14 Conclusion Flashcards
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Overview Summary
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This session brings together material from across this module to help you understand the distinct nature of global health policy making, what actors are involved, and what processes are engaged in furthering collective action. After reviewing the key concepts and frameworks, in relation to the issues covered in this module, we will consolidate your learning by discussing evaluation and good governance principles as two ways of strengthening global health policy making.
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Overview Aims
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The aims of this session are to provide you with a summary of the key concepts covered in this module, as they apply to specific issues in global health, and to understand the role of evaluation and good governance principles in strengthening global health policy making.
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Overview Learning objectives
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By the end of this session you should be able: to reflect on the concepts described in Session 1 (Introduction) and how they apply to the issues covered in this module; to understand the distinct nature of policy making within a global context; to apply an evaluation framework for improving policy making to a given global health issue; to understand the criteria for assessing what is “good” global policy including effective global health governance; and to draw lessons from across the module on the challenges of strengthening global health policy making.
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Key terms formative evaluation
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A type of policy evaluation which assesses the operations of a programme at a relatively early stage, while activities are forming, for the purpose of improving the programme and its implementation (Limbani et al., 2019).
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Key terms goal evaluation
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A type of evaluation which assesses the extent a goal set by a policy is desirable, appropriate or feasible (Fischer and Morgenstern, 2008).
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Key terms good governance
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A set of principles to assess how well public institutions conduct public affairs and manage public resources including transparency, accountability, representativeness, effectiveness and the rule of law (Kickbusch and Gleicher, 2012).
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Key terms impact/outcome evaluation
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A type of evaluation which assesses the broader intended or unintended consequences of a policy beyond an agreed goal (Fischer and Morgenstern, 2008).
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Key terms policy evaluation
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A systematic process for assessing the design, implementation and outcomes of public policies (Mookerji and Meck, 2015).
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Key terms process evaluation
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An assessment of whether the adoption and implementation of a policy decision has been carried out in accordance with agreed or appropriate procedures (Limbani et al., 2019).
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Key terms summative evaluation
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A type of policy evaluation which seeks to determine the extent to which a policy achieved its intended goals (Limbani et al., 2019).
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1 What is ‘Global’ about Global Health Policy?
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In Session 1, you were introduced to a framework that sets out what is global about a global policy. In this section, we will briefly review the key concepts related to this framework and how they apply to several of the issues covered in this module.
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1.1 Summary of Key Concepts
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Let’s begin by reviewing three basic concepts from Session 1
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1.1 Summary of Key Concepts Policy
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can be defined as a “broad statement of goals, objectives and means that create the framework for activity” which translates the intentions of government into action. Policy can often take the form of explicit written documents but may sometimes be implicit or unwritten (Buse et al. 2012).
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1.1 Summary of Key Concepts Public policy
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is 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 (Soroos, 1991).
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1.1 Summary of Key Concepts Health policy
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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. This includes policies of both the public and private sectors, as well as health and non-health sectors (Buse et al., 2012).
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1.1 Summary of Key Concepts
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You will also recall the framework put forth by the Global Policy Journal which describes how public policy has become “global” (Figure 14.1). If we apply these concepts and framework to some of the health issues covered in this core module, how do they measure up? To what extent do they concern global health policy making?
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Q
1.1 Summary of Key Concepts Six components of global policy
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1 Globally relevant risks and collective acton problems, 2 International policy coordination, 3a) normative theories of global governance and it’s reform 3b) competing discourses of global governance, 4 The shift from national level to bloc level, 5 The shift from unipolar to multipolar governance, 6 Innovations in global governance
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Q
1.2 Pandemic Diseases
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The emergence and spread of a pathogen, for which there is limited or no immunity in human populations, poses a globally relevant risk. Pathogenicity (capacity to cause disease), virulence (capacity to cause severe or harmful illness) and transmissibility (capacity to be passed on from one organism to another) vary across different pathogens, determining the degree of global risk posed. Applied to influenza viruses, for example, the H1N1 outbreak in 2009 proved to be highly pathogenic and transmissible, but not highly virulent (i.e. causing severe illness) for most people. In contrast, between 2003-2020, there have been 861 reported human cases of the highly pathogenic and virulent H5N1 avian influenza virus across 17 countries, resulting in 455 deaths (53% case fatality rate) (WHO, 2020b). To date, H5N1 has not been highly transmissible from person-to-person. Preparing for the worse-case scenario of pandemic influenzas, namely a highly pathogenic, virulent and transmissible virus, such as during the 1918-20 pandemic, which caused between 50-100 million deaths worldwide, is a clear collective action problem within and across countries. While not as pathogenic or virulent as the H5N1 influenza virus, the novel coronavirus SARS-CoV-2 which emerged in 2019, causing the coronavirus disease (COVID-19) pandemic, illustrates how severe public health and wider societal impacts can still be from viruses with low pathogenicity (~80% of people develop mild or asymptomatic cases) and moderate to medium transmissibility (based on information available to date) (Chen, 2020). As of June 2020, there have been over 7 million reported cases causing more than 400,000 deaths worldwide (WHO, 2020a). The economic and social impacts have been widespread and profound.
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1.2 Pandemic Diseases
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The risks of pandemics, from influenza and other types of viruses, has led to closer international policy coordination via such initiatives as the WHO-based Global Influenza Surveillance Network. Coordinated by WHO, the network is underpinned by an international network of collaborating centres and national/regional influenza centres. Internationally agreed national pandemic preparedness plans have been developed by many governments based on WHO guidelines. Since the 1990s, efforts have been made to improve fragmentation in public health surveillance systems for emerging diseases, notably zoonotic diseases, through such initiatives as WHO’s Global Outbreak and Alert Network, Healthmap.org and One Health initiatives led by WHO, Food and Agriculture Organization and World Organization for Animal Health (Morse et al. 2012).
