A report/presentation on the changing dynamics of the power of the state viz. external actors in formulating health policy, particularly in low income countries and middle income countries.

1. The state in global health
(focus on LICs/MICs)
Jack Cullen, Ashleigh De Verteuil,
Albert Domingo, Eleanor Dow, and Kurt Olson
16 October 2014

2. Outline
1. Scope of state capacity to shape health policy
a. States and external entities
b. The delivery of health (policy) aid
c. Deciding when to “go in”
d. Does ideology matter?
e. State capacities to shape policy vary
f. Case study: reproductive health in the
Philippines

3. Outline
2. Dimensions of policy transfer in health issues
a. Towards a “global state”
b. Dimensions of policy transfer
c. Policy transfer loops
d. Dimensions in the first loop
e. Dimensions in the second loop
f. Dimensions in the third loop
g. Dimensions and loops in TB DOTS

4. THE SCOPE OF STATE CAPACITY TO
SHAPE HEALTH POLICY

5. 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

6. 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
Sovereignty
Administrative and
logistics systems
Soft power
Trust issues

7. 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.

8. 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?

9. 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?

10. 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?

11. 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?

12. Case Study:
Reproductive Health in the Philippines
(Adapted from Goldie 2010)

13. 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

14. 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?

15. DIMENSIONS OF POLICY TRANSFER
IN HEALTH ISSUES
HEALTH OUTCOMES VIA INTERNATIONAL GROUPS AND
NATIONAL (DOMESTIC PLAYERS)

16. 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”?

17. 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??

18. 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

19. 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!

20. Population Health
2nd Loop
Consensus-building
Problem-solving Cascading
1st Loop 3rd Loop
Compatibility?

21. 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

22. Dimensions in the Second Loop
• The Second Loop: National Policy Networks
Closely 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.

23. 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”

24. 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

25. 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.”

26. 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

27. Main References
Okuonzi, 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].