Health politics + coporations - 2.11 - 2.14; 2.16, 2.18, 2.19

Question 1

Define reverse innovation

Answer 1

Process where HICs learn from + adopt ideas developed or conceived in countries that are doing more with less, for the many

Usually a negative connotation

Question 2

Give 3 examples of reverse innovations

Answer 2

GE Mac 400 - portable, rugged design; lightweight, affordable
Orthopedic surgery - drill cover
Aravind eye hospital - 350 000 ops/year; 60% delivered at low or no cost; mid-level trained assistants

Question 3

What are the barriers to reverse innovation?

Answer 3

Post-colonial theory - imaginative geographies
Power 
Cognitive bias
Institutional 
Organisational learning

Question 4

Briefly describe the evolution of the definition of civil society

Answer 4

Classical/Ancient Western- CS = state
Modern (19th century) - CS = Inequalities + economic relationships between family and state
Post-modern (late 20th century) - CS = All non-market + non-state organisations functioning for the public good, in this case, public health

Question 5

What 2 declarations/charters highlighted the role of civil society?

Answer 5

Alma Ata Declaration (1978) - promotes maximum community…participation in planning, organisation, operation + control of primary care…appropriate education the ability of communities to participate

Ottawa Charter for Health Promotion (1986) - health promotion demands coordinated action by all concerned (including civil society)

Question 6

Name at least 3 roles of the civil society

Answer 6

Watchdog - holding institutions to account + promoting transparency + accountability
Advocate
Service provider
Expert
Capacity builder
Incubator - developing solutions that may require a long gestation/payback period
Representative
Citizenship champion
Solidarity supporter
Definer of standards

Question 7

What are the 3 change-making approaches of civil society?

Answer 7

Direct action
Lobbying
By invitation

Question 8

What is meant by civil societies using a ‘direct action’ approach for impact?

Answer 8

Action that seeks to achieve an end directly and by the most immediately effective means e.g. boycott or strike

Question 9

Give an example whereby a civil society used a direct action approach for impact

Answer 9

Act Up (1980s) - One of the first organisations that used direct action to great effect

A response to homophobic climate of 1980s + lack of any real movement to challenge the systemic inadequacies of US healthcare system

Question 10

Briefly describe the history + case study of Act Up (1980s)

Answer 10

Founded in 1987, US govt was ignoring AIDS crisis + blaming gay community for new deadly disease
ACT UP was a response to homophobic climate of 1980s + lack of any real movement to challenge the systemic inadequacies of US healthcare system

1987 - 250 members protested in Wall St (due to drug companies) - demand for greater access to HIV/AIDS drugs + national policy to deal with AIDS crisis
1988 - members took action against Cosmopolitan magazine for publishing misleading + harmful info about AIDS + sex
1991 - draped giant condom over homophobic Republican Senator Jesse Helms with ‘Helms is Deadlier than a Virus’; US Gulf war began, ACT UP drew connections between military spending and lack of funds for AIDS

Question 11

What are the wins of ACT UP (1980s)? (x3)

Answer 11

1) Federal funding to combat AIDS increased tenfold between 1986 - 1992
2) Targeted corporations lowered price of drugs
3) PWA (people w/ AIDS) representation on boards setting policies for Tx

Question 12

What is meant by civil societies using a ‘lobbying’ approach for impact?

Answer 12

Still stood outside a decision-making space but INFLUENCE decision-makers

Question 13

Give a case study whereby a civil society took a ‘lobbying’ approach

Answer 13

TTIP (Transatlantic Trade + Investment Partnerships) 2016

Consumer interest organisations + shifted public opinions giving political capital to influence policy - directly communicated with EU officials

Mixture of inside + outside tactics but really effectively took specific issues to focus on

Question 14

What is meant by civil societies using a ‘by invitation’ approach for impact?

Answer 14

Invited actively as stakeholders

Stated in SDGs 2030

Question 15

Give a case study whereby a civil society took a ‘by invitation’ approach for impact

Answer 15

FCTC 1999 - present (Framework Convention on Tobacco Control)

Civil society has ongoing role throughout negotiations
Pressuring governments to support the best measures
Providing information on best practices
Publicly divulging names of countries whose positions were aligned with the interests of the tobacco industry

Question 16

Give 4 challenges facing civil society

Answer 16

Shrinking spaces
Over-professionalism - are CSOs losing touch with grassroots activism?
Pseudo-representation
Conflicts of Interest - strong ties to the industry

Question 17

Why are drugs controlled in the UK?

