1 Introduction Flashcards
Introduction Summary
GHM104 Issues in Global Health Policy is the fourth of four compulsory modules for the Global Health Policy Master of Science, Postgraduate Diploma and Postgraduate Certificate courses. This module introduces key concepts, theories and methods that will help you understand the following sessions.
Introduction Aims
The aims of this session are to provide you with a brief introduction to the structure and content of this module. The session also familiarises you with key concepts to be explored in this module related to policy making in global health
Introduction Learning Outcomes
By the end of this session, you will achieve the following objectives: 1· to understand what is policy making and, specifically, what is global health policy making; 2 · to recognise the specific challenges of making health policy in a global context; 3 · to apply selected approaches and frameworks to the analysis of policy making on key global health issues; and 4 · to understand the purpose, structure and content of the remaining sessions of this module.
Key terms Collective action
An agreed action undertaken together by a group of people to achieve a common objective
Key terms Epistemic community
A transnational network of knowledge-based experts who, given their technical expertise, influence what issues are addressed by policy makers and the ways to potentially resolve them
Key terms Evidence-based policy
An approach that seeks to inform public policy with rigorously established objective evidence
Key terms Evidence-informed policy
An approach to policy decisions that aims to ensure that decision making is well-informed by the best available research evidence
Key terms Framing
A way of packaging and positioning an issue, such as a policy problem, that promotes a particular problem definition, causal interpretation, moral evaluation and/or treatment recommendation
Key terms Global governance
The formal and informal institutional arrangements and processes, including rules and decision making, operating among state and non-state actors for collective action on shared issues
Key terms Global health diplomacy
Policy-shaping processes through which state and non-state actors negotiate responses to health challenges, or utilise health concepts or mechanisms to achieve non-health political, economic or social objectives
Key terms Global health governance
The formal and informal institutional arrangements and processes, including rules and decision making, operating among state and non-state actors for collective action on shared health issues
Key terms Global health policy
Policy that concerns the goals, rules and actions that address, or have an impact on, the health determinants, needs and impacts that transcend the boundaries of individual countries
Key terms Global policy making
A process of multi-level policymaking, by public and private actors, which involves and transcends national, international and transnational policy regimes
Key terms Global public policy network
A loose alliance of government agencies, international organizations, corporations, and elements of civil society such as nongovernmental organizations, professional associations, or religious groups that join together to achieve what none can accomplish on its own
Key terms Governance
The formal (government) and less formal (e.g. rules, customs, norms) ways in which a society structures and organises itself and steers towards desired goals
Key terms Health policy
A type of public policy concerned with principles or rules to guide decisions and achieve rational outcome(s) that affect the set of institutions, organizations, services and funding arrangements of the health system. This includes policies of both the public and private sectors, as well as health and non-health sectors
Key terms Policy
A broad statement of goals, objectives and means that create the framework for translating intentions into action to address an identified problem. Policy can often take the form of explicit written documents but may sometimes be implicit or unwritten
Key terms Policy network
The formation of formal and informal relationships among a particular set of actors around an issue of importance to the policy community
Key terms Public policy
A decision made by a publicly elected or designated body which is deemed to be in the public (as opposed to private) or common interest
- What is Global Health Policy? What is Global Health Policy?
Policy can be defined as a “broad statement of goals, objectives and means that create the framework for activity” to address an identified problem. Policy can often take the form of explicit written documents but may also be implicit or unwritten. The key distinction is that policy is a principle or rule to guide decisions and achieve an identified outcome. It does not normally describe what is actually done (which is more accurately referred to as a procedure or protocol) (Buse et al. 2012).
- What is Global Health Policy? What is Global Health Policy?
While policy making is relevant to both the public and private sectors, in this module, we will focus on policy for public interests (i.e. public policy) as adopted and implemented by governments and intergovernmental organisations (e.g. UN bodies). Public policy is a decision made by a publicly elected or designated body which is deemed to be in the public interest (Goodin et al. 2011). The decision seeks to achieve a desired goal considered to be in the collective interests of society. A public policy might be directed at an entire population, for example, the development of improved public transport or an improvement in local air quality. Or a public policy might be targeted at a selected population group, for example, a reduction in the rate of teenage pregnancies in disadvantaged communities or an increase in physical activity among older people. Thus, the formulation of public policy involves a process of making appropriate decisions for the public good. This is distinct from a policy that serves a private interest such as how an individual should allocate their savings to different types of financial investments, or how a company should deploy its workforce to optimise sales.
- What is Global Health Policy? What is Global Health Policy?
How might we apply the above to understanding global health policy? Health policy is a type of public policy concerned with principles or rules to guide decisions and achieve rational outcome(s) that affect the set of institutions, organizations, services and funding arrangements of the health system (Buse et al. 2012). This includes policies affecting the activities of both the public and private sectors which impact on health; as well as policies taken in the health sector and the many non-health sectors (e.g. education, transport, environment, housing) which impact on the broad determinants of health.
1.1 Types of Collective Action Health Problems Types of Collective Action Health Problems
Globally relevant risks and collective action problems arise from the intensification of globalization. In an increasingly interconnected world, the fortunes of populations across multiple countries, and sometimes across all countries, are linked and even interdependent. As described by Lee (2015), globalisation is having direct and indirect impacts on many health determinants and outcomes. These impacts, in turn, are leading to different categories of health problems requiring collective action (Soroos 1991): Each of these problem types need to be addressed through collective action by multiple actors across different jurisdictions.
1.1 Types of Collective Action Health Problems Transboundary or cross border problems
Originate in one state but have ramifications for others (e.g. refugees fleeing conflict, pollution spillovers). Many infectious disease outbreaks, such as the Zika virus or novel coronavirus (COVID-19), begin in one country but are readily spread across national borders to other countries through the movement of disease vectors and/or people.
