## Learning outcomes - Understand what is policy making, specifically global health policy making - Recognise the specific challenges of making health policy in a global context - Apply selected approaches and frameworks to the analysis of policy making on key global health issues - Understand the purpose, structure and content of the remaining sessions of this module ## Key Terms [[epistemic communities]] - a transnational network of knowledge-based experts who, given their technical expertise, influence what issues are addressed by policy makers and the ways to potentially resolve them [[evidence-based policy]] An approach that seeks to inform public policy with rigorously established objective evidence (Behague et al., 2009). [[evidence-informed policy]] - An approach to policy decisions that aims to ensure that decision making is well-informed by the best available research evidence (Behague et al., 2009). ## Types of [[Problems without passports|Collective Action Health Problems]] a. ==Transboundary or cross border problems== - originate in one state but have ramifications for others, eg, refugees fleeing conflict, pollution spillovers, Zika virus, COVID-19 b. ==Common problems==, eg, oceans, the right to assert [[Intellectual Property Rights (IPR)|intellectual property claims]] over biological materials, for the purpose of using them in commercialized activities, has become the subject of [[global health policy]]. c. ==Shared problems== are widely experienced in many countries, eg, cyber bullying, unhealthy lifestyles, urbanized built environments and common cultural practices. As a result, there are a growing number of shared health problems across many societies.  These include the rise of tobacco and alcohol-related diseases, increase in non-communicable diseases such as diabetes and hypertension, new trends in mental health and addictions, and a growth in road traffic accidents. d. ==Planetary problems== have causes or consequences on a scale involving the world as a whole.  These problems may arise from individual actions, such as burning fossil fuels, which then have cumulative effects on a planetary scale (i.e. climate change).  The over- or misuse of antibiotics in many countries is having cumulative effects that are detrimental to all (i.e. antibiotic resistance). This category of problem requires collective action to address them effectively but, arguably, is also the most difficult to achieve policy agreement because of the broad distribution of responsibility for causing and solving the problem. ## Global Policy Making > Scholars often begin with the stages of a rational policy cycle, an ideal model that sets out linear steps, from agenda setting to policy implementation, to monitoring and evaluation (Figure 1.1).  In reality, of course, policy making is rarely rational or linear in process. ![[CleanShot 2024-10-20 at [email protected]]] ## How Can We Identify a Global Health Policy? The _Global Policy Journal_ identifies five further components of global public policy: ·      international policy coordination; ·      different and competing conceptions of what constitutes global order and relevant policies; ·      a shift from national to ‘bloc’ level policy making; ·      a shift from single polar to multi-polar governance; and ·      innovations in global governance. ^5ef96c ### International policy coordination it does not have to be in the category of globally relevant risks and collective action problems, eg, actions to promote equal rights and international standards are developing in many policy spheres. This is occurring for several reasons, such as the increasing interconnectedness of public opinion and economic forces, resulting in companies and consumers seeking assurance that child labour or worker health and safety are being appropriately regulated in developing economies. Other examples - code of marketing of breast-milk substitutes, code of practice on the international recruitment of health personnel, challenges of relying on international policy coordinatio nto deal with access to medicines and illicit trade. ### different and competing conceptions of what constitutes global order and relevant policies a)             Normative theories (i.e. theories concerning what is right or wrong, desirable or undesirable, or just or unjust) of global governance are undergoing rapid development and change.  Norms, for instance, shape thinking about what should be the relative roles of the state (government) versus markets, what should be the relative importance of democratic freedoms versus social order, or what should be the basic entitlements of each citizen?  Importantly, previously dominant normative frameworks such as neoliberalism, which value market competition and economic growth, may be giving way to new frameworks which value sustainability and human rights.  The important points here is that norms shape the nature of global governance and these norms are not fixed but change over time. As the need for collective action is increasingly recognized in global health, different **normative theories of global health governance** are emerging and, in many cases, competing for policy space.  As described above, norms derive from agreed values about what is considered right or wrong, desirable or undesirable, or just or unjust within a society (Soroos, 1991).  As [[Kamradt-Scott]] (2015) writes, norms are “standards of behaviour” or “collective expectations about proper behaviour for a given identity”.  Debates about user fees for health services, the appropriate roles of the public and private sector in global health partnerships, and the achievement of universal health coverage are underpinned by competing normative theories.  McInnes and Lee (2012) analyse how norms of security, biomedicalism and economism, for example, have influenced the framing of HIV/AIDS, tobacco control and pandemic influenza.  The importance of normative theories runs through the entire module but two sessions, in particular, on global health equity, and the debate between horizontal versus vertical approaches to health development, highlight their impact in global health policy. The remaining components of global public policy concern ways that conventional ‘domestic’ policy making is increasingly going beyond a single country focus.  