# Cite as Brugha R, Bruen C, Tancharoensanthien V.  Understanding Global Health Policy.  In Grown G, Yamey G and Wamala S. eds.  _Handbook of Global Health Policy_.  Chichester:  Wiley Blackwell, 2014: 21-46. # Key Points - Global health policy refers to the statement of goals, objectives, and means that create the framework for global health activities. - Actors - individuals, organizations and their networks are central to how priorities are established and how health policies are made and implemented. - Understanding global health policy requires an understanding of the political nature of policy-making, the role of actors' interests, and the centrality of power. - Policy theory, developed to analyze national health policies, can be applied to understanding global health policy processes and the influence of old and new actors. - New global health partnerships, incorporating non-state actors who can mobilize large levels of resources, have become powerful players in setting global health priorities, policy-making, and implementation. # Key Policy Implications Global health policy is an inherently political and complex arena, where the positions, interests, and objectives of nations, organizations, and networks of individuals often determine what policies are formulated and implemented. While there is often consensus on the need for evidence-based policy-making, its achievement can be undermined by a failure to understand and analyze how power and the interests of different groups often shape and can determine global health policies. The application of theories of policy processes can deepen the understanding of the global health policy terrain, highlighting the political obstacles and opportunities for getting population health issues on to the policy agenda. # Introduction Health policy triangle: context (historical, political, cultural, economic, transnational), content (technical content of policies), and process (priority setting, policy formation, implementation and evaluation) — all three done by actors (individuals, organizations, and networks that make policy) # Globalization and the Transformation of Global Health Policy Globalization have had a direct impact on national health policy through increased interaction and interdependence between states. For example, shortages of health workers in low-income countries can be attributed to active and passive health worker recruitment by wealthier countries. # New Global Health Policy Actors The transformation came through the rise in the development assistance for health ([[DAH]]). [[Insights]] However, CGD has published that [[DAH]] has been stagnated, if not, lowering over the years since market crash in 2008. GAVI was formed largely from the influence and contribution of [[Bill & Melinda Gates Foundation]]. The other big organization is Global Fund. Both [[GAVI]] and [[Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM)]] are public private parnership model. GF is unique because there are three civil society delegates with voting rights on its Board; and they are from developed and developing country. GF does not have a presence in countries, and instead award grants directly to country Principal Recipients who can be governments, NGOs, or multilateral agencies. GF engages at a country level primarily through Country Coordinating Mechanisms, which coordinate and submit proposal to the GF, and Local Fund Agents (LFAs) who are employed by the Fund to provide financial oversight of grant disbursement. > GAVI and the Global Fund were established as alternatives to traditional bilateral and multilateral donor agencies, which were considered by many global health policy actors to be too slow in achieving global health goals. Both initiatives have prioritized disease-specific vertical interventions, as opposed to strengthening health systems, advancing comprehensive primary healthcare or other horizontal disease control strategies (WHO 2009). These organizations have a number of common innovative features, such as their emphasis on performance-based funding and their demand-driven approach (Feachem et al. 2010). However, they also work in somewhat different ways, and these differences are rooted in the influence of different stakeholders involved in their formation. Box 1.3 [[Paris Declaration on Aid Effectiveness]] The 2005 Paris Declaration on Aid Effectiveness with follow-up international meetings in Accra (2008) and Bhusan (2012) - was a landmark agreement between donor agencies, developing country governments, multilateral organizations, regional development banks, and international agencies. Its aim was to make aid more effective through adherence to five principles: 1. Country *ownership* of development policies and strategies. 2. Donor *alignment* with the priorities of developing countries, their institutions and procedures. 3. Donor *harmonization* and coordination at country level to avoid duplication. 4. All parties agree to *manage for results* and to develop tools and systems to measure impact. 