1.1 Types of Collective Action Health Problems Commons problems
Concern disputed access and/or use of international commons (e.g. oceans). The right to assert intellectual property claims over biological materials, for the purpose of using them in commercialized activities, has become the subject of global health policy. Public versus private ownership of life-saving treatments and vaccines, such as for COVID-19, and the conditions for accessing them, is another example of a commons problem.
1.1 Types of Collective Action Health Problems Shared problems
Are widely experienced in many countries (e.g. cyber bullying). The acceleration of economic globalization has led to the worldwide spread of unhealthy lifestyles, urbanized built environments and common cultural practices. As a result, there are a growing number of shared health problems across many societies. These include the rise of tobacco and alcohol-related diseases, increase in non-communicable diseases such as diabetes and hypertension, new trends in mental health and addictions, and a growth in road traffic accidents.
1.1 Types of Collective Action Health Problems Planetary problems
Have causes or consequences on a scale involving the world as a whole. These problems may arise from individual actions, such as burning fossil fuels, which then have cumulative effects on a planetary scale (i.e. climate change). The over- or misuse of antibiotics in many countries is having cumulative effects that are detrimental to all (i.e. antibiotic resistance). This category of problem requires collective action to address them effectively but, arguably, is also the most difficult to achieve policy agreement because of the broad distribution of responsibility for causing and solving the problem.
1.2 Global Policy making Global Policy Making
The study of health policy at the national and subnational levels is well-established, with many theories and models of how policy making takes place. Scholars often begin with the stages of a rational policy cycle, an ideal model that sets out linear steps, from agenda setting to policy implementation, to monitoring and evaluation (Figure 1.1). In reality, of course, policy making is rarely rational or linear in process. Nevertheless, this model helps identify the different parts of the policy process. Furthermore, while the precise process of policy making will vary across specific jurisdictions, these levels of policy making focus around formal state institutions and actors, with recognized mandates, authority and resources to adopt and enact policy.
1.2 Global Policy making The policy making cycle
Policy formation -> Decision making -> Policy implementation -> Monitoring and evaluation -> Agenda setting -> Policy formulation
1.2 Global Policy making Global Policy Making
At the global level, where there is no equivalence of government, health policy making is far messier in terms of actors, processes and outcomes. Institutions with the mandate and authority of a government ministry, for example, do not exist at the global level.
1.2 Global Policy making Global Policy Making
The World Bank and International Labour Organisation (ILO), for example, are the closest to global-level ministries of finance and labour. However, both have circumscribed roles, lack the formal authority to make decisions binding on their member states, and can be dominated by high-income country interests. As the Global Policy Journal (2014) describes, The field of global policy focuses on the global as a process (or set of processes) that creates transcontinental or interregional flows and networks of activity and interaction, and the new framework of multi-level policymaking by public and private actors, which involves and transcends national, international and transnational policy regimes. Eventually, global policy processes can lead to agreement by relevant actors to work together in a concerted and coordinated action.
1.3 How can we identify a global health policy? How Can We Identify a Global Health Policy?
The Global Policy Journal identifies five further components of global public policy: 1 · international policy coordination; 2 · different and competing conceptions of what constitutes global order and relevant policies; 3 · a shift from national to ‘bloc’ level policy making; 4 · a shift from single polar to multi-polar governance; and 5 · innovations in global governance. We consider each of these in turn below.
1.3 How can we identify a global health policy? International policy coordination
This is happening in a wide range of areas which do not fit into the category of globally relevant risks and collective action problems. For example, actions to promote equal rights and international standards are developing in many policy spheres. This is occurring for several reasons, such as the increasing interconnectedness of public opinion and economic forces, resulting in companies and consumers seeking assurance that child labour or worker health and safety are being appropriately regulated in developing economies.
1.3 How can we identify a global health policy? International policy coordination
There are many examples in global health policy of international policy coordination. The WHO/UNICEF International Code of Marketing of Breast-milk Substitutes agreed in 1981, “to promote breast-feeding and to overcome problems that might discourage it” (notably by manufacturers), was the first code adopted under the auspices of WHO to coordinate international policy. In 2010, the problem of health worker migration became the subject of a Code of Practice on the International Recruitment of Health Personnel. The Code contains a set of principles to be followed by signatory member states to reduce the problem of “brain drain” in low-resource settings. Sessions in this module will look at the challenges of relying on international policy coordination to deal with access to medicines and illicit trade. The adoption of an International Protocol on forced labour by the ILO in 2014 “addresses existing gaps and strengthens the body of instruments on forced labour, including child labour, trafficking in persons, slavery and slavery-like practices and related human rights violations” (ILO, 2014).
1.3 How can we identify a global health policy? Different and competing conceptions of what constitutes global order and relevant policies
Normative theories (i.e. theories concerning what is right or wrong, desirable or undesirable, or just or unjust) of global governance are undergoing rapid development and change. Norms, for instance, shape thinking about what should be the relative roles of the state (government) versus markets, what should be the relative importance of democratic freedoms versus social order, or what should be the basic entitlements of each citizen? Importantly, previously dominant normative frameworks such as neoliberalism, which value market competition and economic growth, may be giving way to new frameworks which value sustainability and human rights. The important points here is that norms shape the nature of global governance and these norms are not fixed but change over time.
