# Session Overview ## Key terms **formative evaluation** – A type of policy evaluation which assesses the operations of a programme at a relatively early stage, while activities are forming, for the purpose of improving the programme and its implementation (Limbani et al., 2019). **goal evaluation** – A type of evaluation which assesses the extent a goal set by a policy is desirable, appropriate or feasible (Fischer and Morgenstern, 2008).   **good governance** – A set of principles to assess how well public institutions conduct public affairs and manage public resources including transparency, accountability, representativeness, effectiveness and the rule of law (Kickbusch and Gleicher, 2012). **impact/outcome evaluation** – A type of evaluation which assesses the broader intended or unintended consequences of a policy beyond an agreed goal (Fischer and Morgenstern, 2008). **policy evaluation** - A systematic process for assessing the design, implementation and outcomes of public policies (Mookerji and Meck, 2015). **process evaluation** – An assessment of whether the adoption and implementation of a policy decision has been carried out in accordance with agreed or appropriate procedures (Limbani et al., 2019). **summative evaluation** - A type of policy evaluation which seeks to determine the extent to which a policy achieved its intended goals (Limbani et al., 2019). # 1. Introduction There are diseases with globally relevant risk, which is pandemic potential pathogens. Pathogenicity (capacity to cause disease), virulence (capacity to cause severe or harmful illness) and transmissibility (capacity to be passed on from one organism to another). The risk of pandemics has led to international policy coordination, such as Global Influenza Surveillance Network. Coordinated by WHO, the network is underpinned by an international network of collaborating centres and national/regional influenza centres. Vaccine development and treatment with anti-viral drugs have been historically approached from a largely biomedical perspective, with disease surveillance primarily serving the purpose of providing data on circulating strains for vaccine and drug development. However, in 2007, the [[biopiracy|Indonesian government objected to being obliged to share virus samples]] with the global health community. It argued that Indonesia, along with other LMICs, would not in return have equitable access to vaccines developed from such samples by private pharmaceutical companies due to affordability and availability. The debate revealed ==competing discourses or normative theories about global governance==. Amid concerns about equity and fairness, efforts were made to ensure benefits sharing. However, how these benefits should be created and shared remain points of debate, with policy positions on a bloc level (coalition of diverse actors) not yet formed. There has been support for reform of the Global Influenza Surveillance Network amid dispute over the norms or values underpinning collective action.  A neoliberal-based model leaves the development and distribution of vaccines and anti-virals to the competitive market of pharmaceutical companies.  In contrast, a communitarian approach argues that access should be based on need, rather than ability to pay for such drugs.  Recognising the dependence of vaccine development on virus samples, and the benefits of ring-fencing outbreaks at an early stage, public health advocates have made **efforts to find innovative solutions in global governance.**  The agreement of the Pandemic Influenza Preparedness (PIP) Framework, which came into effect in 2011, represents an effort to find a compromise among the above normative theories by integrating market-based and equity principles. ## 1.3 HIV/AIDS Since the mid 1990s, the diffusion of influence on HIV/AIDS policy, from WHO as the focus (**unipolar governance**), to many institutional actors (**multipolar governance**), some but not all working through the Joint United Nations Programme on HIV/AIDS (UNAIDS), is also a notable feature of global policy.  Finally, there has been substantial institutional innovation to collectively address the disease.  The formation of UNAIDS by six co-sponsoring UN organizations to fight one disease, resolutions in the UN General Assembly and UN Security Council, creation of a wide range of global public-private partnerships led by the Global Fund to Fight HIV/AIDS, Malaria and Tuberculosis, and innovative financing of anti-retroviral treatments such as UNITAID, all represent **innovations in global health governance**.  In this sense, HIV/AIDS is a good example of an issue that has given rise to global policy making. ## 1.4 [[Non-Communicable Disease (NCD)]] Recognition of the global factors that are contributing to these trends has prompted calls for greater collective action.  One good example of **international policy coordination** is the WHO Framework Convention on Tobacco Control (FCTC) which came into effect in 2005.  The FCTC negotiation process highlighted different **normative theories and competing discourses of global governance**, namely how strongly regulated the tobacco industry should be, the scope of that regulation, and whether or not it should be a national level or even individual behavioural responsibility only.  The negotiation process also reflected a **shift from national to bloc level** policy making, with consensus building within various WHO regions (especially the Western Pacific and African regions) as negotiations progressed. There has been much evidence of **normative theories** about the causes of NCDs, most notably the contrast between explanations based on individual behavioural choices and structural or systemic factors.   