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1.2 Pandemic Diseases
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Vaccine development and treatment with anti-viral drugs have been historically approached from a largely biomedical perspective, with disease surveillance primarily serving the purpose of providing data on circulating strains for vaccine and drug development. However, in 2007, the Indonesian government objected to being obliged to share virus samples with the global health community. It argued that Indonesia, along with other LMICs, would not in return have equitable access to vaccines developed from such samples by private pharmaceutical companies due to affordability and availability.
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1.2 Pandemic Diseases
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The debate revealed competing discourses or normative theories about global governance. Amid concerns about equity and fairness, efforts were made to ensure benefits sharing. However, how these benefits should be created and shared remain points of debate, with policy positions on a bloc level (coalition of diverse actors) not yet formed.
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1.2 Pandemic Diseases
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There has been support for reform of the Global Influenza Surveillance Network amid dispute over the norms or values underpinning collective action. A neoliberal-based model leaves the development and distribution of vaccines and anti-virals to the competitive market of pharmaceutical companies. In contrast, a communitarian approach argues that access should be based on need, rather than ability to pay for such drugs. Recognising the dependence of vaccine development on virus samples, and the benefits of ring-fencing outbreaks at an early stage, public health advocates have made efforts to find innovative solutions in global governance. The agreement of the Pandemic Influenza Preparedness (PIP) Framework, which came into effect in 2011, represents an effort to find a compromise among the above normative theories by integrating market-based and equity principles.
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1.3 HIV/AIDS
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The human immunodeficiency virus (HIV), which can lead to the disease acquired immunodeficiency syndrome (AIDS), poses a globally relevant risk because of the scale of the pandemic caused and the cross-border spread through the effects of population mobility. The number of people living with HIV/AIDS has grown from 8 million in 1990 to around 37.9 million in 2018, affecting all regions of the world. As a result, the issue has elicited extensive international policy coordination for prevention, control and treatment of the disease. For example, collective efforts have been focused over the past two decade on expanding access to anti-retroviral (ARV) treatment, especially in low and middle-income countries and among those affected by poverty.
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1.3 HIV/AIDS
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International cooperation on HIV/AIDS, from the 1980s onwards, has been characterized by differences in normative theories regarding HIV/AIDS, with competing discourses regarding the global governance of HIV/AIDS. This has broadly taken the form of tensions between a focus on the biomedical aspects of the disease, and recognition of the broader links between HIV/AIDS and human rights, poverty and equity. The prominence of civil society organizations, notably people living with AIDS, in advocating for increased research and action on HIV/AIDS worldwide successfully shifted policy making from the national to multi bloc level (Smith et al. 2017).
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1.3 HIV/AIDS
Since the mid 1990s, the diffusion of influence on HIV/AIDS policy, from WHO as the focus (unipolar governance), to many institutional actors (multipolar governance), some but not all working through the Joint United Nations Programme on HIV/AIDS (UNAIDS), is also a notable feature of global policy. Finally, there has been substantial institutional innovation to collectively address the disease. The formation of UNAIDS by six co-sponsoring UN organizations to fight one disease, resolutions in the UN General Assembly and UN Security Council, creation of a wide range of global public-private partnerships led by the Global Fund to Fight HIV/AIDS, Malaria and Tuberculosis, and innovative financing of anti-retroviral treatments such as UNITAID, all represent innovations in global health governance. In this sense, HIV/AIDS is a good example of an issue that has given rise to global policy making.
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1.4 Noncommunicable Diseases
Session 4 of this module discusses noncommunicable diseases (NCDs) such as cardiovascular disease, cancers, Type 2 diabetes and chronic respiratory diseases as globally relevant risks. This is not only because their incidence is substantial and growing worldwide, killing 41 million people annually and accounting for 71% of deaths (WHO, 2018), but because this upward trend is driven by globalization. Our diets, level of physical activity, natural and built environments, smoking and drinking habits, for instance, are being shaped by transnational corporations, trade liberalization and other aspects of economic globalization.
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1.4 Noncommunicable Diseases
Recognition of the global factors that are contributing to these trends has prompted calls for greater collective action. One good example of international policy coordination is the WHO Framework Convention on Tobacco Control (FCTC) which came into effect in 2005. The FCTC negotiation process highlighted different normative theories and competing discourses of global governance, namely how strongly regulated the tobacco industry should be, the scope of that regulation, and whether or not it should be a national level or even individual behavioural responsibility only. The negotiation process also reflected a shift from national to bloc level policy making, with consensus building within various WHO regions (especially the Western Pacific and African regions) as negotiations progressed. The European Union also closely coordinated its policy positions. At the same time, there was a shift from single to multi-polar policy making, with new countries and regions coming to the fore to assert their positions. Brazil, Thailand, China, India, South Africa and many other emerging countries were all prominent during the negotiations, alongside the more usually dominant countries of the USA, European countries and Japan (Lee, 2020). The funding of the US$20 million STOP (Stopping Tobacco Organizations and Products) Initiative by the Bloomberg Philanthropies (2018) is an example of how non-state actors remain central to global tobacco control efforts.
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1.4 Noncommunicable Diseases
Another good example is the 2011 UN General Assembly High Level Meeting on Chronic Diseases which issued a Political Declaration on the Prevention and Control of Noncommunicable Diseases. This was followed by a UN resolution (2014) and High Level Meeting (2018) to intensify shared efforts including national targets to reduce risk factors and underlying social determinants for NCDs. The 2030 Agenda for Sustainable Development, from which the Sustainable Development Goals (SDGs) were developed, recognises non-communicable diseases as a major challenge. To support countries in their national efforts, WHO developed a Global action plan for the prevention and control of NCDs 2013-2020, which includes nine global targets that have the greatest impact on global NCD mortality. These targets address prevention and management of NCDs. However, these efforts remain in their infancy, with efforts focused at the intergovernmental level.