1.3 How can we identify a global health policy? Different and competing conceptions of what constitutes global order and relevant policies
As the need for collective action is increasingly recognized in global health, different normative theories of global health governance are emerging and, in many cases, competing for policy space. As described above, norms derive from agreed values about what is considered right or wrong, desirable or undesirable, or just or unjust within a society (Soroos, 1991). As Kamradt-Scott (2015) writes, norms are “standards of behaviour” or “collective expectations about proper behaviour for a given identity”. Debates about user fees for health services, the appropriate roles of the public and private sector in global health partnerships, and the achievement of universal health coverage are underpinned by competing normative theories. McInnes and Lee (2012) analyse how norms of security, biomedicalism and economism, for example, have influenced the framing of HIV/AIDS, tobacco control and pandemic influenza. The importance of normative theories runs through the entire module but two sessions, in particular, on global health equity, and the debate between horizontal versus vertical approaches to health development, highlight their impact in global health policy. The remaining components of global public policy concern ways that conventional ‘domestic’ policy making is increasingly going beyond a single country focus. These are:
1.3 How can we identify a global health policy? A shift from national to ‘bloc’ level policy making
New political formations (i.e. the institutional arrangements that are formed within a society to carry out policy making) are emerging beyond the state in two main areas. First, in the European Union, a great experiment in ‘joining up’ national policy approaches is underway, which has already introduced important changes in how the 27 member states make public policies across many sectors. A growing range of public health issues are being addressed through directives such as patients’ rights in cross-border healthcare; good clinical practice in conducting clinical trials of medicinal products for human use; and tobacco advertising. In other regions, this trend has not progressed as far. Second, the development of complex patterns or regionalism, often involving greater economic policy integration, in North and South America, the Asia-Pacific area and sub-Saharan Africa can be observed. These patterns have emerged partly as responses to globalization, and partly as attempts to shape it. Sessions in this module look at collective efforts to address environmental change and health, and tobacco control, which have both seen bloc level policy making in an effort to reach international agreement on ways forward.
1.3 How can we identify a global health policy? A shift from single polar to multi-polar governance
Over the next half century, world order may shift, from being dominated by one centre of power (namely the USA), to several regional blocs based around the EU, USA, China, India and Latin America. Each of these regional blocs will evolve different policy approaches and styles which are likely to have important effects. The G20 group of countries, for example, may experience a revival as economic and political power is more widely dispersed. Are regional blocs, and different policy approaches and styles, emerging in global health? Brazil’s internationally acclaimed HIV/AIDS program, which includes universal access to antiretroviral treatment, has been influential in shaping programs in other low- and middle-income countries. The rapid growth of China as a significant aid donor since the mid 2000s, led by the Belt and Road Initiative (launched in 2013 as a vast collection of development and investment initiatives stretching from East Asia to Europe), has included an exponential growth in health development assistance (US$652 million by 2017) (Micah et al. 2019). One session in this module looks at the advent of new health aid donors as a possible reflection of the shift to multi-polar health governance.
1.3 How can we identify a global health policy? Innovations in global governance
Innovations in the institutional arrangements, rules and processes by which societies steer themselves towards the achievement of agreed goals have emerged in recent decades. These innovations are a response to frustrations with the slow and increasingly “gridlocked” efforts of existing intergovernmental mechanisms (i.e. UN bodies) to effectively address pressing global issues (e.g. climate change, human rights, cybersecurity). These include movements bringing together a diverse collection of actors (citizens, private corporations, NGOs, subnational governments) into coalitions to promote collective action on emerging global risks and challenges. These coalitions may vary in their composition, legal standing, and activities (Kahler et al., 2017).
1.3 How can we identify a global health policy? Innovations in global governance
To what extent are innovations in global governance occurring to address emerging global health risks and challenges? What weaknesses can we identify in existing arrangements for bilateral and multilateral cooperation, and what efforts are being made to overcome them? There has been an especially prolific growth of public-private partnerships and innovative financing mechanisms in global health governance. Sessions in this module, such as Session 3 on the political economy of the global AIDS response, also examine the increased role of civil society and the private sector in innovative global health governance arrangements.
1.3 How can we identify a global health policy? Six components of global policy
Global risks and challenges. Policy levels (nation-states, regional blocs and global governance). 1 Globally relevant risks and collective action problems. 2 International policy coordination. 3 a) Normative theories of global governance and its reform b) competing discoures of global governance. 4 The shift from national level to bloc level. 5 The shift from unipolar to multipolar governance. 6 Innovations in global governnace.
1.3 How can we identify a global health policy? How Can We Identify a Global Health Policy?
In summary, applying the Global Policy Journal framework to health, it is clear that there is a domain which we can describe as global health policy. A growing array of health issues, arising from a more interconnected world, now pose collective action problems which require policy making beyond individual states. At the same time, the conduct of policy making at the national versus global levels is very different given the complexity of actors, distribution of authority, and existing institutional arrangements for advancing agreed goals.
Activity 1 Which of the following is not a public policy goal?
a) The introduction of fluoridation to a local municipality’s drinking water. Feedback: a) is a public policy. Fluoridated water is intended to confer benefits to the oral hygiene of the general population having access to the treated water supply.
Activity 1 Which of the following is not a public policy goal?
b) The immunisation of the members of one family against seasonal influenza. Feedback b) is not a public policy. While immunisation confers benefits beyond individuals, the decision to immunise members of a single family for seasonal influenza would not be considered a public policy goal because it is intended to give private benefits to a relatively small number of individuals.
Activity 1 Which of the following is not a public policy goal?
c) An increase in the amount that can be reimbursed to a member of parliament (MP) for the costs of running their constituency offices. Feedback c) is a public policy. The change in policy regarding the reimbursement of housing costs to a member of parliament (MP) is a decision intended to improve the ability of MPs to serve the interests of their constituencies. As such, this would be considered a public policy decision.
Activity 1 Which of the following is not a public policy goal?
d) The provision of grants to improve the insulation, and thus the energy efficiency rating, of privately-owned homes. Feedback d) is a public policy. Similar to (c), the provision of a grant to improve the insulation of a home, even if privately-owned, would be considered a public policy decision because it is intended to address the collective problem of global warming by reducing the energy consumption of individuals.
