Power in global governance: an expanded typology from global health

Public discourse narratives: from 'Secret Aid Worker' discontent to shifting power in humanitarian systems

Public discourse is rich in meaning, reflecting consensus, dissent, and change. Yet, very little public discourse on the humanitarian sector has been authored by aid workers themselves. We conducted a thematic analysis of the 'Secret Aid Worker' (SAW) series, published in The Guardian newspaper between 2015 and 2018, the only corpus of data on humanitarian life experiences publicly accessible through mainstream media. Our research questions were twofold: how did authors frame their work and appraise humanitarian structures?; and how did they reflect and amplify humanitarian issues of the time? The main themes included: personal challenges of humanitarian life; characterisation of stakeholders; and systemic issues within the humanitarian sector. The SAW narratives reveal a powerful discourse of discontent. They planted seeds of change regarding shifting power, coloniality and racism, sexual abuse, and duty of care. We argue that such public discourse has symbolic power, calling for greater accountability, equity, and justice in remaking the future of the humanitarian sector.

The utilisation of legal instruments by United Nations actors to restrict the exposure of children to unhealthy food and beverage marketing: a qualitative content analysis of UN instruments

INTRODUCTION

United Nations (UN) agencies are influential global health actors that can introduce legal instruments to call on Member States to act on pressing issues. This paper examines the deployment and strength of global health law instruments used by UN actors to call on Member States to restrict the exposure of children to unhealthy food and beverage marketing.

METHODS

Global health law instruments were identified from a review of four UN agencies that have a mandate over children's exposure to marketing of unhealthy food and beverage products namely: the World Health Organization (WHO); the Food and Agriculture Organization (FAO); the United Nations General Assembly (UNGA) and the UN Office of the High Commissioner for Human Rights (OHCHR). Data on marketing restrictions were extracted and coded and descriptive qualitative content analysis was used to assess the strength of the instruments.

RESULTS

A wide range of instruments have been used by the four agencies: seven by the WHO; two by the FAO; three by the UNGA; and eight by the UN human rights infrastructure. The UN human rights instruments used strong, consistent language and called for government regulations to be enacted in a directive manner. In contrast, the language calling for action by the WHO, FAO and UNGA was weaker, inconsistent, did not get stronger over time and varied according to the type of instrument used.

CONCLUSION

This study suggests that a child rights-based approach to restricting unhealthy food and beverage marketing to children would be supported by strong human rights legal instruments and would allow for more directive recommendations to Member States than is currently provided by WHO, FAO and UNGA. Strengthening the directives in the instruments to clarify Member States' obligations using both WHO and child rights mandates would increase the utility of global health law and UN actors' influence.

How states engage in and exercise power in global health: Indonesian and Japanese engagement in the conceptualization of Sustainable Development Goal 3

While long overlooked, power is central to understand how actors engage in global health policymaking. We reviewed how the Japanese and Indonesian governments exerted power and engaged in global health diplomacy during negotiations to conceptualize the post-2015 Sustainable Development Goal for health (SDG3). We conducted deliberative policy analysis including semi-structured, in-depth, interviews with more than 71 policymakers, which we analyzed adapting Barnett and Duvall's power framework. We find that both Japan and Indonesia exerted non-material power (institutional, productive and structural power) to advance largely domestic political interests. Japan's government mainly exerted institutional power, leveraging relationships within the World Bank and the World Health Organization, whereas Indonesia's government focused on structural power, with its president serving as co-chair of the UN Secretary-General's High-Level Post-2015 Panel. Our analysis suggests that the ways in which states engage in global health diplomacy is shaped by the relationship between different intra-state institutions, particularly the Ministry of Foreign Affairs and the Ministry of Health, and is further determined by broader foreign policy and diplomatic priorities. We find that the decline of states' influence is over-stated: states continue to exercise significant power in global health diplomacy, pursuing domestic political imperatives and strategies to improve population health. As states expand their global health engagement, researchers should seek to better understand how states participate in an increasingly crowded and contested global health field.

Fifty shades of partnerships: a governance typology for public private engagement in the nutrition sector

BACKGROUND

Multistakeholder collaboration has emerged as a dominant approach for engaging and mobilising non-state actors; notably embedded in the paradigm of the UN Sustainable Development Goals. Yet, considerable ambiguity and contestation surrounds the appropriate terms of public private engagement (PPE) with industry actors.

