Editorial: Whither globalization and health in an era of geopolitical uncertainty?

Globalization has been declared dead or dying for many years, although recently, the number of voices declaring it ‘over’ has swelled [1]. As editors of a journal interrogating how globalization affects health, we confront the question: Have the COVID-19 pandemic, Russia’s war against Ukraine, a breakdown in multilateralism, and the risk of a return to the stagflation of the 1970s finally sounded a death knell for the research and scholarship we have been publishing in the journal’s 20-year history? We think not and argue below why, in our post-pandemic fractured and fractious era, it is vitally important to retain a focus on this messy construct short-handed as ‘globalization.’

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.

Political Priority for Abortion Law Reform in Malawi: Transnational and National Influences

In July 2015, Malawi's Special Law Commission on the Review of the Law on Abortion released a draft Termination of Pregnancy bill. If approved by Parliament, it will liberalize Malawi's strict abortion law, expanding the grounds for safe abortion and representing an important step toward safer abortion in Malawi. Drawing on prospective policy analysis (2013-2017), we identify factors that helped generate political will to address unsafe abortion. Notably, we show that transnational influences and domestic advocacy converged to make unsafe abortion a political issue in Malawi and to make abortion law reform a possibility. Since the 1980s, international actors have promoted global norms and provided financial and technical resources to advance ideas about women's reproductive health and rights and to support research on unsafe abortion. Meanwhile, domestic coalitions of actors and policy champions have mobilized new national evidence on the magnitude, costs, and public health impacts of unsafe abortion, framing action on unsafe abortion as part of a broader imperative to address Malawi's high level of maternal mortality. Although these efforts have generated substantial support for abortion law reform, an ongoing backlash from the international anti-choice movement has gained momentum by appealing to religious and nationalist values. Passage of the bill also antagonizes the United States' development work in Malawi due to US policies prohibiting the funding of safe abortion. This threatens existing political will and renders the outcome of the legal review uncertain.

Behind the scenes: International NGOs' influence on reproductive health policy in Malawi and South Sudan

Global health donors increasingly embrace international non-governmental organisations (INGOs) as partners, often relying on them to conduct political advocacy in recipient countries, especially in controversial policy domains like reproductive health. Although INGOs are the primary recipients of donor funding, they are expected to work through national affiliates or counterparts to enable 'locally-led' change. Using prospective policy analysis and ethnographic evidence, this paper examines how donor-funded INGOs have influenced the restrictive policy environments for safe abortion and family planning in South Sudan and Malawi. While external actors themselves emphasise the technical nature of their involvement, the paper analyses them as instrumental political actors who strategically broker alliances and resources to shape policy, often working 'behind the scenes' to manage the challenging circumstances they operate under. Consequently, their agency and power are hidden through various practices of effacement or concealment. These practices may be necessary to rationalise the tensions inherent in delivering a global programme with the goal of inducing locally-led change in a highly controversial policy domain, but they also risk inciting suspicion and foreign-national tensions.

"Guilty until proven innocent": the contested use of maternal mortality indicators in global health

The MMR - maternal mortality ratio - has risen from obscurity to become a major global health indicator, even appearing as an indicator of progress towards the global Sustainable Development Goals. This has happened despite intractable challenges relating to the measurement of maternal mortality. Even after three decades of measurement innovation, maternal mortality data are widely presumed to be of poor quality, or, as one leading measurement expert has put it, 'guilty until proven innocent'. This paper explores how and why leading epidemiologists, demographers and statisticians have devoted the better part of the last three decades to producing ever more sophisticated and expensive surveys and mathematical models of globally comparable MMR estimates. The development of better metrics is publicly justified by the need to know which interventions save lives and at what cost. We show, however, that measurement experts' work has also been driven by the need to secure political priority for safe motherhood and by donors' need to justify and monitor the results of investment flows. We explore the many effects and consequences of this measurement work, including the eclipsing of attention to strengthening much-needed national health information systems. We analyse this measurement work in relation to broader political and economic changes affecting the global health field, not least the incursion of neoliberal, business-oriented donors such as the World Bank and the Bill and Melinda Gates Foundation whose institutional structures have introduced new forms of administrative oversight and accountability that depend on indicators.