- Global Health Policy and the Three Pillars of Government
A useful starting point for understanding global policy making is to think about three branches of government typically found at the national level and their respective responsibilities. The three branches are: legislature, executive, judiciary. All three are supported by a bureaucracy of civil or public servants, technical and administrative staff who carry out the work of the three branches of government (Blondel, 2014).
- Global Health Policy and the Three Pillars of Government Legislature
The legislative branch is responsible for the adoption of a country’s laws. This process involves the tabling of new laws (bills), discussion and revision of draft laws by representatives of the country’s citizens (e.g. members of parliament, senators), and the formal adoption of laws (or revision of existing laws). Members of a legislature (elected or appointed) are responsible for making decisions in the public interest.
- Global Health Policy and the Three Pillars of Government Executive
The executive branch is responsible for implementing laws adopted by the legislature. The executive is usually supported by a bureaucracy comprised of civil servants who implement public policy decisions enacting laws.
- Global Health Policy and the Three Pillars of Government Judiciary
The judicial branch is responsible for enforcing laws. It consists of a system of courts of law, whose primary function is to hear cases that challenge legislation or require interpretation of that legislation.
- Global Health Policy and the Three Pillars of Government
There are diverse institutional configurations of these three branches of government across different countries which will vary by what they are called and their specific functions. However, one important principle in many countries is the “separation of powers”. This means that the functions of each branch are kept separate and distinct. This is intended to protect the misuse of power or threats to the public interest by creating a system of “checks and balances” (Persson et al., 1997).
- Global Health Policy and the Three Pillars of Government
When we move beyond the national level, there are some, but not wholly equivalent, bodies which serve as legislature, executive and judiciary. However, these bodies are more circumscribed in scope and powers. Government equivalent to the national level largely does not currently exist above the level of countries. Plenary bodies (e.g. UN General Assembly, European Parliament), are the equivalent of legislatures, where representatives of member states of regional and international organizations meet to discuss global health problems and, in some cases, make policy decisions. The degree to which these decisions are “binding” on member states, requiring compliance to their stipulations, varies substantially. Policies embodied in treaties are legally binding under international law, while compliance with codes and resolutions are voluntary (Soroos, 1991).
- Global Health Policy and the Three Pillars of Government
In general, non-binding policy instruments are far more common in global health. The principle of state sovereignty means that the state has autonomous authority over its own territory and people and, thus, it is not subject to legal control by other states or obligations of international law. This principle, dating from the Treaty of Westphalia (1648), codifies the basic principles of territorial integrity, border inviolability, and supremacy of the state. It also means, with few exceptions, that there is an absence of overarching “supranational” authority above the state. This state of “anarchy”, as scholars of international relations describe the international system, means that there is no authority above sovereign states that can compel states to behave in a given way unless they agree to do so under treaty obligations (Lee and Kamradt-Scott 2014).
- Global Health Policy and the Three Pillars of Government
This lack of supranational authority above the state means that there are important institutional differences between policy making at the national level versus the global level. If we look again at the three branches of government, we can see that their existence, and functions they perform, exist to a more limited degree at the global level. For example, a fully developed legal system at the global level does not exist. Does this mean that global policy making does not take place? The firm answer is no. There is global policy making, including global health policy making, but it is undertaken in a very different way from national policy making (Soroos 1991).
- Global Health Policy and the Three Pillars of Government “Legislature”
In GHM102 (The Politics of Global Health) module, you learned about global health governance, what it means and the key institutions that currently contribute to it. One important international organisation is the World Bank. If we consider the institutional structure of the World Bank, we can see that the Board of Governors, described as “the highest governing body” containing “a seat for every member of the institution,” can be seen to play a legislative role. This means that the representatives of all member states of the World Bank (usually a country’s minister of finance, governor of its central bank, or a senior official of similar rank) regularly meet to set World Bank policies to govern the organisation and its member states (World Bank 2020).
- Global Health Policy and the Three Pillars of Government “Legislature”
Similarly, WHO’s legislative body is known as the World Health Assembly where WHO’s member states meet annually. Each member state is represented by a delegation usually led by a minister of health. The WHA meets to discuss and debate global health issues and priorities, and then makes decisions on the organisation’s work programme, budget and election of WHO officials. Decisions are made through consensus, rather than voting, and are generally non-binding on member states (i.e. resolutions, recommendations) (Lee 2009).
- Global Health Policy and the Three Pillars of Government “Executive”
There are many executive bodies at the international level which are responsible for implementing the decisions taken by legislative bodies. The Board of Directors of the World Bank (2020) is one example. Comprised of Executive Directors, the Board is responsible for: …the conduct of the general operations of the Bank and exercise all the powers delegated to them by the Board of Governors under the Articles of Agreement. The Executive Directors select a President who serves as Chairman of the Boards. The Executive Directors approve the President’s contract and have the authority to remove the President from office.
- Global Health Policy and the Three Pillars of Government “Executive”
In WHO, the executive body is known as the Executive Board whose 34 members meet twice yearly to give effect to decisions taken by the WHA. The WHO Secretariat, at the headquarters, regional and country levels, help implement decisions, as well as support decision making processes by the WHA and Executive Board (Lee 2009).
