The state in global health(focus on LICs/MICs)

Jack Cullen, Ashleigh De Verteuil,Albert Domingo, Eleanor Dow, and Kurt Olson

16 October 2014

Outline

1. Scope of state capacity to shape health policya. States and external entitiesb. The delivery of health (policy) aidc. Deciding when to “go in”d. Does ideology matter?e. State capacities to shape policy varyf. Case study: reproductive health in the Philippines

Outline

2. Dimensions of policy transfer in health issuesa. Towards a “global state”b. Dimensions of policy transferc. Policy transfer loopsd. Dimensions in the first loope. Dimensions in the second loopf. Dimensions in the third loopg. Dimensions and loops in TB DOTS

THE SCOPE OF STATE CAPACITY TO SHAPE HEALTH POLICY

States and external entities (1)

• Donors are just one kind of non-state and external entity that is active in a country’s health policy environment. Other examples:– Churches (Used to be the state… now divorced?)– Aid NGOs like Oxfam, Save the Children, MSF (No coercion

whatsoever?)– Philanthropies like Bill and Melinda Gates Foundation;

recently Mark Zuckerberg (FB) gave $25M to CDC for Ebola control (What are their interests anyway?)

• Non-state external entities are not monolithic; there are also policy debates going on within

States and external entities (2)

• Does a state know better than those outside, or v.v.?– Concept of decentralization/devolution: national level being “outside”

the scope of governance

• When does the good guy helping a state become a bad guy exploiting a state, and why?

External “Aid

”

Strong

State

A valid model?

Sovereignty

Administrative and logistics systems

Trust issues

Soft power

The Case of South Africa• Using South Africa as an example, it is clear that there is significant

confrontation between large multinational companies and the interests of the government.

• The Health Minister of 1998 engineered a strategy to allow the cheapest import for generic drugs in the treatment of HIV/AIDS to the country, however this was severely opposed by dozens of pharmaceutical companies. They brought cases of infringement laws to the government and attempted to destabilize the proposals.

• After a nation-wide public campaign, and substantial pressure from the civil society in their home countries, the pharmaceutical companies finally retracted their case. Many of these organisations have since offered to provide antiretroviral drugs at very little or no cost.

• Clearly, the influence of multinational companies over countries that experience difficulties in health care, is not as significant as it might seem.

The delivery of health (policy) aid

• Is the state really interested? Sociopolitical context is a critical factor (e.g., priority given to health)

• What is the nature of conditionality?– Will accountability and transparency justify them?

• Are the financiers of external entities (e.g., citizens of bilateral donor countries) aware of conditionality being required for aid to be given?

• Is there such a thing as moral hazard or free riding in unconditional aid?

Deciding when to “go in”

• Why would an external entity work with a state?– Geopolitical “externalities” across countries– Spillover effects of infectious diseases, like Ebola

(acute example); TB (chronic example)• Damned if you do, damned if you don’t

– Is “going in” due to own national interests (in the case of bilateral donors) selfish?

– Is “staying out” selfish?

Does ideology matter?

• Note that trade agreements like the NAFTA have side agreements on health (through environment and labor)

• Why did the World Bank increase spending on health in early 90s? – Why did it become interested in health?

• There may be an association between ideology and the delivery of aid… but is it causation or correlation?

State capacities to shape policy vary

• LICs (Uganda, etc) – weak financial, administrative, and delivery systems; poor negotiating position

• MICs (Philippines, etc) – emerging strengths in financing, service delivery, and governance – but still a work in progress; capable of receiving aid efficiently, can negotiate to some extent

• HICs (USA, UK, etc) – corporate interests?

Case Study:Reproductive Health in the Philippines

(Adapted from Goldie 2010)

Who says what on Philippine Reproductive Health (Maternal) Policy

Mothers are

dying; we have to attain MDG 5

All mothers should deliver

in health facilities

Skilled birth

attendants are key.

Also, family

planning

Access to modern

contracep-tion is a human right

It is a sin to use

artificial contra-ceptives

Don’t jump to conclusions…

• External groups may be reacting to “field issues” (corruption, incapacity of states, etc.) at that particular point in time

• Ideological (theological?) interests may be coincidental, or just secondarily linked, or intentional (we’ll never know) there may be an association, but it’s not necessarily causative

• There are bilateral trust issues: we’d like to help (but we don’t trust each other that much) who will give in, and who will referee?

