## Introduction We argue that [[global health policy is the product of various material and ideational drivers]]. [[Power]] is important, but so are ideas. In relation to ideas, a case that the way in which proposed policies are 'framed' is central to explaining how consensus is built around certain policy choices. [[Interesting Phrase]] [[policy entrepreneur]] connects it [framing an issue in a particular way] with a set of deeper paradigms which form the ideational underpinnings of global health governance. These paradigms influence the ways in which actors think and talk about global health problems. [[Question]] What is [[neoliberalism]]? Neoliberalism contends that markets allocate scarce resources, promote efficient growth and secure individual liberty better than governments. In other words, [[markets work; governments don't]]. ## Global Health Policy and Global Health Policy-making [[Question]] What is global health policy? [[global health policy]] is the ways in which globalization may be impacting on health policy, and alternatively what health policies are needed to respond to the challenges raised by globalising processes. In global health, there is no single global policy for particular disease. What exists is a range of overlapping and sometimes competing policies from various sources. ## Global Health Policy Cycles: Insights from the Existing Literature [[Question]] What are the four-stage model of global health policy cycles? 1) problem definition and agenda setting, 2) formal decision-making, 3) implementation, 4) monitoring and evaluation [[Interesting Phrase]] Global public policy processes are messy. Stone has sought to encapsulate this via the metaphor of the '[[global agora]]' which she describes as a "growing global public space of fluid, dynamic and intermeshed relations of politics, markets, culture and society." > One of the defining features of [[global health governance]] is the sheer diversity of actors with the ability to produce policy, including: national governments; formal International Organizations (from the [[World Health Organization (WHO)]] to the [[World Bank (WB)]]); public-private partnerships; civil society organisations and epistemic communities; the private sector; and “global policy networks” encompassing some or all of these actors. [[Non-state actors]] ## A Framework for Analyzing [[global health policy]] making ## Frames and Paradigms ### Frames Frames are linguistic, cognitive and symbolic devices used to identify, label, describe and interpret problems and to suggest particular ways of responding to them, eg, framing influenza as an international security threat, clearly identifies it as a certain type of global problem which requires particular forms of global response. [[Interesting Phrase]] [[Issue construction]] determines whether or not an issue makes it onto the global health governance at all (first stage of policy cycle, problem definition and [[Three faces of power are layered. First face is domination, second face is agenda-setting, and third face is thought-control|agenda setting]]). Actors also use issue construction in the next stage of the policy cycle (formal decision-making) to demonstrate that their proposed policy response is the right one. [[Insights]] At any one time, different governance agents may be pursuing divergent policy approaches in relation to the same global health issue, a problem which is only partly captured by the [[global health governance]] literature’s identification of a lack of coordination in the system. Nevertheless, there are often policy trends evident which are the product of the ascendancy of a particular frame. The growing prevalence of the concept of ‘Global Health Security’ in the policy discourse, for example, is a product of the framing of particular health problems (mainly infectious disease pathogens) as security threats. ### Paradigms Paradigms are “underlying theoretical and ontological assumptions about how the world works” and “paradigmatic effects are profound because they define the terrain of policy discourse”. Thus paradigms structure how actors view and understand the world, embody taken for granted ideas and assumptions about how the world works, and as a consequence "limit the range of alternatives oplicy makers are likely to perceive as useful." [[Question]] Four influential paradigms in global health policy-making: 1. Biomedicine paradigm: focuses on understanding the structure and mechanisms of the human body and diseases. Often presented as being a value-neutral techno-scientific knowledge system and thus as not 'normative' in any real sense. Revolves around positivistic scientific research and prevention and intervention at the level of the individual patient, for example through the development and use of pharmaceuticals. 2. Human rights paradigm: individual liberty and the rights of individuals to make choices about their own body 3. Security paradigm: life and death 4. Economic paradigm [[Question]] What are the other influential paradigms in global health? International development, moral/religious/civilizational, communitarian. ### Relationship between frames and paradigms In our framework, framing provides the linkage between paradigms which reside in the cognitive background of global health and the foreground of policy debates. In framing an issue, actors are (either consciously or unconsciously) labelling it in a way which connects it with these ‘cognitive background’ ideas which, given their broad nature, do not offer precise, uncontroversial or operable principles which could guide a governance response. ==Example== The case of tobacco control provides a classic example of this. Anti-tobacco campaigners have often suggested framing the implications of (passive) smoking as a human rights issue. Their success in doing so can be seen in the [[Framework Convention on Tobacco Control]] which, in its preamble, refers to a whole series of rights, including “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.” Yet the opposing arguments have also been framed in relation to the human rights paradigm. The tobacco industry has often couched its arguments in terms of individual rights, arguing for the existence of a right to smoke (as freedom of choice) and portraying tobacco control policies as discriminatory. [[Question]] [[Insights]] In terms of operationalizing this framework, there are a number of questions which could be applied to any policy cycle, including: What language is used in discussions of a global health issue (i.e. how is it framed)? What competing frames are brought to bear? How well do they resonate with the major paradigms of global health? Who voices particular framings and within what institutional contexts (e.g. particular communities of experts, organisations, the media)? What authorities, texts etc are cited in support of a particular framing? How do the audience react to particular framings (do they gain support or are they opposed? Are they repeated in other contexts? etc)? Are ideational links drawn between different policy fields/issue areas (e.g. are examples of successes/failures in other areas deployed)? How do framings differ at different stages of the policy cycle: are they consistent or do they change? ## Power and Authority > [[Global health governance is not a Habermasian ‘ideal speech’ situation in which the best argument wins out. Power matters, and outcomes are determined not only by the persuasiveness of a particular frame, but also by who is advancing that frame]]. However, sometimes the better argument does win out, even when forwarded by non-powerful actors. It is possible for less powerful actors to successfully advance particular framings of an issue and to persuade other actors to adopt that frame. Bureaucracies of International Organizations are able to "use discursive and institutional resources to induce others to defer to their judgment". ### Power, frames and policy context States and [[Non-state actors]] relocate rulemaking processes to international venues whose mandates and priorities favor their concerns and interests has also been apparent. Helfer, for example, has described the way in which the [[United States and the European Community deliberately shifted negotiations over the intellectual property regime from WIPO to the WTO, and have continued to deploy this strategy with regard to global IPRs]].Framing can also be used deliberately by less materially powerful actors in order to draw new institutions and actors into the debate. [[Open Question]] on Power, frames, and policy context What actors, communities and institutions have a visible stake in the outcomes a policy process? Who is involved in determining policy outcomes? Which institutions/individuals provide leadership, and who is excluded from the policy process? Is the policy process/outcome seen as legitimate or not? What communities of experts are referenced and deployed in policy debates Who provides the resources to implement policy and what conditionalities are attached, if any? Is contestation apparent in the policy cycle, and how is such contestation mediated or settled? In what ways is procedural power evident (e.g. through standard operating procedures, policy templates, institutional structures and hierarchies etc)? Is there evidence that actors without traditional material power have influence on policy outcomes? ## The 'Deep Core' of Neoliberalism Part of the problem with many of the constructivist approaches to global health governance (and indeed to global governance more broadly) is the over-emphasis on agency and ideas to the neglect of deeper structural determinants. The ‘playing field’ on which global policy debates are played out is not level, but is skewed by historically specific and deeply embedded ideas and configurations of power. Constructivists, of course, would argue that agents and structure are mutually constituted. Equally, [[neo-Gramscians]] would see nothing particularly radical in viewing particular ‘world orders’ as the product of a dialectical relationship between power, politics, economics (and production) and ideas. For our purposes this agent-structure debate can be bracketed off. What matters for our framework is not how or why the ‘deep core’ of neoliberalism came to be dominant, but that it is, and that it impacts on global policy processes in a number of ways [[Question]] [[Open Question/How does neoliberalism shape global health policy?]] 1. Neoliberalism has configurated power and authority through the rolling back of state and (international public) authority over health, whilst also diffusing authority across a wider range of both public and private actors. For example, the increasing role of [[World Bank (WB)]], [[International Monetary Fund (IMF)]], and [[World Trade Organization (WTO)]], usurping the agencies of the United Nations System, and bringing with them a very different set of policy references. Increasing importance of private sector as 'partners' in global health governance has also been widely noted, as has [[the appeal to market as the most efficient mechanism for allocating scarce health resources]]. 2. Embodying a series of policy preferences. The most commonly noted of these is the promotion of liberalized and privatized healthcare systems. 