- Global Health Policy and the Three Pillars of Government “Judiciary”
The judiciary is the least developed of the three pillars of government at the global level, in large part, because of the principle of state sovereignty described earlier. National governments are very reluctant to create bodies that have a higher authority over themselves. Nevertheless, bodies playing a judicial role have been created. The Dispute Settlement Body of the World Trade Organisation (WTO) is a good example of a body playing a judiciary role, serving to resolve trade disputes between member states of the WTO. Its decisions are binding and enforceable through sanctions such as tariffs. Importantly, WHO does not have a judiciary body. Policy decisions made by WHO are, for the most part, recommendations such as resolutions requesting member states to take a particular action. As such, member states are encouraged to adhere to adopted resolutions, but they are not bound to do so. Two exceptions are the International Health Regulations (2005), which are binding on member states, and the Framework Convention on Tobacco Control (FCTC) agreed in 2003. Yet, even for these two international treaties, there is no stipulated authority or resources for WHO to enforce compliance through either incentives or punitive measures. Instead, WHO must rely on maintaining positive relationships with member states, moral suasion or public pressure (Lee 2009). The lack of “teeth” by WHO, to enforce compliance with the IHR (2005), was a major concern during the early period of the COVID-19 pandemic.
Activity 2.1 For the following countries, give the name for each of the three branches of government
a) Japan. Legislature (National Diet [House of Representatives and House of Councillors]). Executive (Prime Minister, Cabinet [Ministers of State] and ministries. Judiciary (Supreme Court and three lower courts)
Activity 2.1 For the following countries, give the name for each of the three branches of government
b) Brazil. Legislature (National Congress [Chamber of Deputies, Federal Senate]) Executive ( President, Cabinet [Ministers of State] and ministries). Judiciary (Supreme Federal Tribunal and federal/state courts)
Activity 2.1 For the following countries, give the name for each of the three branches of government
c) Saudi Arabia. Legislature (King advised by Consultative Assembly) Executive (King/Prime Minister, Council of Ministers) Judiciary (King, Sharia Courts and specialised administrative tribunals)
Activity 2.1 For the following countries, give the name for each of the three branches of government
d) Cote d’Ivoire. Legislature (National Assembly) Executive (President, Cabinet [Ministers of State] and ministries) Judiciary (Supreme Court, the High Court of Justice, State Security Court and lower courts)
Activity 2.1 For the following countries, give the name for each of the three branches of government
e) Norway. Legislature (Storting [Great Council]) Executive (King [symbolic head of state], Prime Minister, Council of State) Judiciary (Supreme Court [Hoyeterett] with 18 permanent judges and a president, courts of appeal, city and county courts, conciliation councils and High Court of the Realm)
Activity 2.2 Indicate which pillar of government (legislature, executive, judiciary) each of the following parts of the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria is equivalent to: a) board, b) technical review panel, c) partnership forum
The examples provided so far are drawn from intergovernmental organizations, that is, organizations whose members are countries. There are many global health policy actors whose membership is comprised of both state and non-state actors (e.g. Global Fund to Fight AIDS, Tuberculosis and Malaria and the Global Alliance on Vaccines and Immunisations). The governance structures of these organizations vary in their composition due to differences in purpose, funding and membership.
Activity 2.2 Board
The Board is the supreme governing body of the Foundation. Its powers include setting policies and strategies for the Foundation; setting operational guidelines, work plans and budgets for the Secretariat and the Technical Review Panel; and making funding decisions. As such, it should be considered the executive body. In some ways, the Board plays a legislative role, serving as a plenary body with 20 representatives of donor governments, communities, NGOs, private sector and foundations.
Activity 2.2 Technical Review Panel
The Technical Review Panel is an independent, impartial team of experts appointed by the Board to guarantee the integrity and consistency of an open and transparent proposal review process. It reviews applications submitted for Fund support, makes recommendations to the Board, and undertakes such other functions as may be directed by the Board. It can be seen as equivalent to a judiciary.
Activity 2.2 Partnership Forum
The Partnership Forum is a plenary body open to a wide range of stakeholders that actively support the Fund’s objectives, including representatives of donors, multilateral development cooperation agencies, developed and developing countries, civil society, NGO and community based organizations, technical and research agencies, and the private sector. It is equivalent to a legislature, in that representatives of stakeholders can express their views and feed into the decision making process. However, the Partnership Forum does not have the authority to make policy decisions itself (held by the Board) so its legislative role is limited.
- Understanding Global Policy Actors and Processes
After recognising how the three pillars of government are currently embodied at the global level, as a rather messy collection of institutional arrangements, it is important to understand how policy making takes place in this context. Beyond formal roles, it is useful to consider the power and influence of actors. Policy analysis begins by focusing on appointed officials, civil servants and other actors holding formal authority to make policy decisions. In addition, other types of actors such as interest groups and advocates are necessary to consider.
3.1 Global Health Policy Actors
At the global level, a similarly broad range of actors should be observed. While officials of international organizations and member state delegates formally make decisions, there are other actors to take into account. For example, Haas (1992) describes the increased role of epistemic communities defined as “networks of knowledge-based experts…[who articulate] the cause-and-effect relationships of complex problems, helping states identify their interests, framing the issues for collective debate, proposing specific policies, and identifying salient points for negotiation” (Haas 1992). Epistemic communities are particularly notable in global health policy in the form of groups of scientists, health professionals, technical experts and consultants with specialist knowledge. For example, the WHO Executive Board is composed of 34 individuals selected, not as representatives of their countries, but for their expertise and experience. By contrast, the WHO World Health Assembly is attended by national delegates of member states who represent their countries in an official capacity.
3.1 Global Health Policy Actors
Another useful approach is to focus on the capacity of policy actors to shape normative frameworks. WHO and other global health actors lack supranational authority (i.e. powers above the level of the state). As a result, consensus building in global policy making is especially important. Actors who can influence the norms of what the global community considers to be desirable or aspirational will be able to assert greater policy influence. Kamradt-Scott (2015) describes how WHO acted as a norm entrepreneur by advocating for certain social norms (e.g. reciprocity, solidarity) during the reform of the International Health Regulations. In this way, global actors do not just enforce rules created by member states but can influence the direction of change by shaping the social norms that frame an issue in a particular way. For example, increasing access to anti-retrovirals gained policy traction in the mid 2000s by being reframed as an issue of fairness and social justice. One might thus see the global policy arena as a battleground of multiple, and often competing, normative frameworks put forth by a diversity of public and private sector actors.