"Lives in the balance": The politics of integration in the Partnership for Maternal, Newborn and Child Health

A decade ago, the Partnership for Maternal, Newborn and Child Health (PMNCH) was established to combat the growing fragmentation of global health action into uncoordinated, issue-specific efforts. Inspired by dominant global public-private partnerships for health, the PMNCH brought together previously competing advocacy coalitions for safe motherhood and child survival and attracted support from major donors, foundations and professional bodies. Today, its founders highlight its achievements in generating priority for 'MNCH', encouraging integrated health systems thinking and demonstrating the value of collaboration in global health endeavours. Against this dominant discourse on the success of the PMNCH, this article shows that rhetoric in support of partnership and integration often masks continued structural drivers and political dynamics that bias the global health field towards vertical goals. Drawing on ethnographic research, this article examines the Safe Motherhood Initiative's evolution into the PMNCH as a response to the competitive forces shaping the current global health field. Despite many successes, the PMNCH has struggled to resolve historically entrenched programmatic and ideological divisions between the maternal and child health advocacy coalitions. For the Safe Motherhood Initiative, the cost of operating within an extremely competitive policy arena has involved a partial renouncement of ambitions to broader social transformations in favour of narrower, but feasible and 'sellable' interventions. A widespread perception that maternal health remains subordinated to child health even within the Partnership has elicited self-protective responses from the safe motherhood contingent. Ironically, however, such responses may accentuate the kind of fragmentation to global health governance, financing and policy solutions that the Partnership was intended to challenge. The article contributes to the emerging critical ethnographic literature on global health initiatives by highlighting how integration may only be possible with a more radical conceptualization of global health governance.

Building the nation's body: The contested role of abortion and family planning in post-war South Sudan

This paper offers an ethnographic analysis of public health policies and interventions targeting unwanted pregnancy (family planning and abortion) in contemporary South Sudan as part of wider 'nation-building' after war, understood as a process of collective identity formation which projects a meaningful future by redefining existing institutions and customs as national characteristics. The paper shows how the expansion of post-conflict family planning and abortion policy and services are particularly poignant sites for the enactment of reproductive identity negotiation, policing and conflict. In addition to customary norms, these processes are shaped by two powerful institutions - ethnic movements and global humanitarian actors - who tend to take opposing stances on reproductive health. Drawing on document review, observations of the media and policy environment and interviews conducted with 54 key informants between 2013 and 2015, the paper shows that during the civil war, the Sudan People's Liberation Army and Movement mobilised customary pro-natalist ideals for military gain by entreating women to amplify reproduction to replace those lost to war and rejecting family planning and abortion. International donors and the Ministry of Health have re-conceptualised such services as among other modern developments denied by war. The tensions between these competing discourses have given rise to a range of societal responses, including disagreements that erupt in legal battles, heated debate and even violence towards women and health workers. In United Nations camps established recently as parts of South Sudan have returned to war, social groups exert a form of reproductive surveillance, policing reproductive health practices and contributing to intra-communal violence when clandestine use of contraception or abortion is discovered. In a context where modern contraceptives and abortion services are largely unfamiliar, conflict around South Sudan's nation-building project is partially manifest through tensions and violence in the domain of reproduction.

Living Positively: Narrative Strategies of Women Living with HIV in Cape Town, South Africa

Therapeutic interventions to address HIV in Africa mean that individuals are increasingly diagnosed with HIV prior to severe health crisis. This paper contributes to the anthropological literature on living with HIV by focusing on the creation and use of narrative and practical strategies for addressing HIV in a setting where such experiences have to date received little attention. Specifically, focus is on the discursive strategy of 'living positively', a forceful and much propagated orientation to life following an HIV diagnosis. In this paper the authors examine how this strategy is embraced not only by individuals living with HIV, but also by activists, HIV support organizations and public health agencies. The paper is based on fieldwork in and around Cape Town, South Africa in 2002 and draws on open-ended interviews with 12 women living with HIV and observations from support groups, activist events and public health meetings. The research indicates that the living positively dictum is imbued with a multiplicity of meanings and that it is used in diverse ways. For women living with HIV the practical and philosophical elements of positive living have social and political force in transforming personal and social attitudes about HIV, especially about HIV testing and treatment access. At the same time, however, the dictum poorly addresses the structural constraints of living with HIV and places the responsibility for positive living squarely on the individual. Despite this, the political context that prevailed in Cape Town at the time of the research created a particularly fertile juncture for embracing the living positively philosophy.

