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The Power of Immunization: The WHO and Global Immunization Programs from 1974 to the Present


How do intergovernmental organizations exercise power and how has this exercise of power changed over the last decades? This dissertation addresses these questions through a case study of the WHO's involvement in global immunization programs. It seeks to bridge the gulf between global and local examinations of IGO power by simultaneously exploring the exercise of power at both levels.

This dissertation includes four main empirical studies. The first asks whether global civil society or the society of states has greater influence on the spread of global norms and practices. It employs fixed-effects models to test the influence of IGOs (society of states) and INGOs (global civil society) on immunization coverage with polio, measles, DPT and BCG vaccines for the years 1980-2001. It shows that IGOs have a positive effect on immunization coverage, suggesting that the society of states has a greater influence on the spread of public health norms than global civil society. Further, INGOs have a negative effect on immunization with controversial vaccines, especially in high-income countries. I argue that global civil society's influence on the spread of global norms is particularly strong for controversial issues with ties to transnational social movements, like women's rights and human rights. For less controversial issues strongly associated with the state, like public health, the society of states plays a more important role.

The second analyzes changes in global immunization policy, tracing power dynamics in deciding on policy changes. It assesses whether states or the WHO plays a more important role in determining policy changes through an analysis of WHA debates and by tracing the source of major policy changes. It argues that WHO experts play a particularly important role in determining how immunization policy has changed since the beginning of the Expanded Programme on Immunization in 1974. It further shows how the power to influence policy has shifted dramatically since the mid-1980s with the rise of new supranational coalitions, like the Task Force for Child Survival and the GAVI Alliance. These new coalitions have come to play a particularly important role in determining major policy changes, constraining the WHO's power to act independently on health issues. However, I argue that they represent a change how the WHO exercises power rather than a diminution in its power, per se.

The third study looks at the idea of "health as a human right" as it applies to childhood immunization. In it, I analyze changes in the discourse of responsibility concerning childhood immunization. I show a clear shift from a limited vision, which placed ultimate responsibility for providing immunization on the state, to a vision of shared global/local responsibility which saw immunization as a "right" that both state and global actors had a duty to ensure. Through an analysis of donations to the Voluntary Fund for Health Promotion, I show how changing visions of global responsibility for immunization helped create a new system of shared global/local responsibility for funding immunization programs that relied heavily on long-term, voluntary funding for immunization programs in the developing world. My analysis shows that the EPI had great success increasing donations. However, doing so required constant efforts to maintain donor interest and prevent "donor fatigue," efforts which led to the adoption of increasingly ambitious, and even unrealistic, program goals. Thus, despite increasing actual resources, the WHO's immunization programs came to face a situation of perpetual crisis, with programs facing near constant shortages and funding gaps. I argue that, ironically, the perception of crisis helped sustain needed program funding.

The final study in my dissertation looks at two national immunization programs to examine factors favoring and impeding program success. I use residual analysis to identify states with particularly strong and particularly weak immunization programs, ultimately choosing Malawi (with a particularly strong program) and Cameroon (with a particularly weak program) for comparison. I argue that their divergent experiences arose in part from WHO advisers' lack of consideration of institutional legacies. Especially in the early 1980s, WHO advisers strongly pushed a "primary health care" approach to vaccination that stressed the importance of integrating immunization into basic health services, particularly as part of all-encompassing maternal and child health services, preferably delivered from fixed health centers. This orientation gained ground easily in Malawi, where a heavy missionary presence and a history of government cooperation with missionary health centers had furthered the development of a system of holistic health centers spread across much of the territory. In Cameroon, on the other hand, it contrasted starkly with the existing system, which separated preventive and curative health services, with the later being provided by specialized, mobile "Grandes Endémies" teams. Attempts to reform this system in response to advice from the WHO incited resistance from health personnel on the ground, generally hindering efforts to promote immunization.

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