Pneumonia's second wind? A case study of the global health network for childhood pneumonia

Prioritizing rehabilitation in low- and middle-income country national health systems: a qualitative thematic synthesis and development of a policy framework

BACKGROUND

There is a large and growing unmet need for rehabilitation - a diverse category of services that aim to improve functioning across the life course - particularly in low- and middle-income countries. Yet despite urgent calls to increase political commitment, many low- and middle-income country governments have dedicated little attention to expanding rehabilitation services. Existing policy scholarship explains how and why health issues reach the policy agenda and offers applicable evidence to advance access to physical, medical, psychosocial, and other types of rehabilitation services. Drawing from this scholarship and empirical data on rehabilitation, this paper proposes a policy framework to understand national-level prioritization of rehabilitation in low- and middle-income countries.

METHODS

We conducted key informant interviews with rehabilitation stakeholders in 47 countries, complemented by a purposeful review of peer-reviewed and gray literature to achieve thematic saturation. We analyzed the data abductively using a thematic synthesis methodology. Rehabilitation-specific findings were triangulated with policy theory and empirical case studies on the prioritization of other health issues to develop the framework.

RESULTS

The novel policy framework includes three components which shape the prioritization of rehabilitation on low- and middle-income countries' national government's health agendas. First, rehabilitation lacks a consistent problem definition, undermining the development of consensus-driven solutions which could advance the issue on policy agendas. Second, governance arrangements are fragmented within and across government ministries, between the government and its citizens, and across national and transnational actors engaged in rehabilitation service provision. Third, national legacies - particularly from civil conflict - and weaknesses in the existing health system influences both rehabilitation needs and implementation feasibility.

CONCLUSIONS

This framework can support stakeholders in identifying the key components impeding prioritization for rehabilitation across different national contexts. This is a crucial step for ultimately better advancing the issue on national policy agendas and improving equity in access to rehabilitation services.

A social network analysis of the organizations focusing on tuberculosis, malaria and pneumonia

In this paper,we present an original study on the use of social media data to analyze the structure of the global health networks (GHNs) relative to health organizations targeted to malaria, tuberculosis (TBC) and pneumonia as well as twitter popularity, evaluating the performance of their strategies in response to the arising health threats. We use a machine learning ensemble classifier and social network analysis to discover the Twitter users that represent organizations or groups active for each disease. We have found evidence that the GHN of TBC is the more mature, active and global. Meanwhile, the networks of malaria and pneumonia are found to be less connected and lacking global coverage. Our analysis validates the use of social media to analyze GHNs and to propose these networks as an important organizational tool in mobilizing the community versus global sustainable development goals.

Analysing the global health agenda: A comparison of priority for diabetes and oral diseases

Many claims are made concerning which issues are on the global health agenda and which are neglected. Scholarship is inconsistent and generally vague about how an issue's status is (or should be) measured, however, leaving such claims open to questions about their validity. This inquiry explores a novel way of addressing the largely overlooked matter of how to comparatively assess the agenda status of health issues systematically, over time and in consideration of a global health context that lacks centralised authority. We draw upon a model from sociology which proposes that collective definitions of social problems and public attention evolve in multiple, interacting institutional arenas, each of which has the capacity to give robust attention to a limited number of issues. We systematically track status indicators for two significant global health issues, diabetes and oral diseases, in three arenas since 2000. Oral health's status declined while diabetes rose in international representation, international organisation and scientific research arenas during the past decade. This article sets out some preliminary contours of an analytical approach that holds promise for enhancing understanding of causal mechanisms and outcomes across a wider set of global health issues and agenda setting arenas.

