Discussion
To the best of our knowledge, this study conducted the first network analysis of all resolutions adopted by the WHA from 1948 until 2022. Our findings identify the complex structure of this normative network whereby health issues, and the norms that underpin why and how WHO addresses those issues, can be seen as increasingly linked together. The recognition that many global issues are interlinked with other health issues reflect the complexity of advancing global health diplomacy in an interconnected world. At the level of the whole WHA network, our analysis reveals that WHO governance consists of a core of mainly topical resolutions that are highly interconnected, and a periphery of mainly procedural topics that are much less connected except for core financial issues. Further analysis reveals that not everything is connected to everything else to the same extent. More importantly, the structural patterns found in the network seem to correspond to important multilateral diplomacy processes related to the nature of the issues being addressed. In addition to identifying health issues that have classically attracted a lot of attention, the network analysis uncovers issues that have received comparatively less attention in the global health literature. The focused attention on health crises in Cyprus and Lebanon are cases in point. As WHO is also part of the UN system, this suggests that global health governance might be influenced by dynamics taking place at this level. While the analysis is currently limited to citations from WHA resolutions to other WHA resolutions, the findings confirms not only how prolific and wide-ranging the WHA is as the plenary decision-making body of WHO member states, but also the relevance of approaching global health governance as a set of interlinked components.30 In this regard, network analysis is useful to link different insights together. While the WHO has been criticised for its siloed approach to address global health issues,31 the analysis suggests that this approach is not the collective will of the WHA but may relate to the way the WHO has been increasingly funded through earmarked voluntary contributions to specific programmes.32 33
The variety of patterns found suggests that the topology of the network is not exclusively a matter of implicit rules and conventions. Several mechanisms may be at play to shape the evolution of this network. First, many resolutions are never cited. One explanation might be that many resolutions are on simple procedural matter and do not require an effort at building a consensus among member states. However, some procedural issues such as the scale of assessment of new member states receive a lot of attention at the WHA. This reflects the fact that funding issues are heavily covered by the WHA. Second, the giant component whereby some resolutions are heavily cited while others are not, are typical of the mechanisms of preferential attachment described in many social networks.34 However, other mechanisms may be at play. A simple mechanism is parsimony which might explain why a resolution cites only the most recent and/or the most important resolutions related to its main topic. In some cases, one can clearly discern a chain of resolutions where new nodes are added one after the other. Furthermore, the radial configuration found in relation to several procedural issues might reflect the fact that an agreement has been reached on how to address an issue and this agreement is being constantly referred to once the issue happens again. More densely connected forms of clustering might reflect more intense negotiations where Member States level of disagreement is high. Hence, Member States reassert the content of ‘all’ previous resolutions as part of efforts to move an issue forward. The issue of infant nutrition and breast-milk substitutes, which resulted in the adoption of the International Code of Marketing of Breast-milk Substitutes in 1981, illustrates a topic that was contested and still face several implementation challenges.35 36
The capacity to identify linkages between health issues and priorities may have potential relevance for advancing global health governance and policies. On the one hand, multilateral diplomacy requires knowledge of the broader health context so that prioritisation by member states can be informed by an understanding of the most central issues in global health. On the other hand, how global health issues are connected to each other relates to issue framing, which is an important factor for understanding why some issues get addressed while others do not.37 Competition for attention and resources in global health governance may make it difficult to move a single issue forward. Hence, the capacity to identify norms that are common to several issues may help norm entrepreneurs identify leverage points which may then cascade into the adoption of a shared international norm. Such a pattern was identifiable with resolution WHA48.13 which put together the common challenges associated with the issue of emerging and re-emerging communicable diseases in the 1990s. This may be a necessary (but not sufficient) step to elicit commitment by member states to address an issue through collective action (eg, in this case the revision of the International Health Regulation).38
There are several limitations to the current study. The analysis exclusively focuses on WHA resolutions while resolutions of the Executive Board are also important. The WHA also adopts decisions which are usually shorter than resolutions but may also contain relevant information about global health governance. Another limitation is the choice to remove annexes from the analysis which often corresponds to the instrument adopted by the resolution. In some cases, previous resolutions were cited exclusively in the annex. Furthermore, there is a potential for errors in network analysis despite a multipronged strategy to reduce error risks. Given challenges with OCR, we used manual verification of the results and several additional steps to ensure the validity of the findings. While we are not yet confident in reporting word search of the full content of resolutions (hence the use of metadata from the IRIS database and analysis of the title of the resolutions), we are confident that the future quality of the OCR can be substantially improved by using Natural Language Processing. Having access to the full text in a machine-readable format will be essential for better linking the network analysis and the content of the resolutions. There were also limitations regarding the metadata, as the IRIS database has some errors that we discovered while analysing the data set. While corrected, some errors regarding the attribution of MeSH categories could have persisted. It is also not known whether the MeSH categorisation has been consistently applied to WHA resolutions. Finally, at this point of the research, there are also limitations regarding the interpretation of the patterns found in the network of WHA resolutions including a lack of qualitative evidence on what leads an organ such as the WHA to cite and not cite previously adopted resolutions. It will be important to understand what factors motivate citation between resolutions and whether information and communication plays a role.
Despite these limitations, the current data set provides a novel and systematic way of analysing the normative work of WHO and multilateral diplomacy more broadly. Overall, the methodological approach, based on different computational tools, demonstrates that several aspects of global health governance mainly studied by qualitative research can also be interrogated quantitatively. The current approach creates a research agenda on computational approaches to study multilateral diplomacy that could help address important analytical questions regarding global health governance. First, the evolution of topics covered by the WHA over time demonstrates the need to understand the political and historical context of the normative work of the WHO. More precisely, we need to understand what happens during the policy process and which factors shaped the network the way it is. This also means understanding how power is expressed in different forms.39 Second, we need to understand whether and how changes in the topology of the network potentially influence the effectiveness of the governance system. Previous studies suggest that some features of governance systems can influence effectiveness in addressing some global health issues among several factors.40 Third, the potential for extending the approach adopted in this article is substantial, linking not only to other types of documents within the WHA and other WHO governance bodies, but also other organisations concerned with global health governance (online supplemental material 22 provides examples of relevant documents). These additional documents may be mapped as new nodes and layers in what would become a multilayered network approach of governance.41 42
Within WHO, it would be interesting to compare the network of the agenda documents of WHA (or the resolutions adopted by the Executive Board) and WHA resolutions and test whether some factors may explain whether an issue is more likely to result in the adoption of a resolution by the WHA or not. The multilayer network approach might also teach us about multilevel governance, that is, how WHA resolutions are taken forward at other levels of governance (national and subnational). Finally, given the focus of the global governance literature on understanding regime complexity,43 44 assessing interlinkages between international organisations appears as a promising way to understand how WHO interacts with other organisations in addressing global health issues and more broadly to study interorganisational collaboration.45 Given, the common assumption that 194 member states leads to greater plurality and thus representativeness of decisions-making, potential future analysis might be to compare the structure of the WHA normative web with the plenary bodies of World Bank, the Joint United Nations Programme on HIV/AIDS (UNAIDS), United Nations International Children’s Emergency Fund (UNICEF) or other international organisations with a health mandate. How are they different? How do they intersect? How does their composition and decision-making processes relate to the structure of their normative webs?
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