3.1 Global Health Policy Actors
A related approach to understanding global health policy processes is to see them as policy networks. In contrast with formal, often hierarchical policy structures within the three pillars of government, networks are a looser, more interconnected set of relationships. Through networks, participants can build alliances, establish norms, and construct the consensual knowledge that defines a policy community (Bennett 1991). Importantly, networks also enable national level actors to operate beyond their domestic context. Networks are the means by which organizations, individually and collectively, can inject their policy ideas further (Stone 2004). Reinecke (1999) defines global public policy networks as “loose alliances of government agencies, international organizations, corporations, and elements of civil society such as nongovernmental organizations, professional associations, or religious groups that join together to achieve what none can accomplish on its own”.
3.1 Global Health Policy Actors
An example of such a network is global tobacco control. Despite the substantial health burden inflicted by tobacco use since the early 20th century, tobacco control remained a relatively low priority in public health policy. The process of negotiating the Framework Convention on Tobacco Control (FCTC) included the formation of a global public policy network which brought together civil society organisations, health practitioners, scholars, policy makers and governments (Lee, 2020). This coalition led by the Framework Convention Alliance played a critical role in creating and sharing information and mobilising public support for stronger tobacco control across the world.
3.2 Global Health Policy Processes
One way of understanding global health policy processes is to distinguish between vertical and horizontal policy making. Vertical policy is “developed within a single organisational structure and generally starts with broad overarching policy” (Torjman, 2005). A good example is WHO’s Global Influenza Programme which provides member states with strategic guidance, technical support and coordination of activities essential to make their health systems better prepared against seasonal, zoonotic and pandemic influenza threats to populations and individuals. The focus of the Programme’s work is on surveillance, monitoring and reporting.
3.2 Global Health Policy Processes
Horizontal policy “is developed by two or more organisations, each of which has the ability and mandate to deal with only one dimension of a given situation. Horizontal or integrated policy is created between parts of an organization or among organizational components that are similar in hierarchical position” (Torjman, 2005). The adoption of the Global Pandemic Influenza Action Plan in 2006 to increase vaccine supply reflected the need for coordinated action beyond surveillance and reporting. While initiated by WHO, the initiative involves national immunization programs, national regulatory authorities, vaccine manufacturers and the research community as key stakeholders.
3.2 Global Health Policy Processes
In general, global health problems are more likely to require horizontal policy making given their complexity. A good example is the One Health Approach which Mazet et al. (2009) describe as: The interconnectedness of human, animal, and environmental health is at the heart of One Health, an increasingly important prism through which governments, NGOs (nongovernmental organizations), and practitioners view human health. An important implication of the One Health approach is that integrated policy interventions that simultaneously and holistically address multiple and interacting causes of poor human health—unsafe and scarce water, lack of sanitation, food insecurity, and close proximity between animals and humans—will yield significantly larger health benefits than policies that target each of these factors individually and in isolation. This approach requires collaboration of experts from different disciplines such as agricultural scientists, anthropologists, economists, public health professionals, among others, to promote both human and animal health.
3.2 Global Health Policy Processes
Given the complex array of actors and processes in global health policy making, attention has been given to the concept of global health diplomacy. Global health diplomacy mediates competing interests, normative frameworks and power inequalities towards agreed policy goals. Given the absence of a singular institutional structure of global government, with supranational authority above sovereign states, negotiation of agreed policy action by consensus defines much of global health policy making. The negotiation of binding agreements, such as the FCTC and IHR, requires the skills of traditional diplomats, along with the expertise of epistemic communities. The voices of non-state actors, both for-profit and not-for-profit, may also be influential through lobbying efforts, submissions, and participation as observers or in fringe meetings (Kickbusch et al., 2007). In this context, inequities in power and influence, along with the capacity to participate in global health diplomacy, means that some actors can shape global health policy more effectively than others. This, in turn, raises questions about the adherence of global health policy to principles of good governance which is examined in Session 14 of this module.
3.3 What Factors Hinder “Good” Global Health Policy?
For the public health community, faced with many types of collective action problems, effective policy making is essential. For example, given the rising incidence of hypertension, diabetes and other chronic conditions worldwide, are there measures we should collectively take to address this trend? Similarly, what cross sectoral policies might be appropriate to mitigate future risks of pandemic diseases like COVID-19 from emerging? Global health problems require, in other words, effective human intervention or action. In this context, an important aspect of effective policy making is understanding the factors that hinder good policy making – evidence, policy coherence, accountability, equity and feasibility.
3.3 What Factors Hinder “Good” Global Health Policy? Evidence
A factor frequently pointed to in global health policy is the lack of, or inadequate use of, available evidence to support decision making. Substantial attention over the past decade has thus been given to evidence-based policy. An extension of evidence-based medicine, the essential idea behind evidence-based policy is to reduce the making of decisions based on unproven, subjective and, in too many cases, biased reasoning. Too little policy, it is argued, is driven by research-based evidence due to knowledge gaps, problems with data sharing, time pressures, political expediency and lack of understanding of science by policy makers and, conversely, policy by scientists. The formation of specialist networks (e.g. Evidence Informed Policy Network or EVIPNet), collection of new data and metrics (e.g. Global Youth Tobacco Survey) and conduct of systematic reviews of existing evidence (e.g. Cochrane Collaboration) are intended to facilitate use of evidence in global health policy. More recently, the term evidence-informed policy has been preferred in recognition of the need for diverse forms of evidence, and importance of judgement rather than technical formulas when making policy decisions.