At the same time, powerful vested economic interests (e.g. food and drink, tobacco, alcohol companies) populate the policy landscape, advocating for individual choice rather than regulation of industry.   It will take some time for us to have a **multi-bloc policy process** or **multi-polar governance** for chronic diseases.  Nonetheless, advocacy groups are beginning to mobilise to influence policy debates and are expected to increasingly contribute to global policy making on chronic diseases in coming years. This includes ideas for **innovations in global governance** such as marketing restrictions, and higher taxation or minimum pricing on unhealthy food and drink. ## 1.5 [[access to medicines]] The risks from lack of access may ostensibly be faced by individuals requiring such medicines, but such risks can become **globally relevant** if lack of access means an increased likelihood of a disease spreading more readily across populations and geographies.  Timely access to anti-viral drugs, for example, can serve to ring-fence a pandemic influenza outbreak. Increased access to anti-retrovirals (ARVs) in resource-limited settings has contributed significantly to reducing adult mortality from HIV/AIDS.  There is also evidence of preventive benefits, by reducing the population level viral load, and thereby reducing the overall risk of transmission. **Normative theories** divide the debate between those who see equity of access to key medicines as a basic human right, and those who approach the production and consumption of medicines in market-based terms.  Should access to essential medicines be a fundamental entitlement for all people, regardless of ability to pay, or should access to essential medicines only be available to those who can afford to pay for them?  Normative theories even disagree on what might be considered ‘essential’ medicines. While there seems limited evidence to date of a shift, from national to multi bloc level policy making, or single to multipolar governance, among global health issues, access to medicines is an issue that has generated perhaps the most **innovative forms of global governance**.  Given the substantial economic stakes involved, this may be due to the desire to find workable solutions to the impasse between intellectual property rights and the need for affordable medicines to meet priority health needs. The Doha Declaration on the Trade-Related Aspects of Intellectual Property Rights Agreement ([[TRIPS Agreement]]), Public Health and follow up Decision on Paragraph 6, along with the previously mentioned [[Pandemic Influenza Preparedness Framework]] are examples of efforts to reconcile intellectual property rights and equity of access to medicines through, for example, compulsory licensing to produce generic drugs.  Innovative financing mechanisms to fund increased access through, for example air ticket surcharges, debt relief, bond issues and drug purchase facility, have also proliferated.  [[UNITAID]] formed in 2006, for example, is funded by the levying of surcharges on airline tickets. ## 1.6 Illicit trade Illicit drugs, tobacco products and counterfeit medicines are globally relevant risks in themselves, criminal groups are known to engage in several types of illicit activity, often using the same supply and distribution networks, and financial mechanisms to launder proceeds. International policy coordination: [[International Medical Products Anti-Counterfeiting Taskforce (IMPACT)]] in 2006, which has built coordinated networks around the world. which has built coordinated networks to halt the production and sale of fake medicines around the world. The IMPACT comprises a partnership between international organizations, non-governmental organizations, enforcement agencies, pharmaceutical manufacturers associations and regulatory associations and is divided into working groups which tackle different areas related to counterfeit medicines. # 2. ## 2.4 Challenges in Evaluating [[global health policy]] - Global health policy goals can be unclearly articulated or difficult to measure, characterised by broad statements of principle rather than measurable outcomes (e.g. [[WHO Commission on the Social Determinants of Health]] put forth broadly stated changes to achieve while Sustainable Development Goals put forth measurable targets) - GHP can reflect the priorities of donors rather than target populations - GHP can involve a large number of, and diverse, institutional actors contributing in varying ways to a policy. - GHP is usually implemented amid potentially confounding factors, which cannot be controlled for, that can shape how a policy is implemented (e.g. introduction of a tax on sugary drinks coincides with the launch of a new beverage brand.) - Global health policy suffers especially from a weak evidence base because, by definition, policies can apply across diverse population groups and geographical locations, thus requiring types of data that cannot be captured solely at the national level (e.g. workers health and safety in special economic zones). # 3. Good governance and [[global health policy]] ## 3.1 Principles For example, the OECD (2013) identifies the following principles: - **Accountability**: where the government is able and willing to show the extent to which its actions and decisions are consistent with clearly-defined and agreed-upon objectives which serve the public