Hybrid norms and the politics of integration: evolving linkages between global health security and universal health coverage

This thesis examines the evolving relationship between global health security (GHS) and universal health coverage (UHC), two dominant – yet historically fragmented – normative agendas shaping global health. While GHS prioritizes preparedness and response to acute health threats, UHC emphasizes equitable access and affordability of health services. Despite growing recognition of their interdependence, meaningful integration between GHS and UHC remains limited in policy and practice – potentially weakening coordination and undermining public health outcomes, especially during crises. The COVID-19 pandemic created an inflection point, accelerating discussions on their alignment and potential synergies. However, existing scholarship lacks a robust theoretical framework to explain how two established and influential norms can co-evolve without one subsuming the other. This thesis addresses this gap by introducing two related concepts, rooted in constructivist international relations and political science literature: ‘hybrid norms’ (a framework for tracing the construction, convergence, and coherence of previously-distinct norms and their associated regimes) and the ‘politics of integration’ (a lens for unpacking the strategic processes of framing, negotiation, and institutionalization that shape normative integration). The study unfolds through three empirical chapters, each interrogating GHS-UHC integration at successive stages of development, reflecting the hybrid norm framework. The first empirical chapter traces their historical (re)construction through major crises and international agreements, employing a discursive analysis of key policy texts to argue that both norms have been shaped through repeated interaction and contestation, rather than linear adoption. The second empirical chapter utilizes a multimethod qualitative analysis to examine recent diplomatic negotiations (WHO Pandemic Agreement and the 2023 UN Political Declaration on UHC), analyzing normative convergence between GHS and UHC through the co-promotion of complementary discourse and core functions – while also revealing how political contestations, institutional path dependencies, and operational trade-offs constrain deeper integration. The third empirical chapter uses thematic analysis of key informant interviews to explore how stakeholders across governments, global health organizations, donors, and civil society conceptualize and operationalize GHS-UHC coherence in practice. It finds that a hybrid norm linking GHS and UHC is emerging, which may help overcome geopolitical power asymmetries, foster strategic collaboration across diverging actor priorities, and enable more integrative forms of diplomacy to better address multiple overlapping crises. This project offers novel contributions to global health policy and governance, constructivist norm theories, and international relations and political science scholarship. Empirically, it traces the emergence of a hybrid norm linking GHS and UHC through diplomacy and institutional design – revealing how normative integration unfolds incrementally across geopolitical and operational contexts in response to longstanding fragmentation. Conceptually, it introduces a new framework that reorients integration from a technical fix to a dynamic, contested, and co-evolving normative process to improve cross-sector collaboration and coordination. Methodologically, it advances a real-time discursive analysis approach for studying norm development across overlapping regimes through global negotiations. Taken together, these contributions provide a new lens for understanding the politics of integration, and offer fresh insights and practical implications for building a more equitable, resilient, and sustainable global health architecture.