3.3 What Factors Hinder “Good” Global Health Policy? Evidence
For the various global health issues covered in the sessions of this module, is poor evidence affecting the quality of policy making? What evidence do we have about a specific global health issue? To what extent is this evidence appropriate or accessible to policy makers? To what extent is it used by policy makers to inform decision making?
3.3 What Factors Hinder “Good” Global Health Policy? Evidence
While poor quality evidence can often be a contributing factor to bad policy making in global health, and there is much need to improve the evidence base for a broad range of global health issues, other problems can also be at play. One such problem is disagreement about the goals to be achieved by policy makers. Global health is concerned with health determinants and outcomes that transcend national boundaries. Global health policy is about making decisions that serve the public interest. This might be broadly described as minimising the harms to, and maximising the benefits for, human health arising from such determinants and outcomes. However, beyond this broad goal, agreeing more concrete and specific goals can be elusive. As Reinicke (1998) writes, One central challenge is the fact that what is and what is not in the collective or public interest often differs across countries. Hence, for global public policy to be successful, not only would participating societies have to show a willingness to cooperate in the establishment of internal sovereignty; in practice they would have to recognise and accept others’ notion of the collective interest and others’ definition of the public good.
3.3 What Factors Hinder “Good” Global Health Policy? Evidence
In other words, global public policy is not necessarily characterised by a shared collective interest. Indeed, as you will have learned GHM102, global health is a highly contested field with many different, often competing, interests and perspectives on what issues should be given priority. These differences in interest may arise between countries of varying levels of socioeconomic development. Or they may arise from individual value systems based on cultural or ideological differences.
3.3 What Factors Hinder “Good” Global Health Policy? Evidence
What is important to think about here, in progressing through this module, is that global health policy is not necessarily about reaching universal consensus on how to address a problem. This rarely, if ever, happens. It is true that global health policy, like all public policy making, is about processes that allow different interests to be expressed. However, it is also about processes for negotiating among these different interests in such ways that decisions taken serve collective interests. This usually means that some interests will gain while others will not.
3.3 What Factors Hinder “Good” Global Health Policy? Policy coherence
Policy making at any level involves engagement with, and weighing of, different actors and their interests. When we move to the global level, the number of actors increase further which can hinder effective policy making. Different actors may adopt their own policy decisions based on their specific interests. This can result in diverse and even opposing policies. As actors have proliferated, there have been substantial efforts to improve “coherence” in global health policy making.
3.3 What Factors Hinder “Good” Global Health Policy? Policy coherence
Better policy coherence means to improve coordination of the policy decisions and activities of key institutional actors. One of the longstanding problems in health development has been poor coordination – a large number of institutions doing a wide variety of activities independently, often leading to overlaps, gaps and even mutual detriment. In a 2010 speech, “The quest for a coherent global health policy,” then Director-General of the World Health Organization Margaret Chan (2010) described this serious problem as follows: There are more partners and agencies implementing programmes in health than in any other sector. The problems are familiar: duplication of efforts, fragmentation of care, high transaction costs, poor alignment with national priorities and capacities, and unpredictable funding for a sector with high recurrent costs. In 2007, for example, Vietnam hosted more than 750 donor missions. As you progress through this module, think about whether a lack of coherence poses a challenge for effective policy making for each global health issue.
3.3 What Factors Hinder “Good” Global Health Policy? Equity
Another factor identified as hindering effective global health policy is equity. Equity, in this context, concerns how policy making is carried out (i.e. to what extent appropriate interests are involved in decision making), the content of the policies taken (i.e. are the health needs of relevant stakeholders addressed by the policy), and the impact of the policies made (i.e. the fair distribution of the costs and benefits of a policy decision in the short and longer term). The effects of policy decisions might be health-related or they might be broader impacts such as economic, social or environmental. For the global health issues covered in this module, to what extent is equity a consideration in policy making? If relevant, how has the need to address equity been dealt with at the global level?
3.3 What Factors Hinder “Good” Global Health Policy? Accountability
A related factor affecting the quality of policy making is whether there are appropriate processes for reconciling or weighing up different interests at the global level. Which interest groups should feed into global health policy on a given issue? How are voices heard? Are these processes fair and equitable? Do they enable appropriate interests to contribute to decision making (and by extension exclude those that are inappropriate)? How is global consensus achieved? Do existing processes lead to decisions that are accepted as legitimate by those affected by the decisions? What rules and procedures do we have to govern the exercise of authority over decision making?
3.3 What Factors Hinder “Good” Global Health Policy? Accountability
These types of questions have been the subject of much study as the world has become more interconnected, but the political institutions we have to represent our interests remain focused on national governments. For example, the UK-based nongovernmental organisation One World Trust (n.d.), as part of its mandate of “to promote improved models of global governance,” has undertaken a variety of initiatives relevant to the task of achieving good global health policy. The Trust’s Global Accountability Project seeks to “bring greater levels of transparency and accountability to large and influential inter-governmental organisations (IGOs), transnational corporations (TNCs) and international non-governmental organisations, with the aim of enhancing their accountability to the individuals and communities they affect.” Fuller discussion of accountability will be discussed in Session 14 of this module in relation to principles of good governance.
3.3 What Factors Hinder “Good” Global Health Policy? Accountability
Similar questions are being asked about the role of the private sector (notably big corporations and related actors such as Chambers of Commerce, private foundations and industry associations), with concerns about the need to better balance the benefits of private sector involvement with the need to protect the public interest. And, of course, the role of governments remains subject to much debate. How do governments feed into the global policy making process? How can we ensure a fair voice for all governments? And, perhaps most challenging of all, given the need for collective action across governments, what should this look like? What should global health governance look like if our aim is to achieve good global health policy?
