Comparing Global Health Stakeholders

Policy can be defined as ‘The process by which governments, institutions or organisations translate their political vision into programs and actions to deliver ‘outcomes’ – desired changes in the real world’ (UK Cabinet Office 1990). Taken more broadly, policy can be translated to mean “decisions”, however, it is important to think about policy as both a decision and a process. Thinking about policy as a process allows you to engage more directly in the global agora to consider systematically where outcomes can be changed in global health policy (Stone 2013).

Global health policy is the process of making decisions that affect the health of populations across national borders. With the rise of globalization, movement of people across national borders has increased dramatically, and so has the amount of people living in large cities. Both of these situations have affected global health by increasing the rate of the spread of disease, creating lifestyle changes, and more. The way these issues are framed by actors ultimately influence how global health policy is built by limiting what is ‘sayable’, ‘doable’ and ‘thinkable’ (Rushton and Williams 2012). Issues that plague the great powers are ultimately pushed forward in policy-making through persuasive framing and funding.

Q: Compare and contrast the influence of two different stakeholder types.

In stakeholder analyses, power is defined as “the combined measure of the amount of resources a stakeholder has and his or her capacity to mobilise them” (Schmeer 1999). Multinational institutions operate at the global level and have considerable power; they are able to bring global attention to the issue or policy in attention, fund resources to advance solutions, and negotiate and mobilise the position of other actors. E.g., the tobacco industry planned to weaken the impact of the FCTC by biasing member state’s perceptions by shifting the focus from health to economic losses and impacts on national GDPs.

NGO’s are known to play a critical role in global health policy and are categorized as having a clear bias for particular issues and interests. Their power is somewhat limited by their access to funds, mainly relying on donations or grants, and their ability to mobilise resources which may not always be stable. However, an NGO’s role in advocacy and research raises their legitimacy and expertise in, potentially inspiring mobilisation and increasing power. E.g., MSF played a critical role in the advocacy of the Ebola crisis which enabled them to mobilise resources and deliver frontline care, in turn increasing their legitimacy.

Q: Analyse the impacts of the Global Burden of Disease Study

The Global Burden of Disease study was the driving force behind the creation of the DALY which enabled a new way of identifying the relative contributions of diseases and allowed for global health and policy to be analysed with an evidence-based approach and become attentive to neglected diseases and populations. A benefit of the DALY was its revelation that mental health was one of the leading causes of disability globally. The DALY also facilitated calculating the cost-effectiveness of interventions, and when combined with more accurately identifying the burden of disease, this has enabled proper guidance on the prioritisation and allocation of resources in the global health space and in policy agendas.

One of the limitations of the GBD, and DALY, is the focus on the years of life lost due to disability which had the unintended consequence of neglecting the social impact of disease. E.g., the DALY does not accurately weight the relative importance of death in high vs. low-income countries where resources and responsibilities closely shared within the community. Another limitation is the lack of adequate data available from resource poor settings, consequently affecting how policy interventions are generalized across countries perceived to be similar, rather than being targeted.

Question Set 4 – Refer to Keshavjee p. 933

What happened to TB funding under Selective Primary Health Care?

• Tuberculosis required long-term treatment programs and longer-term follow ups to ensure cure, thus it was deemed too costly and complex to attempt large-scale treatment programs in resource poor countries.

What did the World Bank do and find in 1993 which changed attitudes to TB control?

• The WB used the DALY to measure the cost-effectiveness of short-course chemotherapy for tuberculosis and found that it was actually a highly cost-effective. Seizing on this momentum in changing attitudes, WHO promoted the DOTS (directly observed therapy, short course) strategy (Keshavjee and Farmer, 2012).

What was attractive to WHO about TB DOTS?

• It conformed with the Selective Primary Health Care agenda, in that it was simple to treat and inexpensive.

What approach was taken in New York City and Peru? Why?

• As part of a national action plan that also increased funding, New York diagnosed patients through the “use of microbacterial culture and fast-track drug-susceptibility testing, access to second-line antituberculosis medications, proper infection control and delivery of medications under direct observation” (Keshavjee and Farmer, 2012). This was because DOTS was an ineffective treatment against TB strains that were resistant to the drugs this strategy relied upon.
• After an outbreak outside Lima revealed that many patients were infected with “broad spectrum resistance to first line drugs” (Keshavjee and Farmer, 2012), NGO’s worked with the Peruvian Health Ministry to provide community-based care, a modified version of New York’s standard of care treatment approach.