3. Neoliberalism colonizes many of the paradigms of global health which we highlighted above, eg, biomedicine and neoliberalism have made natural bedfellows (biopower), sharing as they do an emphasis on individuals as being autonomous and rational consumers ultimately responsible for their own risk behaviours and their own well-being. [[Interesting Phrase]] [[neoliberalism]] and biomedicine also come together in what has been termed ‘[[biopower]]’, wherein risk, behaviour (including sexual behaviour) and choice are individualized and made subject to governance (via measurement, monitoring etc). We witness this relationship, for example, in the growth of global markets for processed and fast food, ==whereby demand is often structured by aggressive marketing and franchising, where decisions about health risks are devolved to the consumer, and where regulation (health policy) is largely absent==. At the same time, a range of governance actors are exploring ways of harnessing the market to modify individual behaviour. It is apparent in these moves that neoliberalism has deep-going effects vis a vis health governance, not least in the reconstitution of individuals and patients as rational economic actors (as is also present in QALY and DALY methodologies). In this way, [[not only are the macro-level economic, political and social determinants of health left to a great extent unaddressed, they are actually concealed]]. A similar colonization can be seen in relation to human rights and health. In short, the hegemony of the neoliberal orthodoxy results in a situation where all of the paradigms of global health exist and develop in a context defined by neoliberal ideas. The deep core of neoliberalism, therefore, has both direct and indirect effects upon global public policy. It both privileges particular policy preferences and also structures the terrain on which policy debates take place. The challenge for the researcher, however, lies in identifying how the deep core permeates and manifests itself. We propose the following questions which aim to reveal its structuring power, focusing on the three lines of force detailed above (namely, the privileging of certain actors and voices; evidence of distinctive policy templates, and the manner in which it colonizes the paradigms of global health). Whist none of these questions in and of themselves provide conclusive proof of the role of neoliberalism, taken together they may provide persuasive evidence of its overarching structuring impact: Whilst this claim is clearly normative and the power and presence of neoliberalism continues to be a divisive and contentious referent in global political life, for us it is persistent and powerful enough to characterise the overarching meta-framework under which global health policy is at least presently conducted. ### Actors - What is the role of global economic actors and private interests in specific global health policy cycles? - Are particular states or groupings of states (e.g. G8) associated with particular policies, do they promote them, or mediate their facilitation? - How does their role relate to that of other global health governance actors? Are they dominant or just another voice? - How seriously are actors who critically engage with neoliberal policies taken? ### Policy templates - What particular role is ascribed to states and other international public policy actors in the policy cycle? What roles are assigned to markets and private actors? - How are competing interests, for example between economic development and individual health status, balanced or reconciled? Does one set of objectives or interests predominate? - Have policy templates from other regimes or areas of policy been imported into global health policy, and are such templates associated with or indicative of neoliberalism? - To what extent are private actors and market mechanisms seen as legitimate or useful in securing policy outcomes? ### Paradigmatic effects - Are successful arguments framed in economic logics (e.g. efficiency, cost-saving) or do they employ economic evidence or methodologies? - Do certain policy debates/discourses include framings which combine paradigms of health with neoliberal ideas? - Are arguments put forward which bring together paradigms which may appear to be diametrically opposed (e.g. are policy debates ostensibly about development or public goods for health couched in discourses of market efficiency, consumer power and choice or the failure/inefficiency of public initiatives and interventions)? - Are policy debates characterised by framings which stress the individual nature of risk, responsibility and (un)healthy behaviour? - Are regulatory powers or policy interventions challenged on the basis that they infringe on private/individual/market rights? ## Conclusion We conclude with three deliberately normative contentions as to why global health governance is presently failing to adequately address manifest health needs. Firstly, [[global health problems are often framed in unhelpful ways]]. This may be deliberate – actors seeking to justify certain policies in pursuit of an ulterior motive – or it may be the product of genuine beliefs. Either way, successfully framing a problem in a particular way determines the linguistic and cognitive terrain (and can therefore exclude other terrains), leading to consensus being built around the ‘wrong’ responses. This is obviously more likely to happen when the framer is a powerful actor, and it is for this reason that the framings put forward by powerful actors should be submitted to particular scrutiny. Secondly, [[the relationship between paradigms of health changes over time]], and it may well be that in the contemporary system of global health governance the paradigms which dominate (we would identify in particular economics and biomedicine) militate against a broad social understanding of the determinants of health. Thus the cards are stacked against policy approaches which attempt to address these issues. Thirdly, and most fundamental for us, is [[the structuring logic of neoliberalism which exacerbates economic and health inequalities and limits the range of likely responses to global health problems]]. Many of the most innovative recent global health initiatives have been an attempt to smooth some of the rougher edges created by neoliberal global governance. They have not, however, fundamentally challenged it. So for now the crisis of global health seems likely to persist, and global health governance will likely continue to fail. ## Links [[How does neoliberalism shape global health policy?]]