3.3 What Factors Hinder “Good” Global Health Policy? Feasibility
Finally, it is important to consider the extent to which global policy decisions are feasible to implement. Feasibility concerns the likelihood of a policy being achieved. Once a policy decision is taken, is it capable of being brought about or accomplished? There are three considerations when assessing feasibility. The first is technical feasibility. Are there appropriate technical skills, technologies, knowledge base and expertise to carry out the policy? For example, at present a vaccine for HIV/AIDS remains elusive. It would thus not be technically feasible to adopt a global health policy calling for mass vaccination to prevent HIV/AIDS.
3.3 What Factors Hinder “Good” Global Health Policy? Feasibility
Second, policies must be economically feasible. Are there sufficient resources, both monetary and otherwise, to carry out the policy effectively both immediately and in the long term? The latter concerns the sustainability of policies. While donors may provide funding to carry out polio eradication for the next five years, if this target is not achieved, will donors continue to provide funds for this purpose?
3.3 What Factors Hinder “Good” Global Health Policy? Feasibility
Third, policies must be feasible politically. Political feasibility is the extent to which policymakers are willing to adopt a public policy based on anticipated support by citizens, officials and other stakeholders. Without political feasibility, policies will not have the necessary support to move from a draft document to a formally adopted policy such as legislation. Indeed, even if a policy is assessed as technically and economically feasible, if it is not politically feasible, it will go nowhere. Of the three measures of feasibility, it is often argued that political feasibility is the most important.
3.3 What Factors Hinder “Good” Global Health Policy? Feasibility
For example, Rogers Van Katwyk et al. (2016) analyse the political feasibility for adopting an international agreement on antimicrobial resistance (AMR). They write that AMR is a global issue because “[i]nternational trade, travel, agricultural practices, and environmental contamination all make it possible for resistant microbes to cross national borders.” As a result, “collective action is needed in the form of an international agreement or other mechanism that brings states together at the negotiation table and commits them to adopt or implement policies to limit the spread of resistant microorganisms.” The study concludes that a small groups of influential countries could act as initiators of such an agreement which, when shown to be effective, could scale up global action as political support increases.
3.3 What Factors Hinder “Good” Global Health Policy? Summary
In summary, global health policy is characterised by the following features: a) uneven development of the three pillars of government at the global level; b) lack of formal power over the formal authority of sovereign states; c) greater capacity for epistemic communities of technical experts to shape global policy processes including norms; d) increased importance of working through global policy networks by alliance and coalition building, sharing discourses and construct consensual knowledge; e) greater need for horizontal policy making to deal effectively with the complex and multi-sectoral health challenges posed by globalisation; and consensus building through global health diplomacy bringing together traditional diplomats and technical experts. Beyond actors and processes, there are many factors which can potentially impact the quality and effectiveness of global health policy making. As you progress through this module, you should reflect on how these factors might explain varying degrees of success by different global health policies at achieving the desired change.
Activity 3
In each of the following global health issue areas, how do you think an epistemic community might assert policy influence? a) access to anti-retrovirals for HIV/AIDS, b) climate change and human health and c) non-communicable diseases
Activity 3 a) access to anti-retrovirals for HIV/AIDS
An epistemic community on anti-retrovirals for HIV/AIDS might influence policy decisions regarding investment of resources for research and development on future drugs, which sub-type of the virus might be prioritised for drug research and development, and which populations might be prioritised for receiving ARVs, and what priority access to ARVs should be given in wider global health policy debates.
Activity 3 b) climate change and human health
An epistemic community on climate change and human health might influence policy decisions on how urgently action should be taken, what policies should be adopted to address the human health effects of climate change (e.g. adaptation, mitigation), and what priority climate change should be given in wider global health policy debates.
Activity 3 c) non-communicable diseases
An epistemic community on non-communicable diseases might influence policy decisions on which conditions require most urgent action, what causal factors contributing to the rise in non-communicable diseases need the most concerted policy attention (e.g. lifestyle factors, corporate marketing, environmental factors), what measures would be most effective and should be adopted to address these causal factors, and what priority non-communicable diseases should be given in wider global health policy debates.
- Integrating Activity
Read the brief article, “Can scientists and policy makers work together?” by Choi et al. (2005) which can be found at: https://jech.bmj.com/content/jech/59/8/632.full.pdf. Using the discussion board, share your responses to the following questions with your fellow students and please respond to at least one other post: a) How is the work of scientists and policy makers assessed? To what extent are these criteria different? b) Who should have greater influence over global health policy - scientists or policy makers? c) How might the two worlds of the scientist and policy maker be brought closer together in global health policy making?
- Summary
In summary, this session introduces the module GHM104 Issues in Global Health Policy. The aim has been to provide you with an understanding of health policy making in the global context and introduce you to key concepts. The main points of this session are: what makes health policy global in nature can be understood by applying six components of global policy (Figure 1); • the three institutional pillars of government (legislature, executive and judiciary) are less developed at the global level than they are at the national and subnational levels which influences what actors and processes shape global health policy; • global policy making processes involves more complex configurations of actors participating in formal and informal processes (networks, epistemic communities) than at the national level due to the lack of supranational (above the state) authority; and • there is a need to address the factors which hinder “good” global health policy to achieve effective collective action. The remaining sessions in this module are intended to integrate the contents of the other three core modules of the MSc in Global Health Policy which consider economic (GHM101), politics (GHM102) and environmental aspects (GHM103). This module will bring together key concepts, approaches and issues to enhance your understanding of global health policy. The final session of this module will provide an overall summary.