HEALTH OUTCOMES VIA INTERNATIONAL GROUPS AND NATIONAL (DOMESTIC PLAYERS)

DIMENSIONS OF POLICY TRANSFER IN HEALTH ISSUES

Towards a “global state”

• Are we now moving towards a global state?• Who’s pushing towards that goal, health-wise?

WB, WHO, UNICEF?• Do we need centralized organizations that

represent only “certain countries”?

Dimensions of Policy Transfer

• Voluntary vs. coercive– Voluntary - NAFTA (Health rider NAO’s)– Coercive - IMF Greece vs. Iceland post Crash

• Uniform vs. adaptive– Uniform - (CDC approach Ebola) The United States

health care system is congruous with the US economy and with prevailing local values: it is resource intensive, technology-focused, consumer-oriented, individualistic, and unequally available. (Jameton Peirce 2006)

– Adaptive??

Uniform Standard for Ebola handling?

http://en.wikipedia.org/wiki/Biosafety_level

http://www.guardian.co.tt/news/2014-08-11/tighter-border-control-over-ebola-virus-threat

Policy Transfer Development

• Bottom up- research oriented policy- which seeks to adopt a problem and adapt technological response.

• Top Down- marketing oriented- which seeks to promote health measures and solutions via social context.

We need scholarly science to solve problems,and savvy marketing to move people!

2nd Loop

3rd Loop1st Loop

Small

-scale Global

Population Health

Compatibility?

Consensus-building

CascadingProblem-solving

Dimensions in the First Loop

• The First Loop: Field-Level, Context-Specific Genesis of Policy. (Bottom up)

This Loop is characterized by knowledge generation and experimentation. Making policy congruent with the specific dynamics and related data of this health issue. Eg. Treating TB in the field and not in hospital.

• Hidden participants - managing TB at local level• Narrow scientific and technical policy community (epistemic)• Motivated by the urgency and need of a solution to a problem

Dimensions in the Second Loop

• The Second Loop: National Policy NetworksClosely aligned networks who can achieve more together than apart.Field level information from Loop 1 is moved up and consolidated for international policy consideration.Eg. Stylo Field tests for TB (WHO)+ World Bank funding, brought TB to the international frontal lobes.

Dimensions in the Third Loop

• The Third Loop: Global Marketing and Dissemination

Global, standardized best practice and strategies to disseminate policies.Leads to uniformity and disagreement about how to create a needed “one size fits all policy”

Dimensions and Loops in TB DOTS

• 1st loop - work of Styblo, a public health physician, developing a short course treatment programme for patients with TB

• 2nd loop - WB and other international organisations recognise TB as a health priority - TB re-emerges in the west with rising cases of HIV

Dimensions and Loops in TB DOTS

• 3rd loop 1993 - Kraig Klaudt - ‘advocacy expert’ from US - declared global emergency - 1994 WHO launch Framework for Effective Tobacco Control - then DOTS - accused of being a simplification of Stybo's work

• importance of branding: “I look at the DOTS campaign as being a remarkable success in brand name dissemination around the worldyDOTS is perhaps the best-ever public sector campaigny When you manage to get your brand name disseminated to the lowest possible level, then you’ve succeeded. This is an important mechanism of policy transfer—you need to have a message that is simple enough to rally people around so that even if they don’t understand it they can say that they want it.”

Key Messages

• Branding to increase funding vs effective implementation

• 3rd loop - One size fits all? Top down? Scientific?

• The influence of effective publicity in global health initiatives

Main ReferencesOkuonzi, S.A. and J. Macrae. (1995) Whose policy is it anyway? International and national influences on health policy development in Uganda. Health Policy and Planning, 10(2), pp.122-132.

Umali, V.A. (2010) The Politics of Population Policy-Making in the Philippines: Insights from the Population and Reproductive Health Legislative Proposals. Unpublished Doctor of Philosophy Dissertation, University of Vienna.

United States Agency for International Development (2012) USAID/Philippines: Performance Evaluation of the Family Planning and Maternal and Child Health Portfolio. Available at: http://pdf.usaid.gov/pdf_docs/pdacw275.pdf [Accessed: 12 October 2014].

Walt, G. et al. (2004) International Organizations in Transfer of Infectious Diseases: Iterative Loops of Adoption, Adaptation, and Marketing. Governance: An International Journal of Policy, Administration, and Institutions, 17(2), pp.189-210.

World Bank (2013) Philippines - Second Women's Health and Safe Motherhood Project. Washington, DC: World Bank Group. Available at: http://documents.worldbank.org/curated/en/2013/12/18780439/philippines-loan-second-womens-health-safe-motherhood-project [Accessed: 13 October 2014].