy Roman Empire. Scholars point to the peace at Westphalia as a source for ideas seminal to modern international relations, including the notion of states as sovereign territories. Yet, today, the Westphalian system is contested by groups demanding transborder justice. Some human rights groups insist that citizenship in a particular nation should not be a prerequisite for protection of fundamental human rights.

Lending support to the idea of transborder justice was the emergence of a political doctrine, R2P, first formulated in response to human rights abuses in Rwanda, Kosovo, Bosnia and Somalia, during the 1990s involving ethnic cleansing and genocide. R2P articulates cross-border responsibilities in instances where a state is unwilling or unable to halt or avert serious harms its people are suffering; in these instances, states must protect the citizens of another state.27 The International Commission on Intervention and State Sovereignty, which formulated the doctrine, elucidated it in terms of three subresponsibilities: preventing atrocities; responding to them when they arise; and building, adapting and recovering capacities for self-sufficiency. So understood, R2P converges with the view that a primary responsibility for the protection of people rests locally, with the state, but holds that responsibility does not end there.

R2P gains further support from the sober recognition that it is in each state’s interest to promote the interests of every other state. Power and Faden put the point this way: ‘in all countries, including the world’s most developed and wealthiest nations, the well-being of their citizens is very much influenced by what happens in global markets for energy, food, capital and currency, as well as political decisions by powerful states with regard to their trade and investment priorities’.28 Young argues that such externalities provide a reason for considering responsibility for justice as extending beyond people close by or in the same nation as oneself.29

Despite its appeal, R2P has generated controversy. Médecins Sans Frontieres voiced concern when R2P was used to justify militarised intervention and ‘killing in the name of humanitarianism’.30 It argued further that the doctrine blurred lines between military and humanitarian action, putting relief workers at risk. One response was spelling out practical tactics, including a ‘responsibility while protecting’ doctrine, to help address such concerns. Today, a global consensus about cross-border responsibility has solidified and R2P is an agreed upon norm in the UN system.31 Although R2P was conceived around in-country conflicts, its underlying ideas have broader appeal, as a global call to action to protect fundamental human rights in the face of mass disasters that threaten to undermine them.

During the pandemic, R2P begins upstream, in partnerships formed between researchers and private industry, advance market deals made by governments and drug companies, and scaling up of clinical trials. Table 2 illustrates one way to translate R2P at multiple levels across the range of global actors discussed in Section 1.

Implementing the responsibility to protect

Implementing these responsibilities requires global health governance that articulates core values and goals, assigns ethical responsibilities to diverse stakeholders, and coordinates action across diverse global actors. States do not function as the sole, or even primary, drivers. Instead, global health policy is ‘the outcome of various political processes (that) involve a range of individual and collective (group) actors below, outside, surrounding, and populating the state’.32 Stone likens global policy-making to the ancient Athenian agora, which designated not only a particular gathering place, but also a concept to identify a growing global public space of fluid, dynamic and intermeshed relations of politics, markets, culture and society. This public space is shaped by the interactions of its actors—that is, multiple publics and plural institutions. Some actors are more visible, persuasive or powerful than others. Today the global agora is a social and political space—generated by globalisation—rather than a physical place.33

The global agora is simultaneously a font of community and space of ‘relative disorder and uncertainty where institutions are underdeveloped and political authority unclear and dispersed through multiplying institutions and networks’.33

How can just global policies arise from such disorder and uncertainty? To illustrate one possible path, consider the 2007 UN Declaration of the Rights on Indigenous People. The seed for the declaration was planted in the 1948 UN Declaration of Human Rights. Coleman relates that indigenous people considered these rights, ‘tools for decolonising their oppressed lives’; they came to an understanding of the meaning of ‘indigenous’ that captured what they shared with similar peoples, wherever they lived on the planet. The identity is based on an attachment that all participants share to some form of subsistence economy, to a territory or homeland that predates the arrival of settlers and surveyors, to a spiritual system that predates the arrival of missionaries and to a language that expresses everything that is important and distinct about their place in the universe. Most importantly, they share the destruction and loss of these things.34

A central component of the UN’s assistance was serving as a locus for meetings among indigenous peoples and state representatives, creating spaces for an emerging identity and global policy to take hold. This support fortified and strengthened smaller associations, linking them to each other and outside entities.

