## Learning outcomes - Define and compare competing conceptualisations of power - Critically discuss sources of power - Critically evaluate the ways in which power shapes and influences global health governance ## 1. Introduction [[Governance is both a social process and a collection of norms and arrangements]] [[Colin Hay defines politics as being concerned with the distribution, exercise and consequences of power]] [[David Baldwin argues that all politics is power politics in the sense that all politics involves power]] ### Activity 3.1 How would you define the term 'power'? If you speak one or more languages other than English, can you think about how the term 'power' translates in these languages? Post your thoughts. ## 2. Conceptualising power ### 2.1 Power as influence or control [[Robert Dahl argued that power is the ability to influence outcomes, to prevail in decision-making, to impose one's preferences, and even to dominate]] According to the political theorist Robert Dahl (1957), ‘A has power over B to the extent that A can get B to do something that B would not otherwise do’. Power, in other words, is the ability to influence outcomes, to prevail in decision-making, to impose one’s preferences, and even to dominate. [[According to German sociologist Max Weber, power appears as an attribute of actors and states, an inherent trait, a characteristic]]. This conceptualisation of power is often associated with authority and legitimacy – where authority was defined by the German sociologist Max Weber (1921/1968) as ‘accepted power’ or power that people agree to follow. From this perspective, power appears as an attribute of actors and states, an inherent trait, a characteristic. [[Open Question]] [[How does power came to be?]] The existing power relation, the value judgments. The definition from Robert Dahl and Max Weber does not fully investigate the mechanisms of exercising influence or control or the resources required to exercise power. > Yet this conceptualisation of power suffers from certain shortcomings. For example, it tacitly accepts existing power relations and makes no value judgements about either how these came to be and are reproduced, or the need (or even possibility) for these to change. In addition, it does not fully investigate the mechanisms of exercising influence or control or the resources required to exercise power. Analysts who conceptualise power in this way tend to see policymaking as a top-down process, [despite there being plenty of evidence that the implementation of policy is rarely as intended by policymakers]([[Scientific knowledge generation does not automatically translate into (policy) solutions and practices]]), and that policy is often influenced by a broad spectrum of actors, not just those in power. ### 2.2 Power as resources or capabilities > Power is traditionally conceptualised in terms of material capabilities (often military hardware and personnel) or control over other resources (such as the size of a state's economy or their access to natural resources such as oil) One of core assumptions of traditional international relation theories, e.g., realism, neo-realism, [neo-liberal institutionalism]([[neoliberalism]]) is that main national interest (the *raison d'etat*) is the pursuit of security and the best way to achieve security is through power (see Morgenthau 1948/1960; Waltz 1979; Mearsheimer 2001). However, questions of resources and capabilities are also central to many critical, and particularly Marxist or structuralist analyses of international politics (see Cox 1987). This conceptualisation conceives of power as the sum of a state’s material resources; what Baldwin (2013:275) terms ‘power as a possession’. In this context, ==the power of states is often estimated by using particular metrics and indicators relating to the size of a state’s population, territory, army and other military resources, its wealth, and natural resources.== The main challenges to this conception of power was posed by political developments in which states or groups or states with lesser capabilities were still able, in some circumstances, to prevail over states or groups of states with significantly greater capabilities (e.g., the defeat of the US in the Vietnam war or the outcomes of later conflicts in Iraq or Afghanistan). Furthermore, it has been argued that politics and the exercise of power has, in recent decades, become less dependent on military capabilities in the context of an inter-connected, globalising world. For example, the rise in state-sponsored cyber-crime and ‘non-linear warfare’ using online misinformation campaigns and related strategies to influence societal relations and political decision-making in other states demonstrate the new and evolving ways for political actors to exert power through non-military means. Thus, conceptualising power simply in terms of resources or capabilities misses more complex and nuanced aspects of power relations. In [[global health governance]] we can observe similar dynamics. Material capabilities can indeed be used in bargaining and negotiations - as incentives or means of influence and control, but material capabilities alone cannot provide a coherent and logical explanation of all policy developments as we will further discuss in section 2.4. Thus, in their discussion of the emergence of the global [[Intellectual Property Rights (IPR)]] regime, Sell and Prakash (2004) demonstrate how [[MNCs]] were able to ‘graft their agenda’ onto the 1994 Agreement on Trade Related Intellectual Property Rights (TRIPs) negotiations at the Uruguay Round of the [[General Agreement on Tariffs and Trade (GATT)]], but were