The process of prioritization of non-communicable diseases in the global health policy arena

Although non-communicable diseases (NCDs) are the leading cause of morbidity and mortality worldwide, the global policy response has not been commensurate with their health, economic and social burden. This study examined factors facilitating and hampering the prioritization of NCDs on the United Nations (UN) health agenda. Shiffman and Smith's (Generation of political priority for global health initiatives: a framework and case study of maternal mortality. The Lancet 370: 1370-9.) political priority framework served as a structure for analysis of a review of NCD policy documents identified through the World Health Organization's (WHO) NCD Global Action Plan 2013-20, and complemented by 11 semi-structured interviews with key informants from different sectors. The results show that a cohesive policy community exists, and leaders are present, however, actor power does not extend beyond the health sector and the role of guiding institutions and civil society have only recently gained momentum. The framing of NCDs as four risk factors and four diseases does not necessarily resonate with experts from the larger policy community, but the economic argument seems to have enabled some traction to be gained. While many policy windows have occurred, their impact has been limited by the institutional constraints of the WHO. Credible indicators and effective interventions exist, but their applicability globally, especially in low- and middle-income countries, is questionable. To be effective, the NCD movement needs to expand beyond global health experts, foster civil society and develop a broader and more inclusive global governance structure. Applying the Shiffman and Smith framework for NCDs enabled different elements of how NCDs were able to get on the UN policy agenda to be disentangled. Much work has been done to frame the challenges and solutions, but implementation processes and their applicability remain challenging globally. NCD responses need to be adapted to local contexts, focus sufficiently on both prevention and management of disease, and have a stronger global governance structure.

Agency, Structure and the Power of Global Health Networks

Global health networks-webs of individuals and organizations linked by a shared concern for a particular condition-have proliferated over the past quarter century. In a recent editorial in this journal, I presented evidence that their effectiveness in addressing four challenges-problem definition, positioning, coalitionbuilding and governance-shapes their ability to influence policy. The editorial prompted five thoughtful commentaries that reflected on these and other challenges. In this follow-up editorial, I build on the commentaries to suggest ways of advancing research on global health networks. I argue that investigators would do well to consider three social theory-influenced global governance debates pertaining to agency-the capacity of individuals and organizations to act autonomously amidst structural constraints. The three debates concern the relationship between agency and structure, the power of ideas vis-à-vis interests and material capabilities, and the level of influence of non-state actors in a global governance system that most scholars identify as state-dominated. Drawing on these debates, I argue that rather than presume global health network influence, we need to find more robust ways to investigate their effects. I argue also that rather than juxtapose agency and structure, ideas and interests and non-state and state power, it would be more productive to consider the ways in which these elements are intertwined.

Four Challenges That Global Health Networks Face

Global health networks, webs of individuals and organizations with a shared concern for a particular condition, have proliferated over the past quarter century. They differ in their effectiveness, a factor that may help explain why resource allocations vary across health conditions and do not correspond closely with disease burden. Drawing on findings from recently concluded studies of eight global health networks—addressing alcohol harm, early childhood development (ECD), maternal mortality, neonatal mortality, pneumonia, surgically-treatable conditions, tobacco use, and tuberculosis—I identify four challenges that networks face in generating attention and resources for the conditions that concern them. The first is problem definition: generating consensus on what the problem is and how it should be addressed. The second is positioning: portraying the issue in ways that inspire external audiences to act. The third is coalition-building: forging alliances with these external actors, particularly ones outside the health sector. The fourth is governance: establishing institutions to facilitate collective action. Research indicates that global health networks that effectively tackle these challenges are more likely to garner support to address the conditions that concern them. In addition to the effectiveness of networks, I also consider their legitimacy, identifying reasons both to affirm and to question their right to exert power.