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1.4 Noncommunicable Diseases
There has been much evidence of normative theories about the causes of NCDs, most notably the contrast between explanations based on individual behavioural choices and structural or systemic factors. At the same time, powerful vested economic interests (e.g. food and drink, tobacco, alcohol companies) populate the policy landscape, advocating for individual choice rather than regulation of industry. It will take some time for us to have a multi-bloc policy process or multi-polar governance for chronic diseases. Nonetheless, advocacy groups are beginning to mobilise to influence policy debates and are expected to increasingly contribute to global policy making on chronic diseases in coming years. This includes ideas for innovations in global governance such as marketing restrictions, and higher taxation or minimum pricing on unhealthy food and drink.
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1.5 Access to Medicines
Access to medicines demonstrates the tensions that can arise in global health policy making between commercial and public health goals. The risks from lack of access may ostensibly be faced by individuals requiring such medicines, but such risks can become globally relevant if lack of access means an increased likelihood of a disease spreading more readily across populations and geographies. Timely access to anti-viral drugs, for example, can serve to ring-fence a pandemic influenza outbreak. Increased access to anti-retrovirals (ARVs) in resource-limited settings has contributed significantly to reducing adult mortality from HIV/AIDS. There is also evidence of preventive benefits, by reducing the population level viral load, and thereby reducing the overall risk of transmission.
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1.5 Access to Medicines
Normative theories divide the debate between those who see equity of access to key medicines as a basic human right, and those who approach the production and consumption of medicines in market-based terms. Should access to essential medicines be a fundamental entitlement for all people, regardless of ability to pay, or should access to essential medicines only be available to those who can afford to pay for them? Normative theories even disagree on what might be considered ‘essential’ medicines.
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1.5 Access to Medicines
While there seems limited evidence to date of a shift, from national to multi bloc level policy making, or single to multipolar governance, among global health issues, access to medicines is an issue that has generated perhaps the most innovative forms of global governance. Given the substantial economic stakes involved, this may be due to the desire to find workable solutions to the impasse between intellectual property rights and the need for affordable medicines to meet priority health needs. The Doha Declaration on the Trade-Related Aspects of Intellectual Property Rights (TRIPS) Agreement, Public Health and follow up Decision on Paragraph 6, along with the previously mentioned Pandemic Influenza Preparedness Framework are examples of efforts to reconcile intellectual property rights and equity of access to medicines through, for example, compulsory licensing to produce generic drugs. Innovative financing mechanisms to fund increased access through, for example air ticket surcharges, debt relief, bond issues and drug purchase facility, have also proliferated. UNITAID formed in 2006, for example, is funded by the levying of surcharges on airline tickets.
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1.6 Global health impacts of Illicit Trade
Collective action is essential to address the growth of illicit trade in a globalising world. Although illicit drugs, tobacco products and counterfeit medicines are globally relevant risks in themselves, criminal groups are known to engage in several types of illicit activity, often using the same supply and distribution networks, and financial mechanisms to launder proceeds. These activities are enabled by increased globalisation in the form of worldwide communication and transportation systems, and financial deregulation. The interconnected nature of illicit trade means that the public health community must work across sectors, and individual governments must work across countries, to be effective.
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1.6 Global health impacts of Illicit Trade
There have been varied efforts to strengthen international policy coordination on illicit trade. Interpol is an international body that conducts law enforcement across member states. On counterfeit medicines, WHO launched the International Medical Products Anti-Counterfeiting Taskforce or IMPACT in 2006, which has built coordinated networks around the world. IMPACT comprises a partnership between international organizations, non-governmental organizations, enforcement agencies, pharmaceutical manufacturers associations and regulatory associations and is divided into working groups which tackle different areas related to counterfeit medicines. The UN Office on Drugs and Crime issues a World Drug Report to improve understanding of the illicit drug trade and foster international cooperation for countering its impact on health, governance and security (UNODC, 2020). The FCTC Protocol to Eliminate the Illicit Tobacco Trade, which entered into force in 2018, commits acceding state parties to adopt a variety of agreed measures to combat the trade.
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1.6 Global health impacts of Illicit Trade
In summary, here is a reminder of the six components applied to the global health issues covered in this core module which were presented in the introduction (Figure 1). Overall, the six components are a useful way of thinking about what makes a health policy issue potentially global, and the degree to which policy making on an issue needs to therefore be undertaken at the global level. Where no ticks are indicated, this does not necessarily mean that an issue is not globally relevant. What it does mean, in many cases, is that we do not have sufficient evidence at present to make this assessment. We will look at the need to strengthen the evidence base for global health policy making later in this session.
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Activity 1 Apply the global policy framework (Figure 1) to sessions of this module not covered in this section. Complete Table 1 by identifying what is global about each remaining global health policy issue.
