A framework on generating attention for global health issues: case study of maternal survival<br />Based on paper publishe...
What I will present today<br />Background to research:<br />Question of issue attention in global health<br />Development ...
A fundamental question in global health<br />Why do some global health issues attract extensive political support (i.e. at...
Why variance across issues?<br />Much speculation:<br />Severity of problem? <br />Availability of intervention?<br />Medi...
Six simplistic hypotheses (not wrong but inadequate)<br />It’s about particularly powerful, rich or glamorous individuals<...
It’s about advocacy<br />Statement doesn’t help much.  Almost every issue has advocates.  Among other things we are trying...
Severity not an adequate explanation*<br />*Jeremy Shiffman, David Berlan and Tamara Hafner. 2009.  ‘Has Aid for AIDS Rais...
My dependent variable is political priority (not public health impact)<br />Definition:<br />Degree to which leaders of in...
First study: maternal survival and development of initial framework<br />Between 350,000 and 500,000 deaths annually due t...
Maternal survival: struggles from 1987-2007<br />1987-2007:<br />Funding<br />Few large grants for maternal survival from ...
Methods for case study<br />Process-tracing<br />Establishing origins and causal processes<br />Data sources:<br />Key inf...
The framework<br />In formative stage<br />Intended to launch research<br />Hypothesis generation rather than testing<br /...
Framework on determinants of issue ascendance in global health (Lancet 2007)<br />
Actor power (category one)<br />
Actor power:Policy community cohesion (factor 1)<br />What it is:<br />Coalescence among network of concerned organization...
Actor power:Leadership (factor 2)<br />Who they are:<br />Individuals acknowledged as strong champions for the cause<br />...
Actor power:Guiding institutions (factor 3)<br />What they are:<br />Powerful coordinating mechanisms with mandate to lead...
Actor power:Civil society mobilization (factor 4)<br />What it is:<br />Engaged social institutions that press political a...
Actor power: Findings on the safe motherhood initiative<br />Policy community cohesion:<br />Historically problematic; now...
Actor power: Intervention debates hinder policy community cohesion <br />“[People became] extremely defensive about their ...
Ideas (category two)<br />
Ideas:Internal frame (factor 5)<br />What it is:<br />Common policy community understanding of definition of problem and s...
Ideas:External frame (factor 6)<br />What it is:<br />Public positioning of the issue that inspires external audiences to ...
Ideas: Findings on maternal survival initiative<br />Internal frame:<br />Long-standing agreement maternal mortality a neg...
Political contexts (category three)<br />
Political contexts: Policy windows (factor 7)<br />What they are:<br />Moments in time when global conditions align favora...
Political contexts:Global governance structure (factor 8)<br />What they are:<br />Set of institutions that govern a secto...
Political contexts: Findings on maternal survival initiative<br />Policy windows:<br />Some have opened, facilitated by MD...
Issue characteristics (category four)<br />
Issue characteristics:Clear indicators (factor 9)<br />What these are:<br />Credible measures that demonstrate severity of...
Issue characteristics:Severity (factor 10)<br />What it is:<br />Large burden relative to other problems<br />Why it matte...
What these are:<br />Means of addressing the problem backed by evidence and clearly explained<br />Why they matter:<br />P...
Issue characteristics: Findings on the safe motherhood initiative<br />Credible indicators:<br />Maternal mortality more d...
Issue characteristics: Consequence of intervention and measurement problems <br />“We focus on uncertainties.  That is the...
The framework applied to the initiative through 2007<br />
New momentum for safe motherhood<br />New momentum for issue:<br />Financial commitments from British, Norwegian and US go...
Developing the framework<br />Applying to other health issues, such as community health<br />Identifying other factors<br ...
Developing the framework: Applying to other issues, such as community health<br />
Developing the framework: Identifying other factors<br />Category of actor power<br />Opponents<br />Disease constituencie...
Developing the framework: Discerning fundamental factors<br />Hunch that policy communities, ideas and institutions are co...
Developing the framework:Subjecting to empirical examination<br />Global Health Advocacy and Policy Project (GHAPP): funde...