The account we are developing implies a normative ordering among diverse global actors. The primary objective of such ordering should be to function as a subsidiarity to the many moving parts that constitute global health justice. The term, ‘subsidiarity’ derives from ‘subsidiary’ which means, ‘to serve, help, assist or supplement; providing assistance or supplementary supplies’.35 A principle of subsidiarity defines the role of global health governance as serving and supporting individuals and groups by coordinating their efforts at prevention, response and capacity building to protect against calamities of global significance. Historically, subsidiarity had diverse applications, as a founding principle of the European Union (EU),36 a basis for American Federalism37 and an ordering standard in medieval and contemporary Catholicism. It is also rendered as a principle of social and political philosophy with application to global governance.38 Philosophically, subsidiarity’s traces to Aquinas’ interpretation of Aristotle’s political philosophy, and his application of subsidiarity to the institutional pluralism that characterised medieval Europe. While Aristotle regarded the city-state (polis) to be the primary subject of justice and its hallmark a proper ordering among parts, Aquinas extended the notion of multiplicity by elevating all the various associations prominent in his day and regarding each as a component of justice, rather than a means to realise a just state. Aquinas characterised many and various purposes for which various associations and forms of human community exist and are formed, giving rise to a whole host of familial, geographical, professional, mercantile, scholarly and other specialised societies. All of these groups and groupings, from the smallest to the largest, have their place and their proper function… each should be allowed to make its unique and special contribution…without undue interference from any others, including the state.39

For Aquinas, justice applied to the whole assortment at every level. The collection of associations was just when large and small bodies interrelated in ways that enabled the relatively larger to support the relatively smaller, for example, states supported local governments, trade unions supported trades, churches supported parishioners and villages helped neighbourhoods, who in turn, helped families. Applied to the pandemic, this vision speaks to the crucial role of civic society groups and local governments in global health governance, and the need to encourage and bolster their efforts. The classic modern formulation of Aquinas’ principle was rendered by Pope Pius XI, who restated it: ‘just as it is gravely wrong to take from…individuals and commit what they can accomplish by their own initiative and industry and give it to the community, so it is also an injustice…to assign to a greater and higher association what lesser and subordinate organisations can do’.40 As a secular principle governing global health, subsidiarity offers a tactic for allocating powers and responsibilities at multiple levels in the absence of a unitary sovereign.

Yet, subsidiarity is not just a method of ordering. It identifies certain values as hallmarks of good governance. These values resemble normative ideals associated with democratic rule, namely, ‘policies must be controlled by those affected’.41 The formation of the EU illustrates. When the 1992 Treaty on European Union (also known as Maastricht Treaty) set out the Union’s constitutional basis, it invoked subsidiarity: Under the principle of subsidiarity, in areas which do not fall within its exclusive competence, the Union shall act only if and in so far as the objectives of the proposed action cannot be sufficiently achieved by the Member States, either at central level or at regional and local level, but can rather, by reason of the scale or effects of the proposed action, be better achieved at Union level.42

The appeal to subsidiarity was designed to prevent domination by the Union over states and to avoid policies from deteriorating into conflicts that thwart aims of member states. Extending these ideas, Archibugi and Held coin the phrase ‘cosmopolitan democracy’, to refer to democratic governance that operates at multiple levels, including the global level, and supports people’s efforts to ‘participate in world politics parallel to and independently from…their…states’.43

These analyses suggest that subsidiarity encompasses both vertical and horizontal dimensions. The vertical dimension indicates a presumption in favour of local governance, through empowering, building capacity and lending tangible support. It has roots in imperial Rome, where military leaders relied on reserves that functioned in the role of a subsidium (literally, to ‘sit behind’) and lent support in case of need; analogously, subsidiarity regards the roles of states and other large social institutions as ‘sitting behind’ smaller institutions and lending support only in case of need. The horizontal dimension indicates a presumption in favour of engaging actors across multiple domains, viewing each contribution as distinct and legitimate. It is present in Aquinas’s emphasis on a broad range of private and public associations.