unable to persuade the US government to pursue alleged TRIPs violations associated with access to HIV/AIDS drugs by developing countries (notably Thailand, South Africa and Brazil) (Sell and Prakash 2004: 144). In this example, the authors argued that [[NGO]] (non-governmental organisations) networks were able to get the US government on their side using advocacy and awareness campaigns, despite the significant disparity in material capabilities between the two types of actors. [[Insights]] I probably should use this argument to advise political dynamic of power in terms of clinical research and local manufacturing. ### 2.3 Relational and critical conceptualisation of power Lasswell and Kaplan (1950) defined power as relational - i.e., as occurring in the context of a given relationship. Baldwin (2005) considers this a more relevant way to think about power and uses the metaphor of a game of cards to demonstrate the utility of the concept of relational power. The ability of a card player to win depends, in part, on the hand of cards that the player has been dealt, in part on the rules of the game, and in part on the cards that other players have in their hands. Consequently, the relevant power of each player depends on the strength of the cards they have in relation to other players, in the context of the specific rules of the game they are playing. Furthermore, Baldwin argues that a relational approach to power allows us to see that power is multidimensional, depending on a range of assets belonging to different actors and the environment in which they engage (Baldwin 2013: 275). This is a particularly important observation in a global system defined by great complexity as well as the scarcity and unequal distribution of resources. [[Post-colonialists see power as NOT purely a characteristic of a relationship, they see it as something that constitutes and structures that relationship, so power is much more pervasive and ubiquitous]] In a similar vein, critical perspectives, including feminist and post-colonial approaches, draw attention to complex understandings of power, which focus on the embedded and often structural forms of inequality and power relations evident in national and global society. These perspectives resonate with the relational approach in that they place a strong emphasis on context. The difference in these approaches is that rather than seeing power as purely a characteristic (or effect) of a relationship, they see it as something that constitutes and structures that relationship, defining its key characteristics and dynamics. These approaches conceptualise power as ubiquitous and pervasive, underpinning all aspects of social, political, and economic interactions and relations. For [[Marxist]]s, unequal power relations are rooted in economic relations and the fundamentally oppressive nature of the capitalist economy – e.g., exploitation, resource extraction, unequal exchanges (Rupert 2010: 157-176) For post-colonial scholars, unequal power relations are perpetuated by the continuing legacy of (largely European) imperialism. This has been compounded by the structure of the global economy and global institutional order, which was created by, and serves the interests of, former colonial centres. The combination of these factors, they argue, ensures the continued dominance of former colonial powers over the ‘periphery’ or the [[Global South]] (Grovogui 2010). ### Activity 3.2 Choose one of the conceptualisations of power outlined and discuss it through an example of how such power manifests in global health. Post your answer in Activity 3.2. Discussion forum on Moodle and comment on the post of at least one other student. ## 3. Taxonomies of power ### 3.1 Lukes - Three faces of power [[Three faces of power are layered. First face is domination, second face is agenda-setting, and third face is thought-control]] Following Weber (1947), Robert Dahl (1957) defined what became known by Lukes as the ‘first face’ of power, namely the ability of actor A to make actor B do something that B would otherwise not do. Bachrach and Baratz (1962) describe the ‘second face’ of power as (often covert) agenda-setting – i.e., determining not only which issues appear on the political agenda, but also which issues are kept off it. This face of power focuses on a person or group’s ability to limit or direct the scope of the policy discussions, to manipulate the agenda in line with their preferences and interests, to establish the primacy of their values and beliefs, and to silence opposition or dissent. Lukes (1974/2005) introduced a ‘third face’ of power, which he defined as the ability to influence the way people think, and thereby the choices that they make. He critiqued Bachrach and Baratz’s view for being too focused on individual agency, while neglecting the influence of ‘socially structured and culturally patterned behaviour of groups, and practices of institutions’ (Lukes 2005: 25). Furthermore, Lukes’ critiqued their exclusive focus on situations of actual, observable conflict which misses key dimensions of the policy process. Since a key aspect of agenda setting in the second face of power involves preventing policy issues becoming activated and debated in overt ways, a key aspect of the exercise of power is that power is non-observable or relates to the absence of observable policy events amenable to study. The third face of power is, therefore, what Lukes called ‘thought-control’ or the ability to shape an individual or a group’s preferences, thoughts, desires, interests, perceptions without exercising direct or overt control. Such thought control, he argued, takes more ‘mundane’ forms such