Your response should have included specific examples for each of the remaining global health policy issues. For instance:
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Activity 1 Application of the Framework to Health-Related Illicit Activities
Although counterfeit medicines, cigarette smuggling and organ trafficking pose individual challenges in themselves, criminal groups often engage in several types of illicit activities at the same time, using the same supply and distribution networks, and financial mechanisms to launder proceeds. These activities are enabled by increased globalization in the form of worldwide communication and transportation systems, financial deregulation, and trade and investment liberalisation. The capacity of individual governments to regulate and police such illicit activities is limited by resources, knowledge and jurisdictional boundaries. You may have mentioned how Interpol is an international entity that has sought to regulate some of these illicit activities since they pose globally relevant risks which require collective action. In the case of counterfeit medicines, WHO launched the International Medical Products Anti-Counterfeiting Taskforce or IMPACT in 2006, which has built coordinated networks to halt the production and sale of fake medicines around the world. The IMPACT comprises a partnership between international organizations, non-governmental organizations, enforcement agencies, pharmaceutical manufacturers associations and regulatory associations and is divided into working groups which tackle different areas related to counterfeit medicines. The FCTC Protocol to Eliminate Illicit Tobacco Products requires acceding governments to adopt a variety of agreed measures to combat the trade. Despite recognized need for more coordinated action to address health-related illicit activities, differences in laws and in their enforcement, sensitive issues such as jurisdiction, and the sheer scale and reach of global crime have directly challenged the capacity for effective international policy coordination. It is for this reason, perhaps, that there is limited evidence of a shift, from national to multi bloc level policy making, or single to multipolar governance.
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Activity 1 Application of the Framework to Population Mobility
Population mobility has also increased in scale and reach in a more globalised world. Population mobility poses diverse challenges for health policy at both the national and international levels. At the international health policy level, migration can pose globally relevant risks through the transportation of pathogens from one place to another. A review by Smith et aliii of 12,000 infectious disease outbreaks, found that the number of outbreaks and causal diseases (20%) increased significantly from 1980-2013. Bacteria, viruses, zoonotic diseases (originating in animals) and those caused by pathogens transmitted by vector hosts were responsible for the majority of the identified outbreaks. Many global outbreaks of international concern, in turn, have been linked to increased population mobility of human populations amid globalization. SARS, pandemic influenza, viral haemorrhagic fevers, MERS and Zika are examples of diseases which have spread through population movement. The revised International Health Regulations (IHR) agreed at the 2005 World Health Assembly (WHA) seeks to provide a policy framework focusing specifically on migration-related risks of infectious diseases of international concern. Subsequent WHA resolutions in 2007 and 2008 put greater emphasis on migrant rights and health care needs. Furthermore, there are several international treaties that include provisions to protect migrants’ rights to health demonstrating how despite little international policy-level attention to the health and human rights of migrants, there is a push towards international policy coordination in this area. Needless to say, there has been little bloc formation or multipolar governance so far in this area. And little innovation as a result.
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Activity 1 Application of the Framework to Carbon Reduction and the Health Sector
Large-scale anthropomorphic or human-induced changes to the natural environment have generated major global public health threats such as increased exposure to reservoirs of zoonotic diseases, clean water scarcity, disasters, food scarcity and population displacement. Many emerging infectious diseases are specifically related to environmental changes due to urbanization, transport and travel, deforestation, climate change, and other related variations. Importantly, environmental degradation is not only a local problem, but can have implications for wider ecosystems and even the world. Given globally relevant risks which require collective action, the United Nations Environment Programme (UNEP) is the leading global environmental authority, is mandated to promote international policy coordination in the field of the environment; provide general policy guidance; review the implementation of environmental programmes; promote the contribution of different scientific communities, and exchange environmental knowledge. However, although it is clear that action is needed to reduce deterioration of the environment, and mitigate the impacts, there remain conflicts about the causes of global environmental change. These reflect particular normative theories which are undoubtedly shaped by different economic and political interests, interpretations of evidence and ideas about the appropriate legal measures available to protect the environment. Global policy making is tasked with reaching consensus on collective action to address environmental change as a key health determinant.
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2 Evaluation in Global Health Policy
In this module, and other core modules of the GHP MSc, we have analysed global policy making as distinct from national policy making. We learned how global policy making may seek to address four types of collective action problems. We also learned that global policy making involves many types of actors, spanning individuals (e.g. technical experts, political leaders) and groups of varying sizes (e.g. partnerships, civil society organisations, epistemic communities, national governments). These actors engage in policy processes spanning across populations in different countries (e.g. advocacy coalitions, policy networks, health diplomacy) to reach consensus on addressing collective action problems. We then examined global policy making related to a range of issues (e.g. pandemic diseases, population mobility).
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2 Evaluation in Global Health Policy
Now that we have learned about the main features of global health policy, across a wide range of issues areas, it is important to understand how well global health policy achieves desired goals. This section discusses the role of policy evaluation and how it can be used to improve global health policy.
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2.1 Policy Evaluation Policy evaluation is regularly used in all areas and levels of policy making as a source of learning and improvement. Policy evaluation is a systematic process for assessing the design, implementation and outcomes of public policies (Mookerji and Meck, 2015). There are four main reasons for conducting a policy evaluation: to assess the merit and worth of a policy; to improve a policy, related programmes and, by extension, the organization delivering the policy; to provide oversight and compliance; and to develop knowledge. An evaluation may be carried out by the organisation itself or, more ideally, by parties independent of the policy making body concerned (Rist, 1995).
Policy evaluation is regularly used in all areas and levels of policy making as a source of learning and improvement. Policy evaluation is a systematic process for assessing the design, implementation and outcomes of public policies (Mookerji and Meck, 2015). There are four main reasons for conducting a policy evaluation: to assess the merit and worth of a policy; to improve a policy, related programmes and, by extension, the organization delivering the policy; to provide oversight and compliance; and to develop knowledge. An evaluation may be carried out by the organisation itself or, more ideally, by parties independent of the policy making body concerned (Rist, 1995).
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2.1 Policy Evaluation In global health policy, policy evaluation is conducted regularly for the above purposes. Key organisations, such as WHO (2018a), World Bank (2019) and Global Fund (2019), have agreed frameworks and principles for evaluating their activities. As Mookherji and Meck (2015) write, however, “the context for global health interventions and their evaluations has become more complex in the 21st century.” This is due to the increase in funding initiatives, multiplicity and diversity of actors, and the disbursed nature of policy processes (e.g. advocacy coalitions). In such cases, evaluation can be more challenging but even more important to carry out.
