PUBLIC HEALTH 3pages APA not including title and min 5 references on reference page

Health Policy in a Globalising World

Edited by

Kelley Lee, Kent Buse and Suzanne Fustukian

PUBLISHED BY THE PRESS SYNDICATE OF THE UNIVERSITY OF CAMBRIDGE

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CAMBRIDGE UNIVERSITY PRESS

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C© Cambridge University Press 2002

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First published 2002

Printed in the United Kingdom at the University Press, Cambridge

Typeface Plantin 10/12 pt. System LATEX2ε [TB]

A catalogue record for this book is available from the British Library.

Library of Congress Cataloguing in Publication data Health Policy in a Globalising World / edited by Kelley Lee, Kent Buse and Suzanne Fustukian.

p. cm. ISBN 0 521 80419 1 (hardback) – ISBN 0 521 00943 X (paperback) 1. World health. 2. Globalization – Health aspects. 3. Medical policy. I. Lee, Kelley, 1962– II. Buse, Kent. III. Fustukian, Suzanne, 1953– .

RA441 .H44 2001 362.1–dc21 2001035097

ISBN 0 521 80419 1 hardback ISBN 0 521 00943 X paperback

Contents

List of figures page ix List of tables x List of boxes xi Notes on contributors xii Foreword xix Preface xxi Acknowledgements xxv Abbreviations xxvii

Part I

1 An introduction to global health policy 3 KELLEY LEE, SUZANNE FUSTUKIAN AND KENT BUSE

2 The public health implications of multilateral trade agreements 18 M. KENT RANSON, ROBERT BEAGLEHOLE, CARLOS M. CORREA, ZAFAR MIRZA, KENT BUSE AND NICK DRAGER

3 Globalisation and multilateral public–private health partnerships: issues for health policy 41 KENT BUSE AND GILL WALT

4 Global approaches to private sector provision: where is the evidence? 63 RUAIRI

′ BRUGHA AND ANTHONY ZWI

5 Regulation in the context of global health markets 78 LILANI KUMARANAYAKE AND SALLY LAKE

6 Global policy networks: the propagation of health care financing reform since the 1980s 97 KELLEY LEE AND HILARY GOODMAN

vii

viii Contents

7 The globalisation of health sector reform policies: is ‘lesson drawing’ part of the process? 120 BARBARA MCPAKE

8 Cost-effectiveness analysis and priority-setting: global approach without local meaning? 140 LILANI KUMARANAYAKE AND DAMIAN WALKER

Part II

9 Global rhetoric and individual realities: linking violence against women and reproductive health 159 SUSANNAH H. MAYHEW AND CHARLOTTE WATTS

10 The globalisation of DOTS: tuberculosis as a global emergency 181 JOHN PORTER, KELLEY LEE AND JESSICA OGDEN

11 Ageing and health policy: global perspectives 195 PETER LLOYD-SHERLOCK

12 Workers’ health and safety in a globalising world 208 SUZANNE FUSTUKIAN, DINESH SETHI AND ANTHONY ZWI

13 Globalisation, conflict and the humanitarian response 229 ANTHONY ZWI, SUZANNE FUSTUKIAN AND DINESH SETHI

Part III

14 Globalisation and health policy: trends and opportunities 251 KENT BUSE, NICK DRAGER, SUZANNE FUSTUKIAN AND KELLEY LEE

References 281 Index 317

Figures

5.1 Range of private sector activity. page 79 5.2 The process of regulating. 83 5.3 Institutional actors and actions to achieve regulatory goals. 94 6.1 Institutional map of global network on health care financing

reform (1978–1986). 107 6.2 Institutional map of global network on health care financing

reform (1987–1993). 108 6.3 Institutional map of global network on health care financing

reform (1994–2000). 111 7.1 The convergence hypothesis. 121 7.2 Incentive environments. 133

13.1 The linkages between globalisation and violent political conflict. 242

ix

Tables

2.1 Modes of health services trade under GATS page 28 4.1 Percentage of private physicians, private beds and

visits made to private facilities by the poorest and richest 20 per cent of the population in selected countries 68

6.1 Summary of key events and periods of policy development 106 8.1 Cost-effectiveness of the health interventions

(and clusters of interventions) included in the minimum package of health services in low- and middle-income countries 146

9.1 Selected studies on the global prevalence of physical violence against women by an intimate male partner 162

9.2 Selected evidence on the global magnitude of coerced sex against girls 164

9.3 Landmark events in the evolution of global debate on reproductive health and violence against women 167

9.4 Operational linkage: reproductive health worker responses to violence 175

9.5 Contrasting situations at global and national levels of action for women’s health and rights 176

9.6 National activity foci for reproductive health and violence against women 178

10.1 The twenty highest burden countries from tuberculosis 184 11.1 Estimated medium variant projection of total population

aged 65 years or more by world region 196 11.2 Countries with highest and lowest proportions of

population aged 65 or over by world region, 1990 196 13.1 Indicators of states at risk of violent political conflict 241

x

Boxes

2.1 United States – Standards for Reformulated and Conventional Gasoline (WTO 1996). page 21

2.2 The ‘Bolar exception’ (WTO WT/DS114/R). 23 2.3 Canadian asbestos case. 25 2.4 European Community – measures affecting meat and meat

products (hormones) (WTO 1998a). 27 3.1 The partnership–network continuum. 44 3.2 The Mectizan® Donation Program – a product-based

health GPPP. 46 3.3 The International AIDS Vaccine Initiative – a product

development-based health GPPP. 47 3.4 The Bill and Melinda Gates Children’s Vaccine Program –

a systems/issues-based health GPPP. 48 5.1 Activities related to patent protection and the

implementation of TRIPS. 88 8.1 Different types of economic evaluation. 143 8.2 Definitions of efficiency and economic evaluations. 143 8.3 The DALY (disability-adjusted life-year). 145