as the control of information, mass media reporting, wider societal discourses, and processes of socialization (Lukes 2005: 27). ### 3.2 Barnett and Duvall - the four types of power ![[CleanShot 2023-12-23 at 16.45.18.png]] Compulsory power as ‘a range of relations between actors that allow one to directly shape the circumstances or actions of another’. Compulsory power is not limited solely to the control over material resources and use the example of how non-governmental organisations have used advocacy and campaigns to influence targeted states to change their policies or how transnational corporations have controlled capital to influence the foreign policy of states. Institutional power refers to the actors’ control of others **in indirect ways** – for example through the rules and procedures of institutions. Rules and procedures shaped the behavior and choices of distant others by using international institutions. Structural power is premised on the assumption that social structures (such as capitalist system, class systems within states, or prevailing gener, racial minority stereotypes) constitute actors' identities and capacities, determining their social position, options, and choices - examples include capital-labour or master-slave relations, but also gener roles, race relations, class relations. Productive power is the production of subjects through diffuse social relations. Barnett and Duvall note that productive power overlaps with structural power in that it is a diffuse type of power that shapes social identities and capacities. The crucial difference is productive power does not require structures to underpin it. Productive power resonates with the concept of 'power-knowledge', a term introduced by the French philosopher [[Foucault]] to emphasize that power is based on knowledge and at the same time, produces and shapes knowledge to serve its aims. Barnett and Duvall argue that while using individual conceptualisations of power can be a useful analytical tool, social and political relations are complex and what they demonstrate instead is that [[power operates in multiple and interconnected ways and that different forms of power are at play simultaneously in socio-political relations]]. In keeping with this view and connecting it to the field of global health governance, Moon (2019) argues that while the various conceptualisations of power are important for understanding global governance, none are sufficient on their own. She concludes that multiple types of power can mutually reinforce tremendous power disparities in global health, that these are neither absolute nor immutable, and that further research and innovative methods are needed to understand power’s complexity. [[Insights]] So what is the relevance of this theory to my study? LOL ### 3.3 Nye - Hard and Soft Power The political scientist [[Joseph Nye]] argued that while hard power is material (military or economic) and offers the ability to influence outcomes through coercion and threat, soft power is the ability to ‘get others to want what you want’ (Nye 1990:31-2; emphasis added). [[Soft power, such as development assistance for health, is close to the definition of third face of power but does not fully overlap because it still relies on resources and capabilities to exert influence]] In a later work Nye defined soft power as ‘the ability to affect others through the co-optive means of framing the agenda, persuading and eliciting positive attraction in order to obtain preferred outcomes’ (2011:20-21). This definition of power is conceptually close to Lukes’ third face of power, but does not fully overlap with it, because ‘soft power’ as defined by Nye still relies on resources and capabilities to exert influence – just a different type of influence. The term ‘soft power’ is widely used to refer to a broad range of initiatives, including development assistance for health. However, Baldwin critiques this concept for lacking clarity and calls for more research into soft power in global politics – into what it is, how it is used, by whom and for what purposes (Baldwin 2013: 288-290). ## 4. Power in global governance ### 4.1 Power and international institutions > International (or inter-governmental) institutions can be said to be a product of relationships of power since they are created by powerful states to cater for their own interests. Barnett and Duvall (2005a) argue that institutional power is also expressed through agenda setting, the establishment of priorities, governing biases, and the perpetuation of future interests and positions of advantage. Evidence of how institutions cater to the interests of powerful states can be found in their institutional mandates, structure, representation, and voting rules. For example, the [[UN Security Council (UNSC)]] – the body responsible for the maintenance of international peace and security – comprises five permanent members (P5): the US, Russia, China, France, and the United Kingdom, and only 10 other members selected from the remainder of the UN membership, who serve fixed-time mandates. This creates a clear structural advantage for the P5 in terms of representation. In addition, they enjoy a right of veto over Security Council resolutions. Decisions taken by the UNSC require an affirmative vote from nine of its members, and no veto by any of the permanent five members in order to authorise international action. [[Insights]] This is what happens with Israel-Hamas war when US vetoed to reject ceasefire. The [[World Bank (WB)]] and the [[International Monetary Fund (IMF)]] operate a system of weighted voting, where countries, which contribute most to the organisation