# Session Overview - Why do global health initiatives succeed or fail? The field of policy analysis for health - Professor Johanna Hanefeld - Who do Global Health Initiatives really serve? -_ Professor Mishal S Khan # 1. Who do Global Health Initiatives really serve? *Prof. Mishal Sameer Khan* Her research in Pakistan and Bangladesh for TB where she engaged private labs, which was for-profit healthcare sector, she encountered conflict of interest of profit-making and providing the best healthcare. Basically according to the labs: to keep cost low for patients and make profits is to throw away the specimens and tell them the result is negative. Prof. Mishal researched about this and the result came back as stated by the lab owners. Different stages of policy process and areas where there are conflicts of interest: 1. [[Three faces of power are layered. First face is domination, second face is agenda-setting, and third face is thought-control|agenda setting]] 2. [[global health policy]] making: loopholes left in policies that are made so it's easier to transgress. 3. [[Policy]] implementation: allocating insufficient resources for meaningful implementation, ignoring instances of failure to abide by regulations 4. policy evaluation: success of certain policies is not assessed, or data reporting is manipulated. > People in institutions do act in their own interest irrespective of what the mission statement is. If we think about interests and at the same time, ideas about what expertise we consider valuable, what expertise is considered less valuable or marginalised, it goes back to the example of academic credentials versus someone who really knows the local context These beliefs about what is considered 'valuable' expertise determines in certain people being elevated, certain people getting more power and others being marginalised. Another thing is lens; the way see a problem. For example in AMR, if people in high-income countries see this through a lens where they are afraid people from LMICs will infect them somehow, they're going to focus on surveillance. However, people in LMICs doesn't see it that way. They are not thinking about spreading it to other countries. Their main concern is how can we have less of our population sick, so they focus on water and sanitation instead of surveillance. # 2. Why do global health initiatives succeed or fail? The field of policy analysis for health *Prof. [[Johanna Hanefeld]]* Health policy analysis is about trying to understand why global health initiatives succeed or fail. ## Global health and the rise of evidence-based solutions > Evidence based medicine to evidence based global health: quantify the problem and test a solution - **take this, to scale**.' [[Global health moves from evidence-based medicine to evidence-based global health]] And at the same time, over the last 20 or 30 years, we've really, seen our field move from what you could call it, from evidence based medicine, where you use the scientific method to organise and apply data to improve decision making in clinical settings to evidence based global health. How can we identify technology? How can we identify an intervention that overcomes this challenge and ultimately improves health? If we prove this point, we then take something to scale. Previously we called it [[technology transfer]] across different settings and contexts. Despite the best resources and best intention, sometimes the outcome is different between countries. So, [[health policy analysis]] seeks to unpack and look more closely at the interactions that happen and why policies succeed or fail. > "Health policy analysis is a multi-disciplinary approach to public policy that aims to explain the interaction between institutions, interests and ideas in the policy process. It is useful both retrospectively and prospectively, **to understand past policy failures and successes** and to plan for future policy implementation." > > Gill Walt, Jeremy Shiffman, Helen Schneider, Susan I Murray, Ruairi Brugha, Lucy Gilson, 'Doing' health policy analysis: methodological and nceptual reflections and challenges, Health Policy and Planning, Volume 23, Issue 5, September 2008, Pages 308-317, https://doi.org/10.1093/heapol/c2n024 [[Three faces of power are layered. First face is domination, second face is agenda-setting, and third face is thought-control]] Prof. [[Johanna Hanefeld]] explained her experience on HIV treatment rollout in Zambia and South Africa differences. Even though SA was middle income countries, Zambia was LIC. Why was Zambia with very few resources, able to rapidly scale up when South Africa could not? Equally, how could some parts of SA roll out even though the president publicly opposing this? But the most important work in the subsequent work and understanding the analysis have been the thoughts by [[Bourdieu]]'s capitals in understanding active power: | Sources of actor power | [[Bourdieu]]'s capitals | | ---------------------- | ------------------------------- | | Cultural capital | Education, scientific knowledge | | Symbolic capital | Office/charisma | | Economic capital | Funds | | Social capital | Networks | In South Africa the ability to mobilise of activists and activist clinicians and their connections globally- allowed them to use their [[social capital]]. This combined with the tacit support and symbolic capital of former President Nelson Mandela allowed them to roll-out treatment even securing funding at provincial level from the Global Fund in opposition to national government. In Zambia the economic capital of [[PEPFAR]] together with cultural capital of clinicians enabled a very fast roll -out despite health systems challenges. ## Conclusion from HIV response in Zambia and South Africa > [[Power was not linear and not held by one node and networks allowed actors to share their capitals - their sources of power]] > Understanding actor power, helped understand why policy implementation was successful and where ## Health system resilience in light of shock Prof. [[Johanna Hanefeld]] developed a framework that highlights how health systems responds to shock in light of shocks. She came up with three plus two model: > Three items (Health management information system + health funding/financing + health workforce) — guided by two (values and governance) And what really guided the decision-making was around values. And values were informed by the distribution of power across society. #to-think Prof. Johanna is working with PhD student and post-doc on different stages of COVID-19 responses in Ghana, to what extent these were influenced by the global North, by adoption from other countries, with a view to really identifying governance mechanisms that in the case of health emergency, would allow a better scale up of those responses. ## Conclusion of session One size does not fit all in [[global health]] Evidence-based intervention alone [[Scientific knowledge generation does not automatically translate into (policy) solutions and practices|will not suffice]] Understanding actor power and its sources is as important as developing a new vaccine or health financing mechanism to ensure succesful implementation > This work takes time and resources that need to be built into all processes # Related Notes [[GHM102 Session 03 Power in Global Health Policy]] [[Power asymmetry]]