In global health policy, policy evaluation is conducted regularly for the above purposes. Key organisations, such as WHO (2018a), World Bank (2019) and Global Fund (2019), have agreed frameworks and principles for evaluating their activities. As Mookherji and Meck (2015) write, however, “the context for global health interventions and their evaluations has become more complex in the 21st century.” This is due to the increase in funding initiatives, multiplicity and diversity of actors, and the disbursed nature of policy processes (e.g. advocacy coalitions). In such cases, evaluation can be more challenging but even more important to carry out.
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2.2 Formative and Summative Evaluation
When seeking to evaluate global health policy, it is useful to distinguish between formative and summative evaluation. Formative evaluation examines the operations of a program, usually for the purposes of improving its content and assessing its implementation. Formative evaluations are done at relatively early stages of policy development to inform its further formulation or refinement. This type of evaluation “ensures that a program or program activity is feasible, appropriate, and acceptable before it is fully implemented” (Salabarría Peña et al. 2007). It is usually conducted when a new program or activity is being developed or when an existing one is being adapted or modified. In other words, full operationalisation or implementation of a policy has not yet occurred, and changes or amendments can still be made (see Box 1 for an example).
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2.2 Formative and Summative Evaluation Box 1: Formative evaluation of the UNFPA Innovation Fund
In 2014, the UNFPA established an Innovation Fund with financial support from the Danish government to generate a cultural shift within the organization towards innovation. As of July 2016, the Innovation Fund received 148 proposals and selected 18 for funding. A formative evaluation was conducted by UNFPA to achieve the following objectives: provide key learning and inputs to managers regarding the implementation of the initiative’s first phase; improve programme design, processes, and systems; and inform the next UNFPA Strategic Plan and UNFPA strategies in the area of innovation.
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2.2 Formative and Summative Evaluation
A summative evaluation seeks to determine the extent to which a policy underway for a substantial time period, or already completed, has achieved its intended goal(s). A summative evaluation is usually undertaken when a policy is quite advanced in implementation, to determine whether to end, amend, or extend the policy (see Box 2 for an example).
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2.2 Formative and Summative Evaluation Box 2: Summative evaluation of the UNICEF Catalytic Initiative to Save a Million Lives
The Catalytic Initiative to Save a Million Lives (CI) is “an international partnership with the goal of strengthening health systems to accelerate progress on the health-related Millennium Development Goals (MDGs)”. To achieve this objective, the CI sought to “strengthen health systems by delivering life-saving health and nutritional services to disadvantaged children and pregnant women to dramatically reduce child and maternal mortality” in Africa and Asia. A summative evaluation was conducted in 2014 to achieve the following objectives: Relevance: In terms of alignment to national priorities and plans, enhanced policy environment, and promotion of gender equity. Effectiveness: Effect on strengthening the six (WHO) building blocks of the health system and the capacity of government and/or civil society organizations to train, equip, deploy, and supervise front-line health workers to deliver a limited package of proven, high impact and low cost health interventions. Impact: Effect on coverage of selected maternal, newborn and child health and nutrition interventions, particularly integrated Community Case Management (iCCM), which were supported by the IHSS programme; as well as the effect on the number of additional lives saved by the IHSS programme calculated using the Lives Saved Tool (LiST) disaggregated by groups of interventions (e.g. iCCM) and by individual interventions according to the phases of the programme. Sustainability: The cost of implementing iCCM and the organisational and financial sustainability of this programme.
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2.2 Formative and Summative Evaluation
In practice, both formative and summative evaluations are important tools at different stages of the global health policy process. Organisations engaging in continuous learning will integrate both types of evaluation into policy making.
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2.3 Goal, Process and Impact
Formative and summative evaluations, in turn, can prompt more detailed evaluation of specific goals, processes or impacts. A goal evaluation assesses the extent to which a goal set by a policy is desirable, appropriate or feasible (Fischer and Morgenstern, 2008). Does the target community agree to have a goal pursued? Is it appropriate to the needs of relevant stakeholders? Is the achievement of a goal possible within available resources, scientific and technical capability, political climate or timeframe?
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2.3 Goal, Process and Impact
A process evaluation determines whether the adoption and implementation of a policy decision has been carried out in accordance with agreed or appropriate procedures. This type of evaluation assesses how decisions are made, who is involved, how they participated, and what process is followed. According to Saunders et al. (2005), process evaluations ask questions such as: How aligned was intended and actual implementation of a program? To what extent did the program reach the targeted population? What is the broader social context within which implementation was carried out?
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2.3 Goal, Process and Impact
A good example is the use of process evaluation by the Global Alliance of Chronic Diseases to assess seven hypertension intervention trials. The evaluation analysed “whether interventions were implemented with fidelity, the extent of capacity building, contextual factors and the extent to which relationships between researchers and community impacted on intervention implementation.” The results helped “to highlight a broad range of system requirements such as new policies and capacity building to support implementation” (Limbani et al., 2019).
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2.3 Goal, Process and Impact
An impact or outcome evaluation assesses the resultant achievement of a policy by degree to which an agreed goal(s) is achieved. Importantly, an impact evaluation measures intended and unintended effects within the target population. An impact evaluation addresses such questions as: What impact, and to what degree, is the policy having on the target population and wider communities? Is the policy achieving the desired outcome? Are there any unforeseen effects of this policy? What reasons is the policy having or failing to have the desired impact?