After surgery: the effects of life-saving caesarean sections in Burkina Faso

Background

In African countries, caesarean sections are usually performed to save mothers and babies’ lives, sometimes in extremis and at considerable costs. Little is known about the health and lives of women once discharged after such surgery. We investigated the long-term effects of life-saving caesarean section on health, economic and social outcomes in Burkina Faso.

Methods

We conducted a 4 year prospective cohort study of women and their babies using mixed methods. The quantitative sample was selected in seven hospitals and included 950 women: 100 women with a caesarean section associated with near-miss complication (life-saving caesareans); 173 women with a vaginal birth associated with near-miss complication; and 677 women with uncomplicated vaginal childbirth. Structured interviews were conducted at 3 months, 6 months, 12 months and 3 and 4 years postpartum. These were supplemented by medical record data on delivery and physical examinations at 6 and 12 months postpartum. The lives and experiences of 21 women were documented ethnographically. Data were analysed with multivariable logistic regressions, using survival analysis and thematic analysis.

Results

The physical effects of life-saving caesareans appeared to be similar to women who had an uncomplicated childbirth, although 55 % of women with life-saving caesareans had another caesarean in their next pregnancy. The negative effects were generally economic, social and reproductive when compared to vaginal births, including increased debts (AOR = 3.91 (1.46–10.48) and sexual violence (AOR = 4.71 (1.04–21.3)) and lower fertility (AOR = 0.44 (0.24–0.80)) 4 years after life-saving caesareans. In the short and medium term, women with life-saving caesareans appeared to suffer increased psychological distress compared to uncomplicated births. They were more likely to use contraceptives (AOR = 5.95 (1.53–23.06); 3 months). Mortality of the index child was increased in both near-miss groups, independent of delivery mode. Ethnographic data suggest that these consequences are significant for Burkinabe women, whose well-being and social standing are mostly determined by their fertility, marriage strength and family links.

Conclusions

Life-saving caesareans have broad consequences beyond clinical sequelae. The recent policy to subsidise emergency obstetric care costs implemented in Burkina Faso should help avoid the majority of catastrophic costs, shown to be problematic for women undergoing emergency caesarean section.

The GAVI Alliance and the 'Gates approach' to health system strengthening

Lauded for getting specific health issues onto national and international agendas and for their potential to improve value for money and outcomes, public-private global health initiatives (GHIs) have come to dominate global health governance. Yet, they have also been criticised for their negative impact on country health systems. In response, disease-specific GHIs have, somewhat paradoxically, appropriated the aim of health system strengthening (HSS). This article critically analyses this development through an ethnographic case study of the GAVI Alliance, which funds vaccines in poor countries. Despite GAVI's self-proclaimed ‘single-minded’ focus on vaccines, HSS support is fronted as a key principle of GAVI's mission. Yet, its meaning remains unclear and contested understandings of the health systems agenda abound, reflecting competing public health ideologies and professional pressures within the global health field. Contrary to broader conceptualisations of HSS that emphasise social and political dimensions, GAVI's HSS support has become emblematic of the so-called ‘Gates approach’ to global health, focused on targeted technical solutions with clear, measurable outcomes. In spite of adopting rhetoric supportive of ‘holistic’ health systems, GHIs like GAVI have come to capture the global debate about HSS in favour of their disease-specific approach and ethos.