These are: ### a shift from national to ‘bloc’ level policy making; New political formations (i.e. the institutional arrangements that are formed within a society to carry out policy making) are emerging beyond the state in two main areas. First, in the European Union, a great experiment in ‘joining up’ national policy approaches is underway, which has already introduced important changes in how the 27 member states make public policies across many sectors.  A growing range of public health issues are being addressed through directives such as patients’ rights in cross-border healthcare; good clinical practice in conducting clinical trials of medicinal products for human use; and tobacco advertising.  In other regions, this trend has not progressed as far.  Second, the development of complex patterns or regionalism, often involving greater economic policy integration, in North and South America, the Asia-Pacific area and sub-Saharan Africa can be observed. These patterns have emerged partly as responses to globalization, and partly as attempts to shape it.  Sessions in this module look at collective efforts to address environmental change and health, and tobacco control, which have both seen bloc level policy making in an effort to reach international agreement on ways forward. ### a shift from single polar to multi-polar governance; and **a)**             Over the next half century, world order may shift, from being dominated by one centre of power (namely the USA), to several regional blocs based around the EU, USA, China, India and Latin America.  Each of these regional blocs will evolve different policy approaches and styles which are likely to have important effects. The G20 group of countries, for example, may experience a revival as economic and political power is more widely dispersed. Are regional blocs, and different policy approaches and styles, emerging in global health?  Brazil’s internationally acclaimed HIV/AIDS program, which includes universal access to antiretroviral treatment, has been influential in shaping programs in other low- and middle-income countries.  The rapid growth of China as a significant aid donor since the mid 2000s, led by the Belt and Road Initiative (launched in 2013 as a vast collection of development and investment initiatives stretching from East Asia to Europe), has included an exponential growth in health development assistance (US$652 million by 2017) (Micah et al. 2019).  One session in this module looks at the advent of new health aid donors as a possible reflection of the shift to multi-polar health governance. ### innovations in global governance a)             Innovations in the institutional arrangements, rules and processes by which societies steer themselves towards the achievement of agreed goals have emerged in recent decades.  These innovations are a response to frustrations with the slow and increasingly “gridlocked” efforts of existing intergovernmental mechanisms (i.e. UN bodies) to effectively address pressing global issues (e.g. climate change, human rights, cybersecurity).  These include movements bringing together a diverse collection of actors (citizens, private corporations, NGOs, subnational governments) into coalitions to promote collective action on emerging global risks and challenges.   These coalitions may vary in their composition, legal standing, and activities (Kahler et al., 2017). To what extent are **innovations in global governance** occurring to address emerging global health risks and challenges?  What weaknesses can we identify in existing arrangements for bilateral and multilateral cooperation, and what efforts are being made to overcome them?  There has been an especially prolific growth of public-private partnerships and innovative financing mechanisms in global health governance.  Sessions in this module, such as Session 3 on the political economy of the global AIDS response, also examine the increased role of civil society and the private sector in innovative global health governance arrangements. ![[CleanShot 2024-10-20 at [email protected]]] ## Global Health Policy and the Three Pillars of Government Legislative - Executive - Judiciary Though it's relevant in national level, once it becomes international, there is no equivalent. So, most of international agreements are non-binding, or, binding in a different level of compliance required. ### Judiciary The judiciary is the least developed of the three pillars of government at the global level, in large part, because of the principle of state sovereignty described earlier. As such, member states are encouraged to adhere to adopted resolutions, but they are not bound to do so. Two exceptions are the International Health Regulations (2005), which are binding on member states, and the Framework Convention on Tobacco Control (FCTC) agreed in 2003. Yet, even for these two international treaties, there is no stipulated authority or resources for WHO to enforce compliance through either incentives or punitive measures. Instead, WHO must rely on maintaining positive relationships with member states, moral suasion or public pressure (Lee 2009). The lack of “teeth” by WHO, to enforce compliance with the IHR (2005), was a major concern during the early period of the COVID-19 pandemic. ## Understanding global policy actors and processes [[Global governance is the complex of formal and informal institutions, mechanisms, relationships, and processes|Things are happening beyond formal roles]] - the power and influence of actors. ### GHP Actors [[epistemic communities]], such as groups of scientists, health professionals, technical experts and consultants with specialist knowledge. Actors have the capacity to shape normative frameworks. WHO and other global health actors lack supranational authority, and thus they acted as [[norm entrepreneur]] by advocating for certain social norms, eg, [[Reciprocal measures]], solidarity, during the reform of [[IHR]]. A related approach to understanding global health policy processes is to see them as [[policy networks]]. In contrast with formal, often hierarchical policy structures within the three pillars of government, networks are a looser, more interconnected set of relationships. ## Global Health Policy Process Vertical policy: developed within a single organisational structure and generally starts with broad overarching policy” (Torjman, 2005).  