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2.3 Goal, Process and Impact
For example, we might conclude that a new policy to increase screening of migrants at borders for tuberculosis could be deemed successful, using a process evaluation, because the policy is fully implemented. However, using an impact evaluation, we might find that cases of TB transmission are not reduced by screening of migrants because new cases are largely within the domestic population. The impact evaluation might also assess unintended effects such as deterring migrants from seeking health care or reduced migration to the country. An impact evaluation may also assess immediate and longer-term impacts. For example, an impact evaluation may seek to determine whether a new policy to cover pharmaceuticals under publicly funded health insurance increased the use of anti-viral drugs for seasonal influenza. The impact evaluation could also seek to determine if the rate of transmission slowed across an entire population over ensuing months or years as a result of the new policy. Thus, impact evaluations can be ongoing.
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2.4 Challenges in Evaluating Global Health Policy
The conduct of any type of policy evaluation is rarely simple and straightforward. Challenges may include identifying clear policy goals, accurately measuring performance, and isolating the effects of the policy from confounding or contextual factors. In addition, although policy evaluations may seek to assess policies objectively, evaluations can often be influenced by non-technical considerations such as political pressures, organisational culture or resource constraints. Policy makers might also seek to assess immediate impacts, but a policy may need a longer timeframe to demonstrate results. In global health policy, these challenges can manifest in the following ways:
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2.4 Challenges in Evaluating Global Health Policy
a) global health policy goals can be unclearly articulated or difficult to measure, characterised by broad statements of principle rather than measurable outcomes (e.g. WHO Commission on the Social Determinants of Health put forth broadly stated changes to achieve while Sustainable Development Goals put forth measurable targets);
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2.4 Challenges in Evaluating Global Health Policy
b) global health policy goals can reflect the priorities of donors, rather than target populations, which leads to disagreement about what criteria should be used in an evaluation to measure success (e.g. delivery of family planning services versus decrease in maternal and child deaths);
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2.4 Challenges in Evaluating Global Health Policy
c) global health policy can involve a large number of, and diverse, institutional actors contributing in varying ways to a policy, thus making it difficult to distinguish each of their contributions (e.g. customs officials and law enforcement agencies, alongside public health bodies, seeking to apply a new policy addressing illicit trade);
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2.4 Challenges in Evaluating Global Health Policy
d) global health policy is usually implemented amid potentially confounding factors, which cannot be controlled for, that can shape how a policy is implemented (e.g. introduction of a tax on sugary drinks coincides with the launch of a new beverage brand);
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2.4 Challenges in Evaluating Global Health Policy
e) global health policy suffers especially from a weak evidence base because, by definition, policies can apply across diverse population groups and geographical locations, thus requiring types of data that cannot be captured solely at the national level (e.g. workers health and safety in special economic zones).
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2.4 Challenges in Evaluating Global Health Policy
In summary, this section discussed the role of policy evaluation as a means of improving global health policy towards the achievement of agreed goals. The key points are as follows: Global health policies can be evaluated in different ways depending on what you are seeking to improve. It is important to be clear about these different types of evaluations and when each is appropriate to your needs. The different types of evaluations are also conducted at different points in a policy, from early stages (formative) to when a policy has been underway for some time (summative). There are particular challenges to evaluating global health policy arising from the nature of such policies, diverse actors involved, confounding factors, and weaknesses in available data.
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Activity 2 Select a global health issue covered in this module. Now select a specific global health policy initiative related to this issue. Questions: a) Reflect on how you might conduct a formative and summative policy evaluation. What would you seek to assess? b) What benefit might you achieve from conducting a goal, process or impact/outcome evaluation? Discussion Board: Please share your selected issue, initiative and ideas for evaluation on the Discussion Board.
The global health issues covered in this module are pandemic diseases, HIV/AIDS, non-communicable diseases, access to pharmaceuticals, illicit activities, population mobility, environmental change and emerging infections, sexual and reproductive health, horizontal versus vertical approaches, new aid donors, and mental health. Each of these has been the subject of specific global health policy initiatives. Here are some examples: WHO Special Initiative for Mental Health (https://apps.who.int/iris/bitstream/handle/10665/310981/WHO-MSD-19.1-eng.pdf?ua=1), Migrant Integration Policy Index (http://www.mipex.eu/what-is-mipex), and Health and Environment Linkages Initiative (HELI) (https://www.who.int/heli/en/).
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Activity 2
a) To conduct a formative evaluation, you would assess an initiative at a relatively early point in implementation, while its activities are forming. A formative evaluation of HELI, for instance, would assess the extent to which it is succeeding in supporting action by LMICs. A summative evaluation assesses the extent to which intended goals are achieved. For example, to what extent did the MIPEX lead to the integration of policies for migrants?
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Activity 2
b) These further types of evaluations can provide more critical assessments of whether an agreed goal, the process of developing and implementing the policy initiative, and wider impacts are appropriate. For example, a goal evaluation might assess whether the goal of the WHO Special Initiative for Mental Health, “to ensure universal health coverage involving access to quality and affordable care for mental health conditions in 12 priority countries to 100 million more people,” is achievable within the agreed timeframe (2019-2023). A process evaluation might be conducted to assess the ways HELI is working with LMICs (e.g. engagement, collaboration). An impact/outcome evaluation might be carried out to assess broader impacts of MIPEX on migrant health and well-being, as well as, unintended consequences such as increased or decreased priority given to migrant needs.
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3 Good Governance and Global Health Policy
Along with technical soundness, effective implementation and achievement of desired goals in global health policy, assessed and supported through various forms of policy evaluation, global health policy can be improved through principles of good governance. There is substantial evidence to suggest that policy making that adheres to good governance principles, such as representativeness, transparency, accountability and due process, is more likely to advance agreed societal goals such as improved health and well-being. By contrast, policy making that falls short of such principles is less likely to achieve desired outcomes. This section examines how good governance principles can be used to strengthen global health policy.