Developing the framework:Subjecting to empirical examination<br />Seeking to:<br />Build a general explanation concerning ...
The preceding slides were presented at the<br />CORE Group 2010 Fall Meeting<br />Washington, DC<br />To see similar prese...
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Shiffman Framework

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CORE Group Fall Meeting 2010. A framework on generating attention for global health issues: case study of maternal survival. - Jeremy Shiffman, American University

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Shiffman Framework

  1. 1. A framework on generating attention for global health issues: case study of maternal survival<br />Based on paper published in The Lancet with Stephanie Smith(2007)<br />Funding from MacArthur and Gates Foundations<br />Jeremy Shiffman, PhD<br />Associate Professor of Public Administration and Policy<br />American University, Washington, DC<br />Presentation at Core Group Fall Meeting<br />15 September 2010<br />
  2. 2. What I will present today<br />Background to research:<br />Question of issue attention in global health<br />Development of framework<br />Illustrating the framework: <br />Case of maternal survival<br />Developing the framework:<br />Relevance for community health agenda?<br />Future research on issue attention in global health<br />
  3. 3. A fundamental question in global health<br />Why do some global health issues attract extensive political support (i.e. attention and resources) while others remain neglected?<br />High burden, high support:<br />Child immunization (in the past)<br />Family planning (in the past)<br />HIV/AIDS (presently)<br />High burden, minimal support (many issues at heart of community health agenda):<br />Pneumonia<br />Diarrheal diseases<br />Malnutrition<br />
  4. 4. Why variance across issues?<br />Much speculation:<br />Severity of problem? <br />Availability of intervention?<br />Media interest?<br />Sudden crises?<br />Effective global champions?<br />Rich country fears? <br />Strong advocacy? <br />Donor whims?<br />Little research<br />
  5. 5. Six simplistic hypotheses (not wrong but inadequate)<br />It’s about particularly powerful, rich or glamorous individuals<br />Begs the question: how do President Obama, Bill Gates, Angelina Jolie determine their priorities? They do not operate in a vacuum.<br />It’s about resources, especially financial<br />Of course it is, but this begs the question: what explains why donors and governments give financial resources to some causes and not others? <br />It’s about what rich countries fear<br />May explain H1N1; SARS; HIV/AIDS<br />But what about river blindness, polio, and guinea worm disease that have received significant resources but pose little threat to rich countries?<br />
  6. 6. It’s about advocacy<br />Statement doesn’t help much. Almost every issue has advocates. Among other things we are trying to identify determinants and explain elements of effective advocacy.<br />It’s about the media<br />The media has influence, but responds as much as it leads.<br />It’s faddish and random<br />Undoubtedly randomness plays a role. But research on agenda-setting provides strong evidence there are some systematic elements to issue attention.<br />Six simplistic hypotheses (not wrong but inadequate)<br />
  7. 7. Severity not an adequate explanation*<br />*Jeremy Shiffman, David Berlan and Tamara Hafner. 2009. ‘Has Aid for AIDS Raised all Health Funding Boats?’ Journal of AIDS.<br />
  8. 8. My dependent variable is political priority (not public health impact)<br />Definition:<br />Degree to which leaders of international organizations and national political systems actively pay attention to an issue, and provide resources commensurate with the problem’s severity<br />Political priority does not guarantee public health impact<br />But it facilitates impact and is therefore essential to investigate<br />
  9. 9. First study: maternal survival and development of initial framework<br />Between 350,000 and 500,000 deaths annually due to complications from childbirth<br />Almost all in low-income countries<br />A leading cause of death globally for adult women of reproductive age<br />Unclear to what extent two decade-long safe motherhood initiative (begun in 1987) has made difference in mortality levels<br />
  10. 10. Maternal survival: struggles from 1987-2007<br />1987-2007:<br />Funding<br />Few large grants for maternal survival from major donors<br />Global institutions<br />No major multilateral or bilateral agency embraces as priority<br />National policy adoption<br />Only a handful of low-income countries carry out effective national programs<br />Since 2007: a surge that demands explanation<br />Does framework work to explain this? Not yet explored.<br />