A good example is WHO’s Global Influenza Programme which provides member states with strategic guidance, technical support and coordination of activities essential to make their health systems better prepared against seasonal, zoonotic and pandemic influenza threats to populations and individuals.  The focus of the Programme’s work is on surveillance, monitoring and reporting. Horizontal policy: “is developed by two or more organisations, each of which has the ability and mandate to deal with only one dimension of a given situation.  Horizontal or integrated policy is created between parts of an organization or among organizational components that are similar in hierarchical position” (Torjman, 2005).  The adoption of the Global Pandemic Influenza Action Plan in 2006 to increase vaccine supply reflected the need for coordinated action beyond surveillance and reporting.  While initiated by WHO, the initiative involves national immunization programs, national regulatory authorities, vaccine manufacturers and the research community as key stakeholders. [[Insights]] One Health is a perfect example of horizontal policy. ### Feasibility Three steps: technical feasibility, economically feasible, political feasibility In summary, global health policy is characterised by the following features: a)    uneven development of the three pillars of government at the global level; b)    lack of formal power over the formal authority of sovereign states; c)     greater capacity for epistemic communities of technical experts to shape global policy processes including norms; d)    increased importance of working through global policy networks by alliance and coalition building, sharing discourses and construct consensual knowledge; e)    greater need for horizontal policy making to deal effectively with the complex and multi-sectoral health challenges posed by globalisation; and f)     consensus building through global health diplomacy bringing together traditional diplomats and technical experts. ## Integrating Activity Read the brief article, “Can scientists and policy makers work together?” by Choi et al. (2005) which can be found at:  [https://jech.bmj.com/content/jech/59/8/632.full.pdf](https://jech.bmj.com/content/jech/59/8/632.full.pdf).  Using the discussion board, share your responses to the following questions with your fellow students and please respond to at least one other post: a)  How is the work of scientists and policy makers assessed?  To what extent are these criteria different? Scientists publish or perish. Their work is more narrow, specialist, and gets to the nitty gritty of rationality, methodical, and pointing out flaws in every other study. Policymakers are the complete opposite. Their aim is to get things done, find compromise from available "evidence" and "lesson learned" while managing their partisans and managing their constituents' support. In a way, policymakers must care about their popularity and whether their prescriptions solve people's problems in short-term, tangible reality that can be measured - while scientist will go to the deepest hole of research to find an answer that probably will not be used for anything. b)  Who should have greater influence over global health policy - scientists or policy makers? In my perspective, this is not a zero-sum game. The presence of scientist and policymaker and how they think about a matter is a tension that should be managed, not a problem to be solved. Scientist will be apt and quick to point out if policymakers are moving in the wrong direction and will harm its people, while policymakers can cut through the noise and adopt policies that will actually bring goods to their people. c)  How might the two worlds of the scientist and policy maker be brought closer together in global health policy making? # 5. Summary In summary, this session introduces the module GHM104 Issues in Global Health Policy.  The aim has been to provide you with an understanding of health policy making in the global context and introduce you to key concepts.  The main points of this session are: ·      what makes health policy global in nature can be understood by applying six components of global policy (Figure 1); ·      the three institutional pillars of government (legislature, executive and judiciary) are less developed at the global level than they are at the national and subnational levels which influences what actors and processes shape global health policy; ·      global policy making processes involves more complex configurations of actors participating in formal and informal processes (networks, epistemic communities) than at the national level due to the lack of supranational (above the state) authority; and ·      there is a need to address the factors which hinder “good” global health policy to achieve effective collective action. # 6. References ## [[Essential readings]] Before you begin the work in this session, you will need to have read: - [[@brownHandbookGlobalHealth2014]] - [[@moloneyStateGlobalPolicy2019]] Moloney K, Stone D. Beyond the State: Global Policy and Transnational Administration. _International Review of Public Policy_ 2019; 1(1): 104-118.  [https://journals.openedition.org/irpp/344](https://journals.openedition.org/irpp/344) ## [[Recommended reading]] You are also strongly encouraged to read the following articles as they will further enhance your understanding of policy making within a global context: [[@balboaPolicymakingGlobalContext2015]] Balboa C, Deloffre M. 2015. Policymaking in the Global Context:  Training Students to Build Effective Strategic Partnerships With Nongovernmental Organizations. _Journal of Public Affairs Education_, 21(3): 417-434. [[@choiCanScientistsPolicy2005]] Choi B. et al. 2005. Can scientists and policy makers work together? _Epidemiology and Community Health,_ 59: 632-637. [[@mcdougallPowerPoliticsGlobal2016]] McDougall L. 2016. Power and Politics in the Global Health Landscape: Beliefs, Competition and Negotiation Among Global Advocacy Coalitions in the Policy-Making Process. _International Journal of Health Policy and Management_, 5(5): 309-320.