A framework on the emergence and effectiveness of global health networks

Since 1990 mortality and morbidity decline has been more extensive for some conditions prevalent in low- and middle-income countries than for others. One reason may be differences in the effectiveness of global health networks, which have proliferated in recent years. Some may be more capable than others in attracting attention to a condition, in generating funding, in developing interventions and in convincing national governments to adopt policies. This article introduces a supplement on the emergence and effectiveness of global health networks. The supplement examines networks concerned with six global health problems: tuberculosis (TB), pneumonia, tobacco use, alcohol harm, maternal mortality and newborn deaths. This article presents a conceptual framework delineating factors that may shape why networks crystallize more easily surrounding some issues than others, and once formed, why some are better able than others to shape policy and public health outcomes. All supplement papers draw on this framework. The framework consists of 10 factors in three categories: (1) features of the networks and actors that comprise them, including leadership, governance arrangements, network composition and framing strategies; (2) conditions in the global policy environment, including potential allies and opponents, funding availability and global expectations concerning which issues should be prioritized; (3) and characteristics of the issue, including severity, tractability and affected groups. The article also explains the design of the project, which is grounded in comparison of networks surrounding three matched issues: TB and pneumonia, tobacco use and alcohol harm, and maternal and newborn survival. Despite similar burden and issue characteristics, there has been considerably greater policy traction for the first in each pair. The supplement articles aim to explain the role of networks in shaping these differences, and collectively represent the first comparative effort to understand the emergence and effectiveness of global health networks.

The emergence and effectiveness of global health networks: findings and future research

Global health issues vary in the amount of attention and resources they receive. One reason is that the networks of individuals and organizations that address these issues differ in their effectiveness. This article presents key findings from a research project on the emergence and effectiveness of global health networks addressing tobacco use, alcohol harm, maternal mortality, neonatal mortality, tuberculosis and pneumonia. Although networks are only one of many factors influencing priority, they do matter, particularly for shaping the way the problem and solutions are understood, and convincing governments, international organizations and other global actors to address the issue. Their national-level effects vary by issue and are more difficult to ascertain. Networks are most likely to produce effects when (1) their members construct a compelling framing of the issue, one that includes a shared understanding of the problem, a consensus on solutions and convincing reasons to act and (2) they build a political coalition that includes individuals and organizations beyond their traditional base in the health sector, a task that demands engagement in the politics of the issue, not just its technical aspects. Maintaining a focused frame and sustaining a broad coalition are often in tension: effective networks find ways to balance the two challenges. The emergence and effectiveness of a network are shaped both by its members' decisions and by contextual factors, including historical influences (e.g. prior failed attempts to address the problem), features of the policy environment (e.g. global development goals) and characteristics of the issue the network addresses (e.g. its mortality burden). Their proliferation raises the issue of their legitimacy. Reasons to consider them legitimate include their members' expertise and the attention they bring to neglected issues. Reasons to question their legitimacy include their largely elite composition and the fragmentation they bring to global health governance.

Agenda setting for maternal survival: the power of global health networks and norms

Nearly 300,000 women--almost all poor women in low-income countries--died from pregnancy-related complications in 2010. This represents a decline since the 1980s, when an estimated half million women died each year, but is still far higher than the aims set in the United Nations Millennium Development Goals (MDGs) at the turn of the century. The 1970s, 1980s and 1990 s witnessed a shift from near complete neglect of the issue to emergence of a network of individuals and organizations with a shared concern for reducing maternal deaths and growth in the number of organizations and governments with maternal health strategies and programmes. Maternal health experienced a marked change in agenda status in the 2000s, attracting significantly higher level attention (e.g. from world leaders) and greater resource commitments (e.g. as one issue addressed by US$40 billion in pledges to the 2010 Global Strategy for Women's and Children's Health) than ever before. Several differences between network and actor features, issue characteristics and the policy environment pre- and post-2000 help to explain the change in agenda status for global maternal mortality reduction. Significantly, a strong poverty reduction norm emerged at the turn of the century; represented by the United Nations MDGs framework, the norm set unusually strong expectations for international development actors to advance included issues. As the norm grew, it drew policy attention to the maternal health goal (MDG 5). Seeking to advance the goals agenda, world leaders launched initiatives addressing maternal and child health. New network governance and framing strategies that closely linked maternal, newborn and child health shaped the initiatives. Diverse network composition--expanding beyond a relatively narrowly focused and technically oriented group to encompass allies and leaders that brought additional resources to bear on the problem--was crucial to maternal health's rise on the agenda in the 2000s.