Vertical and horizontal components of subsidiarity carry normative implications for global health governance. The horizontal dimension insists on ‘robust decentralising’44 by sharing power among a broad array of groups, while the vertical dimension requires engaging locally to enable the many moving parts in multilateral global health to perform key tasks they are set up to do. Together, subsidiarity’s dual aspects imply global health governance should ‘sit behind’ state and local governments, for-profit companies, universities and academic researchers, multinational foundations, civil society groups and other key stakeholders.

Most global health approaches drawn on during the COVID-19 pandemic reflect a Westphalian, not a subsidiarity, model. They date to 1945 when, in the aftermath of the World War II, the UN and the organisations under its auspices (eg, the WHO, WTO, International Monetary Fund, UN Children’s Fund and World Bank) were formed to serve at the behest of member states. Today, these organisations require updating to enable them to function in a diffuse global health landscape. The multiplicity of global actors on the world stage today is testament to the fact that we live in an increasingly interconnected world. Globalisation, or ‘the movement of people, goods, services and ideas across a widening set of countries’, now permeates virtually every sphere of human life; it means that individuals can rapidly become players on a global stage and that what happens at a remote location can quickly spread and produce profound effects on a global scale.45 Despite globalisation across social, economic, political and health domains, the ethics and the methods of global health governance have lagged.

For the WHO (or another global coordinator) to serve effectively in a supportive role requires key capacities. First, it requires adequate and stable financing. At present, WHO funding is ‘roughly equivalent to that of a large US hospital system’, receiving three-quarters of its funding from donors, who earmark it to align with their preferences.46 Second, playing a supportive role requires the capacity to exercise oversight and independently assess compliance through information sharing and on-site monitoring. Third, it requires the ability to support capacity-building, enforce guidelines, offer inducements and impose penalties. Under the UN’s current configuration, powers of enforcement rest with member states, not the UN or its agencies, undercutting its subsidiarity function by making compliance voluntary. Absent these core capacities, fulfilling the duty to safeguard and support smaller-scale groups is irregular and unreliable. While exercising these capacities requires a degree of power and compulsion; a principle of subsidiarity directs us to the least intrusive effective measure needed to avoid collective action failures.

A principle of subsidiarity gains ethical backing on multiple grounds. First, it avoids domination. Domination exists when ‘an agent has the capacity to interfere in another’s sphere of action, and when this intervention is arbitrary, which is to say that it is not governed by collectively agreed on norms and laws but rather by the interests and will of the dominator’.47 Preventing domination in vaccine distribution implies not ceding power over it to private philanthropic groups, to a handful of wealthy states, or to any group not accountable to the collective aims of the affected parties. The dispersion of power that subsidiarity sustains avoids domination by dividing power among many hands.

Second, during a global health emergency, subsidiarity rightly prioritises the health of all over the consent of states. During the COVID-19 pandemic, subsidiarity aims to ensure the collective goal of vaccinating the world and ending the pandemic sooner by giving threshold protection to everyone. When groups veer from this path, it steers them back and it is vested with the authority and tools to do so.

Third, subsidiarity embodies justice, understood as the outcome of fair terms of negotiation. It speaks to the fact that a duty to protect cannot be realised in an enduring and stable way by simply redistributing resources while leaving intact unfair structures of negotiation which reproduce inequities.

Fourth, subsidiarity supports human flourishing by fostering active engagement of individuals and smaller-scale associations. It sustains virtues, such as empathy, care and love, by strengthening smaller, less powerful associations that are primary sources for these virtues.

Finally, subsidiarity protects groups ‘for the sake of the groups’.48 It sees families, places of worship, universities, businesses, charities, nations and regional associations, as unique and valuable, not just for individuals, but for the common good. In this respect, subsidiarity gains ethical backing from solidarity, which emphasises smaller communities in which people find fellowship.

In summary, subsidiarity recognises not only a multitude of global actors, but the intricacies of their relationships and the overlapping of their long-range aims. Compared with a statist framing, a multilateral model displays fluidity of governance structure and is less bound by geographic location. While states remain central, they emerge as part of a growing ensemble of players; subsidiarity and R2P are the normative principles best suited to orchestrating them.