have a larger proportion of the vote in decision-making procedures. Countries’ contributions are subject to the same voting procedures, meaning that states cannot unilaterally change the weighting of their vote by contributing more to the organisation. ==Each member state has one vote at the World Health Assembly==, where decisions are made by two-thirds majority of the members present and voting (where those abstaining are not counted as voting). ### 4.2 Power in the practice of global governance As Avant, Finnemore and Sell argue ‘global governance does not unfold naturally or smoothly toward a unique equilibrium. Governance, where it occurs, is the result of a political process and is shaped by power, access, mobilisation, leadership, and other political variables’ (2010:7). Global governance is made up of multiple processes of governance, negotiation, decision-making, implementation, and contestation. Contestation and resistance could be examined in relation to particular norms (e.g. [tobacco control]([[Framework Convention on Tobacco Control]]), the right to health, [intellectual property rights protection]([[Intellectual Property Rights (IPR)]]) and its influence on the accessibility of drugs), in the context of institutional arrangements (e.g. the decision of the United States not to participate in the International Criminal Court or President Trump’s decision in 2020 to withdraw the United States from the World Health Organisation), in relation to emerging practices, norms, policymaking procedures and so on. ## 5. Power in global health governance There are numerous ways to think about power in global health governance – from resources, to institutions, to networks and coalitions between actors; from governance arrangements to ‘forum shopping’ (or the selection of institutions that are likely to deliver the desired results); as power of public institutions, private power, grassroots power, and so on. Global health policy analysts, however, draw attention to an even more important consideration - the ways in which ‘disparities or imbalances of power… result in poorer health for the less powerful’ (Moon 2019:74), which the Lancet Commission on Global Governance for Health had previously defined as morally unacceptable (Ottersen et al 2014: 661). [[Something for later]] This includes the need for analysis, which is multi-scalar – i.e., simultaneously considering interactions across levels of analysis – from the global to the individual, including considerations of systemic effects, of the consequences of institutional arrangements, international treaties, and normative frameworks (Kentikelenis and Rochford 2019). Power asymmetries, as the authors describe relationships of differential power, play a significant role in the politics of global health governance and global governance for health. Quoting the Commission on Social Determinants of Health (2008), the Commission on Global Governance for Health reiterates that ‘the basic, root causes of health inequity lie in the unequal distribution of power, money and resources’ (Ottersen et al 2014: 634). [[Power asymmetries are a permanent feature of social, political, economic relations, but constellations of power (or places where power concentrates) can change]]. Actors and institutions can be empowered, dynamics of power can change, it is therefore possible to reduce inequalities and ultimately to improve population health. ## 6. Integrating Activity Read The Lancet and University of Oslo Global Commission on Global Governance for Health Report (Ottersen et al 2014). Choose one of the case examples presented in the report (Ottersen et al 2014: 638-654). Apply one of the typologies of power presented in the session to your chosen case and reflect on its usefulness in gaining a more nuanced understanding of sources of power and how different actors use power. Post your response in the dedicated forum on Moodle and comment on the response of at least one other student. ## 7. Summary This session presented a broad overview of some of the key conceptualisations and typologies of power. Debates about power have a long history, as evidenced by philosophical writings and research across a range of social science disciplines including anthropology, sociology, political science, international relations, political economy. Summaries of different views on power, albeit brief, aimed to present a broader than usual spectrum of conceptions of power, to support further critical reflection. The discussion of sources of power highlighted the relevance of both material and non-material resources, while the last two sections aimed at putting the broader conceptual debates on power in the context specifically of global governance and global health governance. The concepts of power introduced here will be of foremost importance when examining the actors, institutions structures and issues examined in the remainder of the module and the wider programme. ## 8. References ### [[Essential readings]] [[@moonPowerGlobalGovernance2019]] [[@ottersenPoliticalOriginsHealth2014]] ### [[Recommended reading]] Barnett, Michael, and Raymond Duvall (2004). Power in Global Governance. In: Barnett M, Duvall R (eds). Power in Global Governance. Cambridge University Press. Lukes, Steven (2005) Power: A Radical View. 2nd edn. Basingstoke: Palgrave Macmillan, 14-59. Shiffman, Jeremy. ‘Knowledge, Moral Claims and the Exercise of Power in Global Health.’ International Journal of Health Policy and Management 3, no. 6 (2014): 297–99. Lee, Kelley. ‘Revealing Power in Truth.’ International Journal of Health Policy and Management 4, no. 4 (2015): 257–59. ### Other cited references and sources