MAIN BODY

This paper seeks to conceptualise different forms of engagement with the food industry in tackling diet-related noncommunicable disease, within the context of power asymmetries across engaged stakeholders. It does so by introducing the Governance Typology for Public Private Engagement in the Nutrition Sector, a typology for government-led engagement with food industry actors across three domains: (i) the form of industry and civil society actor engagement (i.e., rules of exercising institutional power), based on the degree of participation in formal decision-making as well as participation at different stages in the policy cycle; (ii) the type of industry actors being engaged (i.e., pre-existing power attributes), based on function, size, and product portfolios for profit; and (iii) the substantive policy focus of engagement.

CONCLUSIONS

The Governance Typology for Public Private Engagement in the Nutrition Sector seeks to inform national level nutrition policy makers on good engagement practice with food industry actors and complements existing risk assessment tools. This typology has the potential to inform decision-making on public sector engagement with other industries that profit from products detrimental to human and planetary health.

A critical interpretive synthesis of power and mistreatment of women in maternity care

Labouring women may be subjected to physical and verbal abuse that reflects dynamics of power, described as Mistreatment of Women (MoW). This Critical Interpretive Synthesis on power and MoW consolidates current research and advances theory and practice through inter-disciplinary literature exploration. The review was undertaken in 3 phases. Phase 1 consisted of topic scoping; phase 2 entailed exploration of key power-related drivers emerging from the topic scoping; and phase 3 entailed data synthesis and analysis, with a particular focus on interventions. We identified 63 papers for inclusion in Phase 1. These papers utilized a variety of methods and approaches and represented a wide range of geographic regions. The power-related drivers of mistreatment in these articles span multiple levels of the social ecological model, including intrapersonal (e.g. lack of knowledge about one's rights), interpersonal (e.g. patient-provider hierarchy), community (e.g. widespread discrimination against indigenous women), organizational (e.g. pressure to achieve performance goals), and law/policy (e.g. lack of accountability for rights violations). Most papers addressed more than one level of the social-ecological model, though a significant minority were focused just on interpersonal factors. During Phase 1, we identified priority themes relating to under-explored power-related drivers of MoW for exploration in Phase 2, including lack of conscientization and normalization of MoW; perceptions of fitness for motherhood; geopolitical and ethnopolitical projects related to fertility; and pressure to achieve quantifiable performance goals. We ultimately included 104 papers in Phase 2. The wide-ranging findings from Phase 3 (synthesis and analysis) coalesce in several key meta-themes, each with their own evidence-base for action. Consistent with the notion that research on power can point us to "drivers of the drivers," the paper includes some intervention-relevant insights for further exploration, including as relating to broader social norms, health systems design, and the utility of multi-level strategies.

Critical barriers to sustainable capacity strengthening in global health: a systems perspective on development assistance

Background: Development assistance for health (DAH) is an important mechanism for funding and technical support to low-income countries. Despite increased DAH spending, intractable health challenges remain. Recent decades have seen numerous efforts to reform DAH models, yet pernicious challenges persist amidst structural complexities and a growing number of actors. Systems-based approaches are promising for understanding these types of complex adaptive systems. This paper presents a systems-based understanding of DAH, including barriers to achieving sustainable and effective country-driven models for technical assistance and capacity strengthening to achieve better outcomes Methods: We applied an innovative systems-based approach to explore and map how donor structures, processes, and norms pose challenges to improving development assistance models. The system mapping was carried out through an iterative co-creation process including a series of discussions and workshops with diverse stakeholders across 13 countries. Results: Nine systemic challenges emerged: 1) reliance on external implementing partners undermines national capacity; 2) prioritizing global initiatives undercuts local programming; 3) inadequate contextualization hampers program sustainability; 4) decision-maker blind spots inhibit capacity to address inequities; 5) power asymmetries undermine local decision making; 6) donor funding structures pose limitations downstream; 7) program fragmentation impedes long-term country planning; 8) reliance on incomplete data perpetuates inequities; and 9) overemphasis on donor-prioritized data perpetuates fragmentation. Conclusions: These interconnected challenges illustrate interdependencies and feedback loops manifesting throughout the system. A particular driving force across these system barriers is the influence of power asymmetries between actors. The articulation of these challenges can help stakeholders overcome biases about the efficacy of the system and their role in perpetuating the issues. These findings indicate that change is needed not only in how we design and implement global health programs, but in how system actors interact. This requires co-creating solutions that shift the structures, norms, and mindsets governing DAH models.