interests of a defined constituency. - **Transparency**: government actions, decisions and decision-making processes are open to an appropriate level of scrutiny by other parts of government, civil society and, in some instances, outside institutions and governments. - **Efficiency and effectiveness**: the government strives to produce quality public outputs, including services delivered to citizens, at the best cost, and ensures that outputs meet the original intentions of policymakers. - **Responsiveness**: the government has the capacity and flexibility to respond rapidly to societal changes, takes into account the expectations of civil society in identifying the general public interest, and is willing to critically re-examine the role of government. - **Forward vision**: the government is able to anticipate future problems and issues based on current data and trends and develop policies that take into account future costs and anticipated changes (e.g. demographic, environmental, economic). - **Rule of Law**: the government enforces equally transparent laws, regulations and codes. The UNDP (2011) cites eight principles of good governance as “critical for developing and implementing effective and equitable policy measures to mitigate the impact of economic crises” including: **Participation/inclusion:** the empowerment through representation in government and through other (e.g., administrative and local) mechanisms facilitating free, active and meaningful participation in decision making processes. **Non-discrimination and equality:**  the addressing of power inequalities (political, economic, legal, or cultural) and extension of development gains to the most excluded groups and individuals. Given their relative importance, inflows of aid can sometimes influence a government’s national health policy, possibly distorting the distribution of limited resources towards donor priorities.  Good governance principles help assess the link between how decision making is carried out (i.e. who participates, who are decision makers accountable to) and the resulting decision. Similarly, the [[Lancet-University of Oslo Commission on Global Governance for Health (2014)]] identifies several systemic global governance dysfunctions including inadequate representation ([[Democratic deficit]]) and weak accountability.  Among the many recommendations of the Commission are: ·      There should be independent monitoring of progress made in redressing health inequities, and in countering the global political forces that are detrimental to health (accountability) ·      State and non-state stakeholders across global policy arenas must be better connected for transparent policy dialogue in decision-making processes that affect health (transparency) It is important to recognise that the specific principles put forth to assess good governance are embedded within normative (value-based) frameworks.  Some argue that certain principles reflect the values of liberal democratic societies and, as such, may not be appropriate for assessing public institutions in countries with different forms of government.  For example, the giving of gifts to public officials is considered acceptable, and indeed, expected in many countries to facilitate policy making.  In other countries, this practice is strictly regulated and even prohibited as potentially corrupting of officials appointed to serve public interests on an impartial basis.  Others, however, argue that there are universal principles emerging that can be applied to public institutions in all countries.  For example, it is broadly agreed that people impacted by a policy decision should be consulted either through direct participation or indirectly through representation. A broader way of thinking about good governance, beyond public institutions, is to consider the rules governing relationships among state (government), market (commercial) and civil society actors. At the national level, the composition of government, and how different parts of government conduct their affairs in relation to market and civil society actors, are generally set out in formal rules.  The extent to which these rules lead to benefits shared by the populace, and are adhered to by different societal actors, can thus be a measure of good governance (van den Dool et al. 2015). # 4. # 5. # 6. Integrating activity # 7. Summary # 8. References ## 8.1 [[Essential readings]] [[@buseGlobalisationHealthPolicy2001]] Buse K, Drager N, Fustukian S, Lee K.  Globalisation and health policy:  Trends and opportunities.  In _Health Policy in a Globalising World_.  Cambridge:  Cambridge University Press, 2002, pp. 251-280. [[@behagueEvidencebasedPolicymakingImplications2009]] Behague D. et.al.  Evidence-based policy-making: the implications of globally-applicable research for context-specific problem-solving in devel oping countries.  _Social Science and Medicine_ 2009; 69(10): 1539-46. ## 8.2 [[Recommended reading]] [[@buseGlobalPublicPrivateH ealth2011]] Buse K, Tanaka S.  Global Public-Private Health Partnerships: lessons learned from ten years of experience and evaluation.  _International Dental Journal_ 2011; 61(S2): 2-10. [[@shiffmanFrameworkEmergenceEffectiveness]] Shiffman J, Quissell K, Schmitz HP, et al.  A framework on the emergence and effectiveness of global health networks.  Health Policy and Planning 2016; 31: i3-i16. [[@sridharMisfinancingGlobalHealth2008]] Sridhar D, Batniji R.  Misfinancing global health: a case for transparency in disbursements and decision making.  _Lancet_ 2008; 372(9644):  1185-1191.