Answer 17

Because they are:
Harmful + might be harmful
Media, majority of politicians, public, international community e.g. WHO + UN want them to be controlled

Question 18

How are drugs controlled in the UK? (x2)

Answer 18

MHRA (Medicines + Healthcare products Regulatory Agency) Medicines Act
Home Office - Misuse of Drugs Act 1971

Question 19

What is the pharmacological definition of a drug?

Answer 19

A natural/synthetic substance that when taken into a living body affects its functioning/structure + is used in the treatment, prevention or relief of disease

Question 20

What is the Misuse of Drugs Act definition of a drug?

Answer 20

Recreational, psychoactive substances

Question 21

How does the Misuse of Drugs Act 1971 work?

Answer 21

Schedules (2,3,4 = medicalised; 1 = not currently/never medical)
Classes (A, B or C) = determine penalties

Question 22

Name a drug that falls under MHRA Medicines Act and Misuse of Drugs act

Answer 22

Morphine

Question 23

Why is getting the relative harm of drugs difficult?

Answer 23

Hard to determine
Poor data on existing controlled drugs due to illegality = covert use
Less data for new entrants

Question 24

How is drug harm classified + quantified?

Answer 24

Harm to self
Harm to others
Comparison with alcohol/tobacco/other risky activities

Question 25

Briefly describe the harms of alcohol

Answer 25

Leading cause of death in men <50 Increased liver deaths in UK: 80% Alcohol + 20% viral deaths (BBV) (Leon et al. 2006) Alcohol became available in supermarkets despite increase in mortality Alcohol companies have a BIG power in parliament Alcohol induced violence, RTA, suicide, mental health, social damage

Question 26

What is a MCDA?

Answer 26

Multi-Criteria Decision Analysis | Used to assess harms

Question 27

How are drug harms assessed?

Answer 27

ICSD (Independent Specific Committee on Drugs) formed the drugs harms model (Nutt D et al. 2010) 20 drugs relatively scored between 0 (=no harm) to 100 (most harm) Criteria is weighted - some criteria represent more harm than others Harm to users + others is determined

Question 28

Briefly name some drug harms

Answer 28

``` Crime Environmental damage Family damage Community effects Cost- healthcare/lost opportunity ```

Question 29

According to Nutt et al, 2010, what are the top 3 drugs with the highest total harm?

Answer 29

Alcohol - BIG harm to others Heroin Crack cocaine There is no correlation with UK Drugs Act or UN Conventions - opiates + illegal drugs have bigger penalties and laws than alcohol + tobacco even though these significantly cause more harm

Question 30

What are the limitations to the MCDA model?

Answer 30

Banning/tightening laws on tobacco + alcohol may lead to more covert use + smuggling Huge loss to UK economy Loss of autonomy to people who drink responsibly

Question 31

What is the policy triangle and what is it made up of?

Answer 31

A non-linear model of health policy creation | Made up of actors in the middle and then context, content and process on each of the 3 corners

Question 32

What are the 3 broad + overlapping sectors of social organisations? Give an example of each

Answer 32

State - WHO, WTO, UNICEF Civil Society - World Vision, Christian Aid Market - Pfizer, International Chamber of Commerce This is illustrative NOT representative as there are some organisation which have a lot of overlap in more than one sector

Question 33

What are the 6 stages of policymaking?

Answer 33

``` Agenda setting Policy formulations Legitimation Implementationw Evaluation Policy maintenance, succession or termination ```

Question 34

What does agenda setting involve in the policymaking process?

Answer 34

Identifying problems that require government attention, deciding which issues deserve the most attention + defining nature of problem

Question 35

What does policy formulation involve in the policy making process?

Answer 35

Setting objectives, identifying the cost + estimating the effect of solutions, choosing from a list of solutions + selecting policy instruments

Question 36

What does legitimation involve in the policy making process?

Answer 36

Ensuring that the chosen policy instruments have support - can involve one or a combination of legislative approval, executive approval, seeking consent through consultation with interest groups and referenda

Question 37

What does implementation involve in the policy making process?