Critical barriers to sustainable capacity strengthening in global health: a systems perspective on development assistance

Background: Development assistance for health (DAH) is an important mechanism for funding and technical support to low-income countries. Despite increased DAH spending, intractable health challenges remain. Recent decades have seen numerous efforts to reform DAH models, yet pernicious challenges persist amidst structural complexities and a growing number of actors. Systems-based approaches are promising for understanding these types of complex adaptive systems. This paper presents a systems-based understanding of DAH, including barriers to achieving sustainable and effective country-driven models for technical assistance and capacity strengthening to achieve better outcomes Methods: We applied an innovative systems-based approach to explore and map how donor structures, processes, and norms pose challenges to improving development assistance models. The system mapping was carried out through an iterative co-creation process including a series of discussions and workshops with diverse stakeholders across 13 countries. Results: Nine systemic challenges emerged: 1) reliance on external implementing partners undermines national capacity; 2) prioritizing global initiatives undercuts local programming; 3) inadequate contextualization hampers program sustainability; 4) decision-maker blind spots inhibit capacity to address inequities; 5) power asymmetries undermine local decision making; 6) donor funding structures pose limitations downstream; 7) program fragmentation impedes long-term country planning; 8) reliance on incomplete data perpetuates inequities; and 9) overemphasis on donor-prioritized data perpetuates fragmentation. Conclusions: These interconnected challenges illustrate interdependencies and feedback loops manifesting throughout the system. A particular driving force across these system barriers is the influence of power asymmetries between actors. The articulation of these challenges can help stakeholders overcome biases about the efficacy of the system and their role in perpetuating the issues. These findings indicate that change is needed not only in how we design and implement global health programs, but in how system actors interact. This requires co-creating solutions that shift the structures, norms, and mindsets governing DAH models.

Framing and the formation of global health priorities

Health issues vary in the amount of attention and resources they receive from global health organisations and national governments. How issues are framed could shape differences in levels of priority. We reviewed scholarship on global health policy making to examine the role of framing in shaping global health priorities. The review provides evidence of the influence of three framing processes-securitisation, moralisation, and technification. Securitisation refers to an issue's framing as an existential threat, moralisation as an ethical imperative, and technification as a wise investment that science can solve. These framing processes concern more than how issues are portrayed publicly. They are socio-political processes, characterised by contestation among actors in civil society, government, international organisations, foundations, and research institutions. These actors deploy various forms of power to advance particular frames as a means of securing attention and resources for the issues that concern them. The ascription of an issue as a security concern, an ethical imperative, or a wise investment is historically contingent: it is not inevitable that any given issue will be framed in one or more of these ways. A health issue's inherent characteristics-such as the lethality of a pathogen that causes it-also shape these ascriptions, but do not fully determine them. Although commonly facing resistance, global health elites often determine which frames prevail, raising questions about the legitimacy of priority-setting processes. We draw on the review to offer ideas on how to make these processes fairer than they are at present, including a call for democratic representation even as necessary space is preserved for elite expertise.

Power Across the Global Health Landscape: A Network Analysis of Development Assistance 1990-2015

Power distribution across the global health landscape has undergone a fundamental shift over the past three decades. What was once a system comprised largely of bilateral and multilateral institutional arrangements between nation-states evolved into a varied landscape where these traditional actors were joined by a vast assemblage of private firms, philanthropies, non-governmental organizations, public-private partnerships. Financial resources are an explicit power source within global health which direct how, where, and to whom health interventions are delivered, which health issues are (de)prioritised, how and by whom evidence to support policies and interventions is developed, and how we account for progress. Financial resource allocations are not isolated decisions, but rather outputs of negotiation processes and dynamics between actors who derive power from a multiplicity of sources. The aims of this paper are to examine the changes in the global health actor landscape and the shifts in power using data on disbursements of development assistance for health (DAH). A typology of actors was developed from previous literature and refined through an empirical analysis of DAH. The emergent network structure of DAH flows between global health actors and positionality of actors within the network were analysed between 1990 and 2015. The results reflect the dramatic shift in the numbers of actors, relationships between actors, and funding dispersal over this time period. Through a combination of the massive influx of new funding sources and a decrease in public spending, the majority control of financial resources in the DAH network receded from public entities to a vast array of civil society organisations (CSOs) and public-private partnerships (PPPs). The most prominent of these were the Bill and Melinda Gates Foundation (BMGF) and the Global Fund for AIDS, TB, and Malaria (GFATM), which rose to the third and fourth most central positions within the DAH network by 2015.