5. To ensure transparency in the use of aid, *mutual accountability* between donors and developing countries is required, including to their citizens and parliaments. [[GAVI]], [[Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM)]], [[PEPFAR]], and other initiatives have helped tackle complex infectious disease priorities. However, recognizing that weak health systems were hindering the scale-up of these commodities, these global health initiatives have expanded their portfolios to include health system strengthening. Global health actors created Health Systems Funding Platform in 2009 but failed to galvanize support and commitment to reach its potential. Middle income countries, particularly [[BRICS]] has also started to emerge and continue their influence, due in part to multipolarisation and shifting of geographies of power. Brazil and India have used flexibilities in [[Intellectual Property Rights (IPR)]] law to locally produce generic medicines that are up to 98% cheaper than branded medicines. BRICS, particularly China, also become an important actor in bilateral assistance and investing in health aid. [[BRICS]] not only critical in the production of health commodities, but also beginning to contribute to financing global health problems, from which they have traditionally been recipients. For example, Brazil has become a donor to [[GAVI]] in early 2011 after gaining legislative approval, pledging US$20 million from 2012 to 2031. This is part of a larger trend where BRICS countries are increasing their foreign assistance budgets and exploring collaboration opportunities, such as the proposal by India to create a development bank funded by developing countries. # Global Health Policy Instruments and Levers ## Financial instruments (eg, principal-agent contracts between donors and implementing agents, incentivizing private markets to develop health technologies, or performance-based health financing) The most pervasive policy influence in 1980s and 1990s was the [[structural adjustment]] by [[World Bank (WB)]] and [[International Monetary Fund (IMF)]], where reforms such as the introduction of user fees or [[IMF and World Bank policies have increased poverty and inequality for poor countries due to their neoliberal views on trade, export-oriented growth model, finance and technologies|limiting the role of the state in service provision]] were some of the conditions that needed to be met in order to gain access to loans and other forms of financial assistance. In effect, a decrease in availability of goods and services and a decline in the health status of poor status. The other financial instrument that were introduced mid 1990s was [[Sector Wide Approach (SWAp)]] favored by many European bilateral agencies, with policy input from the WHO and the [[World Bank (WB)]]. Financial assistance can provide leverage over national policy in LMICs, but international agencies have not always been able to accurately monitor the impact of their finances in a complex implementation environment, particularly to the point of attribution. [[Performance-based funding models]], such as those used by the [[Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM)]], have been proposed and implemented as a financial incentive for improving performance and for tracking results, as has been seen in Rwanda. However, [[Performance-based funding models]] have themselves shown mixed results. Other financial instrument is push/pull mechanisms to incentivize R&D of life-saving medicines, eg, with [[product development partnerships (PDPs)]], [[Advance Market Commitment]]. ## Legal/regulatory instruments (eg, international health treaties) Often termed command and control instruments, where the command refers to standard setting and control refers to its monitoring and enforcement. The latter is not always in place. Examples: - Legally binding agreements and arbritation bodies, eg [[TRIPS Agreement]], [[Dispute Settlement Body (DSB)]] - International regulation, treaties, and guidelines, eg, [[Framework Convention on Tobacco Control]], [[International Health Regulation (IHR)]], [[International Health Partnership (IHP+)]] - Quality assurance and safety of medical products, eg WHO Department of Essential Medicines and Health Products Policymaking is the interplay between four key determinants generating political priority for different global health policies: 1. actor power 2. ideas 3. political contexts 4. the characteristics of health issues (such as the burden of disease and the existence of simple, low cost treatments) In nutrition and health - it can be considered that this is a global health policy failure. The power of [[MNCs]] to influence and lobby policymakers, leverage the opposing interests of countries and exploit countries' vulnerabilities to financial or other favors, cooption, and corruption, we have not been able curb the production and consumption of unhealthy foods. We moved from under- to over-consumption of food. WHO [[World Health Assembly (WHA)]] has met in 2004 and agreed a Global Strategy on Diet, Physical Activity, and Disease that committed Member States to take steps towards improving population diet and activity, and to bring about changes to the food industry. However, a review of the commitments and practices of big food companies found that there was a low level of engagement by these companies. > The current food systems favor maximizing profits over delivery of optimal human health. Factors that may help to explain the inadequate global policy response include: 1. Coalition of economic and commercial interests at national, regional, and global levels benefit from over-production of products with higher price and cost surplus. These actors oppose mandatory regulations on food labeling, marketing, and distribution to children. As we saw on [[@knaiCaseDevelopingCohesive2021]] 2. Governance of global food policy is fragmented - several multilateral institutions and private sector actors form broad issue networks, but are also competing for authority over food-related policies. 