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3.1 Principles of Good Governance
In Session 1, we learned that governance is the formal (government) and less formal (e.g. rules, customs, norms) ways in which an organisation or society structures and organises itself, and steers towards desired goals (Levi-Faur, 2012). Governance is practiced in both public and private institutions, and operates at the local, national, regional and global levels.
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3.1 Principles of Good Governance
For the purposes of this module, on global health policy, it is useful to understand what is considered “good governance”. Good governance is a set of principles or criteria for assessing how well public institutions conduct their affairs and manage resources in way that serve the needs of the many rather than a select few. Principles have been put forth by different organisations to measure good governance. For example, the OECD (2013) identifies the following principles: Accountability: where the government is able and willing to show the extent to which its actions and decisions are consistent with clearly-defined and agreed-upon objectives which serve the public interests of a defined constituency. Transparency: government actions, decisions and decision-making processes are open to an appropriate level of scrutiny by other parts of government, civil society and, in some instances, outside institutions and governments. Efficiency and effectiveness: the government strives to produce quality public outputs, including services delivered to citizens, at the best cost, and ensures that outputs meet the original intentions of policymakers. Responsiveness: the government has the capacity and flexibility to respond rapidly to societal changes, takes into account the expectations of civil society in identifying the general public interest, and is willing to critically re-examine the role of government. Forward vision: the government is able to anticipate future problems and issues based on current data and trends and develop policies that take into account future costs and anticipated changes (e.g. demographic, environmental, economic). Rule of Law: the government enforces equally transparent laws, regulations and codes.
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3.1 Principles of Good Governance
The UNDP (2011) cites eight principles of good governance as “critical for developing and implementing effective and equitable policy measures to mitigate the impact of economic crises” including:
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3.1 Principles of Good Governance
Participation/inclusion: the empowerment through representation in government and through other (e.g., administrative and local) mechanisms facilitating free, active and meaningful participation in decision making processes.
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3.1 Principles of Good Governance
Non-discrimination and equality: the addressing of power inequalities (political, economic, legal, or cultural) and extension of development gains to the most excluded groups and individuals.
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3.1 Principles of Good Governance
It is important to recognise that the specific principles put forth to assess good governance are embedded within normative (value-based) frameworks. Some argue that certain principles reflect the values of liberal democratic societies and, as such, may not be appropriate for assessing public institutions in countries with different forms of government. For example, the giving of gifts to public officials is considered acceptable, and indeed, expected in many countries to facilitate policy making. In other countries, this practice is strictly regulated and even prohibited as potentially corrupting of officials appointed to serve public interests on an impartial basis. Others, however, argue that there are universal principles emerging that can be applied to public institutions in all countries. For example, it is broadly agreed that people impacted by a policy decision should be consulted either through direct participation or indirectly through representation.
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3.1 Principles of Good Governance
A broader way of thinking about good governance, beyond public institutions, is to consider the rules governing relationships among state (government), market (commercial) and civil society actors. At the national level, the composition of government, and how different parts of government conduct their affairs in relation to market and civil society actors, are generally set out in formal rules. The extent to which these rules lead to benefits shared by the populace, and are adhered to by different societal actors, can thus be a measure of good governance (van den Dool et al. 2015).
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3.2 How to Assess Good Governance in Global Health Policy?
When we move beyond the national level, to the global health policy arena, the assessment of good governance can be more challenging but equally important. Evidence suggests that global health policy often falls short of good governance principles. For example, a study by Esser and Keating (2011), of official development assistance and grants from private foundations to 27 low and middle-income countries from 2005-2007, found their purpose often did not correspond to national patterns of disease burden. As a result, funding too often reflects the priorities or latest initiatives of the donor rather than the recipient. Given their relative importance, inflows of aid can sometimes influence a government’s national health policy, possibly distorting the distribution of limited resources towards donor priorities. Good governance principles help assess the link between how decision making is carried out (i.e. who participates, who are decision makers accountable to) and the resulting decision.
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3.2 How to Assess Good Governance in Global Health Policy?
Similarly, the Lancet-University of Oslo Commission on Global Governance for Health (2014) identifies several systemic global governance dysfunctions including inadequate representation (democratic deficit) and weak accountability. Among the many recommendations of the Commission are: There should be independent monitoring of progress made in redressing health inequities, and in countering the global political forces that are detrimental to health (accountability). State and non-state stakeholders across global policy arenas must be better connected for transparent policy dialogue in decision-making processes that affect health (transparency)
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3.2 How to Assess Good Governance in Global Health Policy?
The application of good governance principles to global health policy is challenged, in particular, by the diversity of actors involved. Good governance principles are usually applied to assess public or private sector entities which are clearly delineated. However, global health policy often brings both together as public-private partnerships or global public policy networks. These coalitions of global health actors may seek to pool resources, create and share knowledge, or amplify their voices for advocacy purposes. The Roll Back Malaria Partnership, for example, facilitates collaborative efforts among government agencies, multilateral organizations, NGOs and the private sector to improve health services, promote bednet use, and support vaccine and drug treatment. The Global Research Collaboration for Infectious Disease Preparedness (GLOPID-R) brings research groups together to facilitate collaboration, knowledge sharing and dissemination. The Framework Convention Alliance, Global Fund to Fight AIDS, Tuberculosis and Malaria and UNAIDS are also examples of global policy networks. Policy networks can also be regional in nature such as the Africa Regional Network of Health Systems Global, to facilitate learning and knowledge exchange.
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3.2 How to Assess Good Governance in Global Health Policy?