Expressions of actor power in implementation: a qualitative case study of a health service intervention in South Africa

Background

Implementation frameworks and theories acknowledge the role of power as a factor in the adoption (or not) of interventions in health services. Despite this recognition, there is a paucity of evidence on how interventions at the front line of health systems confront or shape existing power relations. This paper reports on a study of actor power in the implementation of an intervention to improve maternal, neonatal and child health care quality and outcomes in a rural district of South Africa.

Methods

A retrospective qualitative case study based on interviews with 34 actors in three ‘implementation units’ – a district hospital and surrounding primary health care services – of the district, selected as purposefully representing full, moderate and low implementation of the intervention, some three years after it was first introduced. Data are analysed using Veneklasen and Miller’s typology of the forms of power – namely ‘power over’, ‘power to’, ‘power within’ and ‘power with’.

Results

Multiple expressions of actor power were evident during implementation and played a plausible role in shaping variable implementation, while the intervention itself acted to change power relations. As expected, a degree of buy-in of managers (with power over) in implementation units was necessary for the intervention to proceed. Beyond this, the ability to mobilise collective action (power with), combined with support from champions with agency (power within) were key to successful implementation. However, local empowerment may pose a threat to hierarchical power (power over) at higher levels (district and provincial) of the system, potentially affecting sustainability.

Conclusions

A systematic approach to the analysis of power in implementation research may provide insights into the fate of interventions. Intervention designs need to consider how they shape power relations, especially where interventions seek to widen participation and responsiveness in local health systems.

Understanding the role of power and its relationship to the implementation of the polio eradication initiative in india

Background

Power is exercised everywhere in global health, although its presence may be more apparent in some instances than others. Studying power is thus a core concern of researchers and practitioners working in health policy and systems research (HPSR), an interdisciplinary, problem-driven field focused on understanding and strengthening multilevel systems and policies. This paper aims to conduct a power analysis as mobilized by the actors involved in implementation of the polio program. It will also reflect how different power categories are exerted by actors and embedded in strategies to combat program implementation challenges while planning and executing the Global Polio Eradication Initiative.

Methods

We collected quantitative and qualitative data from stakeholders who were part of the Polio universe as a part of Synthesis and Translation of Research and Innovations from the Polio Eradication Project. Key informants were main actors of the polio eradication program, both at the national and sub-national levels. Research tools were designed to explore the challenges, strategies and unintended consequences in implementing the polio eradication program in India. We utilized Moon's expanded typology of power in global governance to analyze the implementation of the polio eradication programme in India.

Results

We collected 517 survey responses and conducted 25 key informant interviews. Understanding power is increasingly recognized as an essential parameter to understand global governance and health. Stakeholders involved during polio program implementation have exerted different kinds of power from structural to discursive, moral power wielded by religious leaders to institutional power, expert power used by professional doctors to commoners like female vaccinators, and network power exercised by community influencers. Hidden power was also demonstrated by powerless actors like children bringing mothers to polio booths.

Conclusion

Power is not a finite resource, and it can be used, shared, or created by stakeholders and networks in multiple ways. Those people who seem to be powerless possess invisible power that can influence decision making. Moreover, these power categories are not mutually exclusive and may be deeply interconnected with each other; one type of power can be transformed into another. Power and relations play an important role in influencing the decision-making of the community and individuals. Mid-range theories of core implementation science like PARIHAS and CFIR can also add an important variable of power in their construct necessary for implementation success of any health program.

Power analysis in health policy and systems research: a guide to research conceptualisation

Power is a growing area of study for researchers and practitioners working in the field of health policy and systems research (HPSR). Theoretical development and empirical research on power are crucial for providing deeper, more nuanced understandings of the mechanisms and structures leading to social inequities and health disparities; placing contemporary policy concerns in a wider historical, political and social context; and for contributing to the (re)design or reform of health systems to drive progress towards improved health outcomes. Nonetheless, explicit analyses of power in HPSR remain relatively infrequent, and there are no comprehensive resources that serve as theoretical and methodological starting points. This paper aims to fill this gap by providing a consolidated guide to researchers wishing to consider, design and conduct power analyses of health policies or systems. This practice article presents a synthesis of theoretical and conceptual understandings of power; describes methodologies and approaches for conducting power analyses; discusses how they might be appropriately combined; and throughout reflects on the importance of engaging with positionality through reflexive praxis. Expanding research on power in health policy and systems will generate key insights needed to address underlying drivers of health disparities and strengthen health systems for all.