3. Lack of trust or perceived conflict of interest can present barriers to developing policy and strategic coherence on nutrition and effective frameworks to guide public sectoor engagement with the private sector. # Contribution of theory to understanding global health policy Frameworks, theories, and models have different menings. - Frameworks is classification - bound and organize an inquiry and lay out the critical features of the landscape being examined, but they do not provide explanations or predictions. The policy triangle (context, content, and process) is framework - Theory is explanation - you assign values to elements/variables in the frameworks. Theories also explain the factors that influence an outcome and the mechanism of such influence. [[Punctuated equilibrium theory]] is an example of a theory. - Models is prediction - allowing policy analysts to test theories. Make precise assumptions about a limited range of variables. Functional rationality and the systems model are examples of this. # Functional rationality: the policy process as a set of stages or a system Cycle and systems models are preferred by scientists and decision-makers who assume that policy-making is normally evidence-based. In reality, it is not always evidence-based because different stages or subsystems are not insulated from each other and the same actors may be involved at different times or in different subsystems. Despite the limitations, the model is useful for top down planning and strategic decision-making. # Explanatory Theories of Policy Processes Theory of [[Punctuated equilibrium theory]] by Baumgartner and Jones (1993) proposes that patterns of abrupt change in policy occur during periods of instability, when new issues emerge and contribute to changes in institutional environment, relations between actors, and preferred policy ideas to resolve a given problem. This theory can usefully be applied to understand the evolution of the [[Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM)]] > [!NOTE] Global Fund > Jan 2002 when GF was led to be created by the fact that HIV/AIDS was recognized as health crisis. The perceived failure of existing systems to effectively respond also led to shift in power and how new actors could influence policy priorities. Following a period of rapid innovation from 2002 to 2005, new modalities for disbursing and overseeing aid became systemized and began to align with pre-existing aid mechanisms, introducing a period of stability. In 2011, major crisis in GF, triggered by: 1) evidence of financial misappropriation in recipient countries, 2) representations of this issue in the media in the context of a global economic downturn and growing skepticism about development aid, 3) a temporary withdrawal of financial support from some donors, 4) the discrediting of some senior officials in the GF. The incident led to a new period of instability where it oppened up opportunities for the introduction of new policy ideas, substantial changes in policy and institutional structures, in the appointment of senior staff with different views and vision, with a new funding model. Other theories: policy stream models from Kingdon (1984). There are three streams: 1. Problem stream: many issues competing for the attention of policy-making 2. Policy stream: comes the set of ideas and available solutions for addressing the problem. Crucial to the success of an idea are policy communities and policy entrepreneurs, who promote particular ideas through journals, conferences, and different forms of media. 3. Political stream: politicians and decision-makers such as donors. Events such as elections, changes in public opinion, or pressure from organized political forces can combine to open up "political windows of opportunity". A momentum to change. > [!NOTE] Applying the Policy Streams Model to Health System Strengthening > Problem stream has been dominated by disease-specific initiatives, such as GF, were unable to achieve their goals due to longstanding weakness in health systems. HSS policy communities were building an evidence base to advance alternative ideas within the policy stream, through Alma Ata Declaration, debates on the relative merits of vertical disease-specific programs vs HSS. Political stream highlight how slow progress towards the health-related MDGs increased pressure on actors to find ways to achieve these goals. This pressure was heightened by the external influence of [[Paris Declaration on Aid Effectiveness]]. However, global financial crisis and lack of technical feasible solutions to the strengthening of systems have raised questions about the sustainability of HSS as a set of ideas and actions to resolve current problems. The [[advocacy coalition framework]] developed by Paul Sabatier and colleagues bring together a number of approaches and frameworks, including that of policy streams. Sabatier focuses on policy subsystems as the unit of analysis, where all public and private sector actors in a policy arena interact. Policy brokers play an important role in negotiating between competing strategies and coalitions. Example: Advocacy Coalitions in the Creation of the Global Code of Practice on the International Recruitment of Health Personnel. Despite pressures from Western countries, African countries consolidated their views and stand strong and maintain the strong legal and institutional provisions in the final text against all efforts to modify and limit such provisions. # Conclusions > [[health policy analysis]] is inherently political, and [[global health policy]] and practice entail working in and understanding a highly complex and politically charged arena, where the positions, interests, and objectives of nations, organizations, and individuals are intertwined in complex ways.