According to Kickbusch and Gleicher (2012), governance in the 21st century is undergoing a shift towards whole-of-government and whole-of society approaches to reflect the changing nature of the challenges facing societies. So-called “wicked problems” such as climate change, pandemics and population movements require systems approaches and networked responses at all levels which force policy makers to move out of their silos. The complexity of global health policy, with its diversity of actors and innovative institutional arrangements, can be understood in this context. Good governance principles are thus needing to be adapted in ways that allow the assessment of policy making in this emerging environment. For example, in creating the Global Fund, its governance bodies incorporated representation beyond governments to include civil society organizations, patient groups and private companies. In an era of digital technology, inequities in participation in global policy making may be partially addressed.
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3.2 How to Assess Good Governance in Global Health Policy?
In summary, this section has examined how global health policy can be strengthened through principles of good governance. The key points to consider are: Several principles have been put forth by various organizations for the purpose of assessing governance from local to global levels. It is important to recognize that these principles are norm or value-based, with many developed to apply universally. Good governance principles have traditionally focused on assessing either public or private sector entities. However, forms of governance advancing global health policy in the 21st century reflect the need for whole-of-government and whole-of-society approaches. There is a need to adapt and apply principles of good governance to this emerging global health policy environment in ways that support collective action to address shared goals.
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Activity 3 Please watch this video (link) and respond the following questions: a) What policies are being transferred from foreign aid donors to Bangladesh? b) What is the main form of foreign exchange according to the interviewees and what significance does this have for foreign aid? c) What are mentioned as obstacles for Bangladesh to become independent of aid? d) How does this example relate to the OECD (2013) principles for good governance?
Due to the influence of foreign aid, policy changes are being undertaken according to a neo-liberal framework. Projects are becoming more expensive and aid is being used as a tool to further the interests of the donor country, especially benefitting their companies. Aid is not seen as tackling the root causes of the problems related to poverty and development, but rather as being perpetuated in order to foster dependence on the donor country. Remittances and export-oriented industries are discussed as the main sources of foreign income with foreign aid contributing a small contribution to the budget. However, the percent of aid is not the issue in discussion but how despite its small amount in economic terms, the entry of foreign consultants and projects has an important effect on policy-making in the country. Corruption, lack of political will, accountability issues and a weak democracy where there is little political participation from the citizens, are seen as the main obstacles for Bangladesh to be self-sufficient. The issue of government accountability is raised by the interviewees, as well as transparency in terms of corruption and rule of law. Efficiency and effectiveness are mentioned when they discuss the issue of management of remittances and taxation, which if improved could increase the internal capital of the government. There is no mention in the video, however, of issues regarding responsiveness and forward vision.
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Integrating activity The 2014–2016 outbreak in West Africa was the largest and most complex Ebola outbreak since the virus was first discovered in 1976, resulting in more cases and deaths than all previous outbreaks combined. There was much criticism of the global response to the outbreak, with attention focused on WHO. Several reviews of the global response were subsequently carried out to understand how to strengthen future outbreak preparedness.
Read the Report of the Harvard-LSHTM Independent Panel on the Global Response to Ebola found here: https://www.thelancet.com/action/showPdf?pii=S0140-6736%2815%2900946-0 and then answer the following questions:
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Integrating activity a) To what extent can this Ebola virus outbreak be considered a global health policy issue?
a) While the Ebola virus outbreak of 2014-2015 was largely limited to west African countries, with only a few cases outside of the region, recalling the six components of Figure 1, the outbreak can be considered a global health policy issue in several respects. The need for international policy coordination was evident during the outbreak including the UN-led mobilisation of resources for the global response to the outbreak, rapid development of a vaccine, and deployment of support on the ground. The outbreak led to a shift from single polar to multi-polar governance with the founding of the Africa Centres for Disease Control and Prevention (Africa CDC) in 2016, as a specialised technical body of the African Union. The Africa CDC describes itself as guided by such principles as leadership, credibility, ownership, delegated authority, timely dissemination of information, and transparency (https://africacdc.org/about-us/). The outbreak prompted innovations in global governance including the World Bank Pandemic Emergency Financing Facility (PEF) intended to enable rapid mobilisation of financing to fight future pandemics (World Bank, 2020). The perceived delays in the disbursement of funds for COVID-19 raised questions about the PEF’s usefulness.
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Integrating activity b) What type(s) of evaluation did this review undertake?
b) While not stated explicitly, the Independent Panel can be described as conducting an impact evaluation in its assessment of how well the global response to the outbreak achieved the goals of containing the virus transmission and preventing deaths. The Panel concluded that the global response was lacking in a number of ways and thus conducted, in part, a process evaluation to understand how decision making was undertaken that shaped the global response. Strictly speaking, the Panel did not conduct a policy, goal or summative evaluation of a specific policy. Rather, the Panel assess the broader global governance of outbreaks and identified a variety of weaknesses needing urgent attention.
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Integrating activity c) What good governance principles were considered during the review?
c) The weaknesses in the global response to the Ebola virus outbreak relate to several good governance principles. For example, the Panel calls for “a clear strategy a clear strategy to ensure that governments invest domestically in building such capacities and mobilise adequate external support”. The strategy should “be supported by a transparent central system for tracking and monitoring the results of these resource flows.” On WHO’s inability to respond to the outbreak, the Panel concludes that “clear lines of accountability should be created at WHO.” The Panel’s recommendations on improving the global system for preventing and responding to outbreaks includes good governance reforms by the WHO Executive Board.
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Summary
We can summarise the final session of this module with the following key points: Global health policy has become a major area of collective action by the state, market and civil society. There is a need to better understand global health policy both descriptively, as a complex and innovative area of policy making, and to strengthen collective action to address global health challenges. Global health policy evaluation can draw on established approaches and methods but faces particular challenges. There is a need to strengthen the evidence base for global health policy, the process of global policy making, and the sharing of experiences via policy transfer to underpin emerging forms of global health governance.