Answer 37

Establishing or employing an organisation to take responsibility for implementation, ensuring that the organisation has the resources + ensuring policy decisions are carried out as planned

Question 38

What does evaluation involve in the policy making process?

Answer 38

Assessing the extent to which the policy was successful or the policy decision was the correct one if it was implemented correctly + had desired effect

Question 39

What does policy maintenance involve in the policy making process?

Answer 39

Considering if the policy should be continued, modified or discontinued

Question 40

What is important to understand about policymaking?

Answer 40

It is fluid - continuous process rather than a single event

Question 41

Is the policy making model representative of what actually happens in reality?

Answer 41

NO Model assumes policy makers approach issues rationally + carefully considering all relevant information BUT when policy fails, blame often on lack of political will, poor management or shortage of resources In reality, political science, sociology, anthropology, international relations + business management all involved in policy-making 'Chaos of purposes + accidents'

Question 42

What are the advantages of the policy making model?

Answer 42

``` Universal Allows identification of stages Clear allocation of resource Easy to identify responsible party Iterative with capacity to adjust over time ```

Question 43

What are the disadvantages of the policy making model?

Answer 43

Not reflective of reality Difficult to incorporate multiple stakeholders Lacks flexibility Slow to achieve change

Question 44

What is meant by the 'Science-policy' gap?

Answer 44

Gap between researchers + policy makers created by differences between the worlds e.g. agendas, needs, time frames etc Aims of each party rarely align: work; attitudes to research accountability; priorities; career/reward; background/training; organisation

Question 45

How is the 'science-policy' gap bridged?

Answer 45

Technical fixes and knowledge brokers (Buse et al., 2012) Both parties must perform certain actions to decrease the gap e.g. researchers should provide jargon free summaries to journal articles and policy makers should have education on critical appraisal of evidence and bias identification in methods Produce interim reports - some evidence produced when required

Question 46

Should the 'science-policy' gap be bridged?

Answer 46

Danger that research will become political To make research worthwhile Scientists also have their own agendas as free from stakeholders

Question 47

What are the key principles to evidence based practice? (x3)

Answer 47

Clear clinical practice question Collecting + critically appraising evidence relating to this Making a decision based on this evidence Use of EBM informs best practice

Question 48

What are the biases against patient and carers in evidence based practice? (Greenhalgh et al, 2016)

Answer 48

Most published research has minimal patient input EBM's hierarchy of evidence devalues patient/carer experience Conflates patient-centredness with use of shared decision-making tools Power imbalances may suppress patient's voice Over-emphasises clinical consultation Concerned mainly with people who seek (+ can access) care

Question 49

What are the advantages of EBP?

Answer 49

Increase transparency, objectivity + certainty

Question 50

Is evidence based practices sufficient for public health policy making?

Answer 50

Value differs depending on the types of evidence used for the question - evidence of intervention effect is not enough for public health policy making All effective interventions require a social transformation that a RCT cannot tell us how to achieve - biomedicine sometimes fails to understand that people live in cultural + social worlds

Question 51

Give a brief history of race

Answer 51

Ancients were geographical + environmental determinists (not colour-prejudiced) 18th + 19th century - naturalists, biological classification + race - 5 distinct species: Americanus, Europeanus, Asiaticus, Africanus, Monstrosus (Linnaeus) 20th + 21st century - Race essentialism = certain universal, innate, biologically/psychologically features of race that are at root of observed differences

Question 52

Is the concept of race valid?

Answer 52

Venter + Collins (one of the first scientists to sequence human genome) confirmed that human genetic diversity cannot be captured by concept of race Race is a social construct, not a scientific one 0.01% genetic difference between any 2 humans Vast majority of variation is at the individual level/local level; geographic barriers that can genetically group by race but not discrete

Question 53

What are biological differences due to?

Answer 53

Environments, exposures + social factors which, to an unknown extent, will impact on our genetics + a contribution of genetic element

Question 54

Give an example whereby the concept of race was a barrier to healthcare delivery

Answer 54

Goyal et al, 2015 found that white children were significantly more likely to be given pain killers (analgesia or opioid) for moderate pain. In severe pain, both groups were given for any analgesia but significantly different in opioid analgesia

Question 55

What is the role of the corporate sector in health policy?

Answer 55

Corporations intrinsically linked to production of good health (provision of services, production of goods, health insurance) AND bad health (environmental degradation, privatisation of essential services, unfair/exploitative practices) TNCs are too large + powerful to ignore Clear evidence that corporations attempt to influence the policy process to defend their business interests - essentially political actors

Question 56

What is regulatory capture?

Answer 56

When a market actor uses its power/resources to obtain regulatory outcomes that advance its interests

Question 57

Which markets are the most influential for health policy?

Answer 57

Tobacco Alcohol Fast food corporations HUGE market power due to strong economic position e.g. Portman Group - trade group composed of 9 alcohol beverage companies founded 1989

Question 58

What are the different entities + categories of corporate actors? (x2)

Answer 58

Associations + regulatory bodies | Semi-autonomous/'astroturf' bodies

Question 59

Name 4 types of associations + regulatory bodies

Answer 59

Business associations e.g. National/international Chamber of Commerce Professional associations with impacts on health e.g. International Private Practitioners Association Standardising Associations (International Standards Organisations) Informal groupings: issue networks, policy communities

Question 60

Name 3 types of semi-autonomous/'astroturf' bodies

Answer 60

Industry sponsored think-tanks + institutes e.g. Institute for Regulatory Policy in US created by Philip Morris Patient groups + grassroots organisations Scientific Organisations e.g. international life sciences institute

Question 61

What are the 2 types of corporate power?

Answer 61

Structural power = derived not from actions but from privileged position of commercial actors within market economy Agency power = deliberate exercise of influence by market actors

Question 62

Explain the concept of structural corporate power

Answer 62

Control over investment in the state Dependence of state revenue on activities of corporation e.g. duty on cigarettes + corporation tax revenues Capacity for exit Ideological power

Question 63

Explain the concept of agency corporate power

Answer 63

Deliberate exercise of influence by market actors Direct political engagement: long term relationship building, lobbying, funding political parties Institutional participation: seats on boards, involved in govt

Question 64

Name 4 ways in which the corporate sector can influence health governance

Answer 64

Influence on public regulation: corporations can exert influence at every stage of the policy process Co-regulation + self-regulation by private standards Influencing the evidentiary content of policy debates Corporate social responsibility (CSR)

Question 65

What are the issues of governance + regulation in relation to corporations and health?

Answer 65

Many corporations are self-regulated = issues around ACCOUNTABILITY + EFFECTIVENESS Conflicts of interest = influence evidentiary content of policy debates Regulatory bodies = Chamber of Commerce; International Standards Organisation

Question 66

How has the corporation influence changed in recent decades?

Answer 66

Influence has increased in recent decades in line with underlying ideological shifts i.e. neo-liberalism

Question 67

Describe the global activity of Trans-national tobacco corporations (TTCs)

Answer 67

TTCs drive sales + increase consumption - lobbying to undermine tobacco control e.g. Eastern Europe Global TTCs can influence + undermine national governments Expansion in 'emerging markets' Vast political + economic power

Question 68

Describe how TTCs create + maintain its market

Answer 68