Interrogating the World Bank's role in global health knowledge production, governance, and finance

Background

In the nearly half century since it began lending for population projects, the World Bank has become one of the largest financiers of global health projects and programs, a powerful voice in shaping health agendas in global governance spaces, and a mass producer of evidentiary knowledge for its preferred global health interventions. How can social scientists interrogate the role of the World Bank in shaping ‘global health’ in the current era?

Main body

As a group of historians, social scientists, and public health officials with experience studying the effects of the institution’s investment in health, we identify three challenges to this research. First, a future research agenda requires recognizing that the Bank is not a monolith, but rather has distinct inter-organizational groups that have shaped investment and discourse in complicated, and sometimes contradictory, ways. Second, we must consider how its influence on health policy and investment has changed significantly over time. Third, we must analyze its modes of engagement with other institutions within the global health landscape, and with the private sector. The unique relationships between Bank entities and countries that shape health policy, and the Bank’s position as a center of research, permit it to have a formative influence on health economics as applied to international development. Addressing these challenges, we propose a future research agenda for the Bank’s influence on global health through three overlapping objects of and domains for study: knowledge-based (shaping health policy knowledge), governance-based (shaping health governance), and finance-based (shaping health financing). We provide a review of case studies in each of these categories to inform this research agenda.

Conclusions

As the COVID-19 pandemic continues to rage, and as state and non-state actors work to build more inclusive and robust health systems around the world, it is more important than ever to consider how to best document and analyze the impacts of Bank’s financial and technical investments in the Global South.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-021-00761-w.

What is considered as global health scholarship? A meta-knowledge analysis of global health journals and definitions

Despite the rapid growth of the global health field over the past few decades, consensus on what qualifies as global health scholarship or practice remains elusive. We conducted a meta-knowledge analysis of the titles and abstracts of articles published in 25 journals labelled as global health journals between 2001 and 2019. We identified the major topics in these journals by creating clusters based on terms co-occurrence over time. We also conducted a review of global health definitions during the same period.

The analysis included 16 413 articles. The number of journals, labelled as global health, and articles published in these journals, increased dramatically during the study period. The majority of global health publications focused on topics prevalent in low-resource settings. Governance, infectious diseases, and maternal and child health were major topics throughout the analysis period. Surveillance and disease outcomes appeared during the 2006–2010 epoch and continued, with increasing complexity, until the 2016–2019 epoch. Malaria, sexual and reproductive health, and research methodology appeared for only one epoch as major topics. We included 11 relevant definitions in this analysis. Definitions of global health were not aligned with the major topics identified in the analysis of articles published in global health journals.

These results highlight a lack of alignment between what is published as global health scholarship and global health definitions, which often advocate taking a global perspective to population health. Our analysis suggests that global health has not truly moved beyond its predecessor, international health. There is a need to define the parameters of the discipline and investigate the disconnect between what is published in global health versus how the field is defined.

[COVID-19: Special Challenges for Theoretical and Practical Public Health]

The COVID 19 crisis offers unique opportunities and poses special challenges for practical and theoretical public health. Management of the pandemic was initially dominated by virologists, supported by epidemiologists who did not always exercise the necessary scientific rigour. Expertise in interdisciplinary health sciences and complex considerations from a broader public health perspective, however, did not have noticeable impact on the COVID 19 debate and even less on the strategies for containing the pandemic. Public health is universal and more than health security or health protection. As an explicitly political discipline, public health takes a far-reaching socio-political approach and must not be reduced to biomedical aspects. Medical and biotechnological solutions alone will not meet the challenges of the corona crisis. The analysis of the political, economic, social and ecological determinants that led to the crisis is indispensable for the sustainable management of the pandemic. In order to improve population health and reduce the risk of future outbreaks of dangerous infections, a comprehensive policy is needed that also addresses hegemonies and power relations.

The world expects effective global health interventions: Can global health deliver?

The COVID-19 crisis offers unique challenges and opportunities for global health. The initial management of the pandemic was dominated by virologists, supported by epidemiologists who did not always meet indispensable scientific requirements. Interdisciplinary and complex global health concerns and expertise, however, did not have tangible impact on the COVID-19 debate, and even less on the strategies to contain the pandemic. As an explicitly political concept global health must safeguard its broad socio-political approach and counteract all tendency towards biomedical reductionism. Global health is universal and goes beyond health security. Above medical and biotechnological solutions, it requires the consideration of both downstream and upstream determinants of health such as the political, economic, ecological and social conditions that led to the crisis.