The politics of unsafe abortion in Burkina Faso: the interface of local norms and global public health practice

In Burkina Faso, abortion is legally restricted and socially stigmatised, but also frequent. Unsafe abortions represent a significant public health challenge, contributing to the country's very high maternal mortality ratio. Inspired by an internationally disseminated public health framing of unsafe abortion, the country's main policy response has been to provide post-abortion care (PAC) to avert deaths from abortion complications. Drawing on ethnographic research, this article describes how Burkina Faso's PAC policy emerged at the interface of political and moral negotiations between public health professionals, national bureaucrats and international agencies and NGOs. Burkinabè decision-makers and doctors, who are often hostile to induced abortion, have been convinced that PAC is ‘life-saving care’ which should be delivered for ethical medical reasons. Moreover, by supporting PAC they not only demonstrate compliance with international standards but also, importantly, do not have to contend with any change in abortion legislation, which they oppose. Rights-based international NGOs, in turn, tactically focus on PAC as a ‘first step’ towards their broader institutional objective to secure safe abortion and abortion rights. Such negotiations between national and international actors result in widespread support for PAC but stifled debate about further legalisation of abortion.

"Playing the numbers game": evidence-based advocacy and the technocratic narrowing of the Safe Motherhood Initiative

Based on an ethnography of the international Safe Motherhood Initiative (SMI), this article charts the rise of evidence-based advocacy (EBA), a term global-level maternal health advocates have used to indicate the use of scientific evidence to bolster the SMI's authority in the global health arena. EBA represents a shift in the SMI's priorities and tactics over the past two decades, from a call to promote poor women's health on the grounds of feminism and social justice (entailing broad-scale action) to the enumeration of much more narrowly defined practices to avert maternal deaths whose outcomes and cost effectiveness can be measured and evaluated. Though linked to the growth of an audit- and business-oriented ethos, we draw from anthropological theory of global forms to argue that EBA-or "playing the numbers game"-profoundly affects nearly every facet of evidence production, bringing about ambivalent reactions and a contested technocratic narrowing of the SMI's policy agenda.

Too poor to live? A case study of vulnerability and maternal mortality in Burkina Faso

This paper examines the concept of vulnerability in the context of maternal morbidity and mortality in Burkina Faso, an impoverished country in West Africa. Drawing on a longitudinal cohort study into the consequences of life-threatening or ‘near miss’ obstetric complications, we provide an in-depth case study of one woman’s experience of such morbidity and its aftermath. We follow Kalizeta’s trajectory from her near miss and the stillbirth of her child to her death from pregnancy-related hypertension after a subsequent delivery less than two years later, in order to examine the impact of severe and persistent illness and catastrophic health expenditure on her health and on her family’s everyday life. Kalizeta’s case illustrates how vulnerability in health emerges and is maintained or exacerbated over time. Even where social arrangements are supportive, structural impediments, including unaffordable and inadequate healthcare, can severely limit individual resilience to mitigate the negative social and economic consequences of ill health.

Capitals diminished, denied, mustered and deployed. A qualitative longitudinal study of women's four year trajectories after acute health crisis, Burkina Faso

Accumulating evidence indicates that health crises can play a key role in precipitating or exacerbating poverty. For women of reproductive age in low-income countries, the complications of pregnancy are a common cause of acute health crisis, yet investigation of longer-term dynamics set in motion by such events, and their interactions with other aspects of social life, is rare. This article presents findings from longitudinal qualitative research conducted in Burkina Faso over 2004–2010. Guided by an analytic focus on patterns of continuity and change, and drawing on recent discussions on the notion of ‘resilience’, and the concepts of ‘social capital’ and ‘bodily capital’, we explore the trajectories of 16 women in the aftermath of costly acute healthcare episodes. The synthesis of case studies shows that, in conditions of structural inequity and great insecurity, an individual's social capital ebbs and flow over time, resulting in a trajectory of multiple adaptations. Women's capacity to harness or exploit bodily capital in its various forms (beauty, youthfulness, physical strength, fertility) to some extent determines their ability to confront and overcome adversities. With this, they are able to further mobilise social capital without incurring excessive debt, or to access and accumulate significant new social capital. Temporary self-displacement, often to the parental home, is also used as a weapon of negotiation in intra-household conflict and to remind others of the value of one's productive and domestic labour. Conversely, diminished bodily capital due to the physiological impact of an obstetric event or its complications can lead to reduced opportunities, and to further disadvantage.

