Amy S. Patterson examines African patterns of involvement in global health governance and questions why states that lack capacity and receive sizeable donor resources do or do not participate in the design and implementation of health campaigns (2). Patterson's main argument and takeaway is that African actors in health governance are far from powerless – African actors are agents in global health governance and the interplay of international, state and societal factors contribute to their agentic behaviour. Patterson combines theoretical insights from international relations theory and contemporary African politics, along with a multi-method research design, including interview and focus group data to theorise the ways in which African actors in acquire and practice agency across scales of governance.
After providing a detailed discussion on the patterns of African involvement in health policy and programmes, Africa's unique public health challenges, and the role of global health governance actors, Patterson creates a typology of African involvement in global health governance based on the framing and/or designing of global health policies and state implementation of global health policies. Patterson argues African states and health actors can acquire and practice agency in three ways: acceptance – which includes the use of rhetoric to shape and adopt policies; challenge global health norms when they are undeveloped, contradictory, and are perceived to undermine the identities of African actors; and ambivalence, particularly when global health structures are in flux, vague, or lack institutional homes (19–20). Patterson discusses variations of health conditions and disease characteristics across Africa and focuses the analysis on three health conditions: the AIDS pandemic, the 2014–2015 Ebola Outbreak in West Africa, and the increasing prevalence of non-communicable diseases (NCDs). The methodological approach allows Patterson to make tangible and empirical connections between seemingly disparate health conditions. Patterson examines acceptance in the context of global AIDS governance (Chapter 2), challenge in the West Africa Ebola outbreak (Chapter 3) and ambivalence with NCDs (Chapter 4).
The structure of the book is straightforward and accessible. The extensive fieldwork data allow for both a narrow examination of health conditions and policy outcomes in countries like Liberia, Botswana and Uganda, and a detailed view of how international norms and institutions shape the framing of health outcomes on the continent of Africa. For example, in Chapter 2, Patterson concludes that African states focus on AIDS because it fosters patronage networks (exhibited in Tanzania and Zambia), AIDS institutions become entrenched in African states through the institutionalisation of universal access to antiretroviral therapy, and enables the state to increase its power and legitimacy over civil society by engaging in global AIDS governance. Similarly, Patterson's discussion of Liberia and the World Health Organisation's respective responses to Ebola exemplifies the tension between the domestic and international, and finds social mobilisation of civil society (particularly NGOs and religious leaders) as the mechanism that provides the agentic capacity for African actors to challenge global health governance.
While Patterson demonstrates how Africans display and practice agency in spite of systems of dependence created by global international structures and state characteristics such as neopatrimonialism and democracy, identifying the process in which Africans arrive at their agency is sometimes elusive. In Chapter 3, there is a long discussion about the framing, institutional development and the activities associated with the governance of NCDs, yet the discussion of African agency in this context is lost and tethers agency to inherently transactional features of governance such as resource funding and political sway (159–62). Theoretically, the book could draw from literature on norm localisation to build on how African actors construct local interpretations of foreign ideas, as the typology of acceptance, challenge, and ambivalence inadvertently reifies top-down features of norm diffusion and leaves out how these acts and their associated micro-processes lead to the construction of routinised African practices and norms in global health governance.
Patterson engages in the tough task of highlighting the multifaceted nature of global health governance and contributes an empirically and theoretically sound account of how African actors navigate, respond and contribute to health outcomes. The book eschews notions of African dependency on Western countries and institutions and makes significant contributions to the growing empirical inquiry of African agency in global governance.
