Institutional Fragmentation as a Means to Obtain Leadership – the World Bank in Global Health

This paper analyzes the fragmentation and the changing role of the World Bank as an actor in global health by looking at its governance structures and its attempts to obtain leadership by integrating governmental and also non-governmental actors. Leadership in global health implies financial resources, being attractive for donors, and being capable of promoting ideas and programs. Looking at global health governance, we come across a highly fragmented set of actors: international organizations (IOs), states, non-governmental organizations (NGOs), foundations, and the private sector are all engaging in global health issues with increasing financial resources and various approaches to improve the health standards across the globe. This paper examines the fragmentation of the World Bank as a consequence of adapting to the complex structure of global health governance. It claims that the World Bank needs to adapt to external pressures to obtain leadership by promoting sub-units (Trust Funds) that raise more financial resources and also attract new governmental and also non-governmental donors. To analyze institutional change, it is important to examine the new governance structures and processes of these sub-units and to evaluate how and to what extend the fragmentation is changing the World Bank’s role in global health. Only a complementary rather than a competitive use of theory allows us to examine these processes: regime theory to explain state/donor interests and an actor-centred institutionalist approach showing that IOs are more than the sum of their members and are in fact capable of performing as quasi-uniform actors in international relations. Constructivist concepts of leadership and norm setting add to the theoretical framework.