Mortality after near-miss obstetric complications in Burkina Faso: medical, social and health-care factors

OBJECTIVE

To investigate mortality in women in Burkina Faso in the 4 years following a life-threatening near-miss obstetric complication and to identify the medical, social and health-care-related causes of death.

METHODS

In total, 1014 women were recruited after hospital discharge and followed for up to 4 years: 337 had near-miss complications and 677 had uncomplicated pregnancies. Significant differences in mortality between the groups were assessed using Fisher's exact test. The medical causes of death were identified from medical records and verbal autopsy data; social and health-care-related factors associated with death were identified from interviews with the deceased women's relatives.

FINDINGS

In the 4 years, 15 (5.3%) women died in the near-miss group and 5 (0.9%) died after uncomplicated pregnancies (P < 0.001). More than half the deaths after a near miss, but none after an uncomplicated delivery, were pregnancy-related. Indirect factors contributed to many of these deaths, particularly human immunodeficiency virus infection. Relatives' accounts suggested that the high cost and poor quality of health care, a lack of follow-up care and an unmet need for contraception contributed to the excess mortality in the near-miss group.

CONCLUSION

Women in Burkina Faso who initially survived a near-miss obstetric complication had an increased risk of all-cause and pregnancy-related death in the ensuing 4 years. The likelihood of survival over the longer term could be increased by offering a continuum of care that addresses the indirect and social causes of death and supplements the emergency intrapartum obstetric care provided by current safe motherhood programmes.

Collapsing the vertical-horizontal divide: an ethnographic study of evidence-based policymaking in maternal health

Using the international maternal health field as a case study, we draw on ethnographic research to investigate how public health researchers and policy experts are responding to tensions between vertical and horizontal approaches to health improvement. Despite nominal support for an integrative health system approach, we found that competition for funds and international recognition pushes professionals toward vertical initiatives. We also highlight how research practices contribute to the dominance of vertical strategies and limit the success of evidence-based policymaking for strengthening health systems. Rather than support disease-and subfield-specific advocacy, the public health community urgently needs to engage in open dialogue regarding the international, academic, and donor-driven forces that drive professionals toward an exclusive interest in vertical programs.

Health of women after severe obstetric complications in Burkina Faso: a longitudinal study

BACKGROUND

Little is known about the health of women who survive obstetric complications in poor countries. Our aim was to determine how severe obstetric complications in Burkina Faso affect a range of health, social, and economic indicators in the first year post partum.

METHODS

We did a prospective cohort study of women with severe obstetric complications recruited in hospitals when their pregnancy ended with a livebirth (n=199), perinatal death (74), or a lost pregnancy (64). For every woman with severe obstetric complications, two unmatched control women with uncomplicated delivery were sampled in the same hospital (677). All women were followed up for 1 year.

FINDINGS

Women with severe obstetric complications were poorer and less educated at baseline than were women with uncomplicated delivery. Women with severe obstetric complications, and their babies, were significantly more likely to die after discharge: six (2%) of the 337 women with severe obstetric complications died within 1 year, compared with none of the women with uncomplicated delivery (unadjusted p=0.001); 17 babies of women with severe obstetric complications died within 1 year, compared with 18 of those born by uncomplicated delivery (hazard ratio for mortality 4.67, 95% CI 1.68-13.04, adjusted for loss to follow-up and confounders; p=0.003). Women with severe obstetric complications were significantly more likely to have experienced depression and anxiety at 3 months (odds ratio 1.82, 95% CI 1.18-2.80), to have experienced suicidal thoughts within the past year at all time points (2.27, 1.33-3.89 at 3 months; 2.30, 1.17-4.50 at 6 months; 2.26, 1.30-3.95 at 12 months), and to report the pregnancy having had a negative effect on their lives at all time points (1.54, 1.04-2.30 at 3 months; 2.30, 1.56-3.39 at 6 months; 2.44, 1.63-3.65 at 12 months) than were women with uncomplicated delivery.

INTERPRETATION

Women who give birth with severe obstetric complications are at greater risk of death and mental-health problems than are women with uncomplicated delivery. Greater resources are needed to ensure that these women receive adequate care before and after discharge from hospital.