  11. 11. Methods for case study<br />Process-tracing<br />Establishing origins and causal processes<br />Data sources:<br />Key informant interviews<br />Total of 23<br />Average 90 minutes in length<br />Document analysis<br />Several hundred in total<br />From international agencies, governments, research<br />Data analysis<br />Developing historical narratives<br />Feedback from actors within and outside communities<br />
  12. 12. The framework<br />In formative stage<br />Intended to launch research<br />Hypothesis generation rather than testing<br />Factors are probabilistic, not necessary or sufficient<br />Grounded theoretically in scholarship on collective action<br />Now developing it empirically:<br />Study of maternal survival<br />Study of newborn survival<br />Comparative research program on six issues<br />
  13. 13. Framework on determinants of issue ascendance in global health (Lancet 2007)<br />
  14. 14. Actor power (category one)<br />
  15. 15. Actor power:Policy community cohesion (factor 1)<br />What it is:<br />Coalescence among network of concerned organizations<br />Policy communities can include multiple organizational types<br />Why it matters:<br />Enhances policy community authority and political power<br />
  16. 16. Actor power:Leadership (factor 2)<br />Who they are:<br />Individuals acknowledged as strong champions for the cause<br />Why they matter:<br />Defining issue; inspiring action; bringing together policy communities<br />Example:<br />Jim Grant for child survival<br />
  17. 17. Actor power:Guiding institutions (factor 3)<br />What they are:<br />Powerful coordinating mechanisms with mandate to lead initiative<br />Why they matter:<br />Especially, initiative sustainability<br />Example:<br />Task Force for Child Survival and Development<br />
  18. 18. Actor power:Civil society mobilization (factor 4)<br />What it is:<br />Engaged social institutions that press political authorities to act<br />Why it matters:<br />Source of bottom-up pressure on political leaders<br />
  19. 19. Actor power: Findings on the safe motherhood initiative<br />Policy community cohesion:<br />Historically problematic; now growing<br />Leadership:<br />Many talented advocates and researchers; dearth of unifying leaders<br />Guiding institutions:<br />Historically no strong institutions and lack of coordinated UN leadership; some institutions may now be emerging<br />Civil society mobilization:<br />Relatively weak; gender inequities give many poor women little political voice<br />
  20. 20. Actor power: Intervention debates hinder policy community cohesion <br />“[People became] extremely defensive about their ideas...If you didn’t agree with the idea you were bad and wrong…It was kind of like President Bush. If you are against this idea then you are a traitor.”<br /> -- Statement from respondent<br />
  21. 21. Ideas (category two)<br />
  22. 22. Ideas:Internal frame (factor 5)<br />What it is:<br />Common policy community understanding of definition of problem and solutions<br />Why it matters:<br />Averts fractiousness; enhances credibility<br />
  23. 23. Ideas:External frame (factor 6)<br />What it is:<br />Public positioning of the issue that inspires external audiences to act<br />Why it matters:<br />Only some resonate widely<br />Different frames resonate with different audiences<br />Examples:<br />Case of HIV/AIDS<br />Finance ministers v. health ministers<br />
  24. 24. Ideas: Findings on maternal survival initiative<br />Internal frame:<br />Long-standing agreement maternal mortality a neglected crisis demanding redress<br />Until recently difficulty finding other points of agreement<br />External frame:<br />Struggle to find public positioning of issue that resonates with political leaders<br />
  25. 25. Political contexts (category three)<br />
  26. 26. Political contexts: Policy windows (factor 7)<br />What they are:<br />Moments in time when global conditions align favorably for an issue<br />Often follow disasters (tsunami), discoveries (vaccines), forums (global UN conferences)<br />Why they matter:<br />Present global windows of opportunity for issue promotion <br />Example:<br />The MDGs: advantageous to those health causes on it<br />
  27. 27. Political contexts:Global governance structure (factor 8)<br />What they are:<br />Set of institutions that govern a sector globally<br />Why they matter:<br />Where strong and cohesive, present possibilities for effective global collective action<br />Example:<br />Increasingly complex global health architecture -difficulties for global coordination on health<br />