``` Increased restrictions in HIC = TTCs target LMICs + emerging economies with weak/ineffective regulatory regimes Trade liberalisation (removal of restrictions on trade) has boosted the market e.g. East Asian trade liberatlisation TTCs are extremely successful in resisting tobacco control measures Target new smokers = women, future smokers, establishing new markets ```

Question 69

What is the tobacco control framework?

Answer 69

First time WHO used treaty making powers (2003) Protocols on illicit trade + best practice on tobacco control measures Article 5.3 - governments need to take active measures to reduce the influence of industry actors over policy

Question 70

What are the arguments for plain packaging for reducing tobacco consumption?

Answer 70

Method of tobacco control Deters smoking - less appealing Reduces cigarette seeking behaviour Health warnings stand out more

Question 71

What are the arguments against plain packaging for reducing tobacco consumption?

Answer 71

More needs to be done, packaging alone is insufficient Breaches IPR (intellectual property rights) No credible evidence that it'll work Increase smuggling + counterfeits

Question 72

What are the public health interventions available to reduce tobacco consumption?

Answer 72

Taxation + combating smuggling Tobacco warning labels, graphic images + plain packaging Advertising ban Smoking ban in public places They are effective - reduced mortality rates and no. of people smoking BUT TTCs try to undermine these interventions