  28. 28. Political contexts: Findings on maternal survival initiative<br />Policy windows:<br />Some have opened, facilitated by MDG 5 on maternal survival<br />Not clear how well policy community, until recently, has taken advantage of these<br />Global governance structure:<br />Not ideal, with complex global health architecture and unclear institutional leadership<br />
  29. 29. Issue characteristics (category four)<br />
  30. 30. Issue characteristics:Clear indicators (factor 9)<br />What these are:<br />Credible measures that demonstrate severity of the problem <br />Why they matter:<br />Numbers can alarm politicians<br />May be used to convince politicians on progress<br />
  31. 31. Issue characteristics:Severity (factor 10)<br />What it is:<br />Large burden relative to other problems<br />Why it matters:<br />Other things being equal policy-makers prefer to devote resources to causes they perceive to be serious<br />
  32. 32. What these are:<br />Means of addressing the problem backed by evidence and clearly explained<br />Why they matter:<br />Policy-makers more likely to act on issues they think they can do something about<br />Example:<br />‘Immunize children’<br />Issue characteristics:Effective interventions (factor 11)<br />
  33. 33. Issue characteristics: Findings on the safe motherhood initiative<br />Credible indicators:<br />Maternal mortality more difficult to measure than many other health outcomes such as fertility<br />Severity:<br />If indicated by deaths alone, high, but not as high as other conditions such as HIV/AIDS and malaria <br />Effective interventions:<br />Do exist but not as simple as those for other conditions such as vaccine-preventable diseases<br />Also, policy community disagreements in past have confused politicians concerning what they are being asked to do<br />
  34. 34. Issue characteristics: Consequence of intervention and measurement problems <br />“We focus on uncertainties. That is the truth but it will not convince the Minister of Finance.”<br />“I would go with my ideas [to a donor] and [X] would go with hers and who was to say who was correct.”<br /> -- Statements from respondents<br />
  35. 35. The framework applied to the initiative through 2007<br />
  36. 36. New momentum for safe motherhood<br />New momentum for issue:<br />Financial commitments from British, Norwegian and US governments<br />G8 attention<br />Gates $1.5 billion for family health<br />UN joint action plan for women and children’s health<br />Country-level attention<br />A surge?<br />If so do shifts on framework factors help explain this?<br />
  37. 37. Developing the framework<br />Applying to other health issues, such as community health<br />Identifying other factors<br />Discerning fundamental factors<br />Subjecting to empirical examination<br />
  38. 38. Developing the framework: Applying to other issues, such as community health<br />
  39. 39. Developing the framework: Identifying other factors<br />Category of actor power<br />Opponents<br />Disease constituencies<br />Category of issue characteristics<br />Rich country fear of contagion<br />Sexiness<br />What other factors may be relevant for international and national attention to community health?<br />
  40. 40. Developing the framework: Discerning fundamental factors<br />Hunch that policy communities, ideas and institutions are core (factors nos. 1, 3 and 6)<br />Challenge to perception that objective ‘severity’ of the issue may be the strongest determinant of issue ascendance<br />New framework paper: ‘A social explanation for the rise and fall of global health issues’<br />Focuses on factors 1, 3 and 6<br />
  41. 41. Developing the framework:Subjecting to empirical examination<br />Global Health Advocacy and Policy Project (GHAPP): funded by $1.1 million three-year grant from Gates Foundation<br />
  42. 42. Developing the framework:Subjecting to empirical examination<br />Seeking to:<br />Build a general explanation concerning issue ascendance in global health<br />Ground the explanation in evidence rather than speculation or ‘expert/practitioner wisdom’<br />Assess value of actors, ideas, political context, issue characteristics framework<br />Facilitate policy-maker attention to neglected conditions<br />Broader research goal:<br />Help establish field of inquiry on global health agenda-setting<br />How applicable is framework, or modified framework, to generating attention for international and national community health initiatives?<br />
  43. 43. The preceding slides were presented at the<br />CORE Group 2010 Fall Meeting<br />Washington, DC<br />To see similar presentations, please visit:<br />www.coregroup.org/resources/meetingreports<br />

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