12.1 The globalisation of the workforce in the microelectronic industry. 212

12.2 Export processing zones. 214 12.3 Double standards in occupational health. 216 13.1 Features of globalisation that increase risks and negative

outcomes of collective violence. 238 13.2 Globalisation and the development of appropriate public

health responses. 245 14.1 A research agenda for global health policy. 271 14.2 An action agenda for global health policy. 276

xi

1 An introduction to global health policy

Kelley Lee, Suzanne Fustukian and Kent Buse

Globalisation is among the most discussed, and is undoubtedly one of the most disputed, terms to have come into common parlance in recent years. Scholarly and popular writing about globalisation has grown expo- nentially over the past decade or so, spurred by often heated debates over whether or not the process is actually occurring, to what extent, for what reasons, in what forms and with what consequences. Economic globali- sation has initially received the lion’s share of attention, but recognition of the political, social, cultural, technological, environmental and other aspects of globalisation has rapidly grown in more recent years.

It is in the latter context that this book, which explores how health policy-making is being affected by forces broadly defined as globalisation, was conceived. Health is an important sector of most economies and a core area of social policy. For example, total expenditure on health as a proportion of Gross Domestic Product (GDP) is as high as 14 per cent in the US and is over 10 per cent in a number of additional OECD (Organization for Economic Co-operation and Development) member countries. Public expenditure on health as a proportion of total public expenditure varies widely between countries, with India and Indonesia spending 3.9 and 3.0 per cent respectively, and Andorra and Argentina spending 38.5 and 21.6 per cent respectively (WHO 2000a). As such, the health sector has been the focus of much policy reform effort over the past two decades, to coincide with shifting ideas worldwide about the welfare state and the role of the public and private sectors in health care financing and provision. Ultimately the subject of health policy is a universally relevant one. Global health has featured prominently on the agendas of the major international political conferences of the 1990s, and has recently been framed as a security issue in the US and at the UN Security Council. Moreover, we are all concerned with our own and others health status, and the factors that optimise it. The health status of individuals and populations is a significant barometer of social progress, broadly reflecting the sustainability of current, and prospective, forms of how we order our lives both locally and globally.

3

4 Kelley Lee, Suzanne Fustukian and Kent Buse

Attention to the links between globalisation and health has increased rapidly since the mid 1990s, initially spurred by concerns over perceived changing threats to national and human security. These concerns have widened, as understanding of the diverse and uneven impacts of globali- sation on human health has grown, to include international trade agree- ments, global financial and trade flows, and global environmental change. Accompanying this attention have been efforts to explore the implications of these challenges to existing institutions and practices of health gover- nance – how should collective action be taken to mediate the positive and negative impacts of globalisation on human health?

The purpose of this book sits between seeking to better understand the impacts of globalisation and finding ways forward to strengthen health governance. We are especially interested in the changing actors, processes and contexts of policy-making, along with the actual policies adopted. In many ways, these four components are intertwined with each other. Yet it is useful to analytically tease them out in relation to how globalisa- tion is impacting on each of them. Selected areas of health policy have been focused on, with a particular emphasis on low- and middle-income countries (LMICs), to illustrate the impact of globalisation on health policy-making. The areas covered are by no means exhaustive, however, and the issues they raise in relation to health policy-making are not exclu- sive to these countries and regions. Indeed, one of the key messages of this volume is that no population group is immune from the health-related causes and consequences of globalisation.

The impacts of globalisation on health

An appreciation of the diversity of impacts that globalisation is having on health is rapidly growing, resulting in a variety of initiatives seeking more detailed understanding of these impacts and designing effective policy responses to them. These initiatives, in turn, have led to the term ‘global health’ which is being increasingly recognised among scholars, policy- makers and practitioners as distinct from ‘international health’, although the difference is not always made sufficiently clear. Indeed, both terms are variably defined and frequently used interchangeably, and there is consequently confusion between them.

International health is a familiar and longstanding term that broadly refers to health matters that concern two or more countries. Alternatively, within the development community, international health usually refers to health matters relevant to the developing world. While all sorts of public and private sector actors (both individuals and groups) may be involved in international health, it is the primacy of the state and state-defined

An introduction to global health policy 5

actors that distinguishes international health. For example, the regular transport of infectious diseases such as plague by trade ships from Asia to western Europe from the twelfth century onwards led to the adoption of maritime quarantine systems by Italian city states and later other European countries, as the foundations of the modern surveillance and control systems. The practice essentially excluded a suspect ship and its passengers from landing at a port of call for a given time until it was granted plague-free status by local authorities. The important feature of this system, which Carmichael (1997) describes as ‘an undeniable stimu- lus to the growth of the modern bureaucratic state’, is its efforts to shore up the territorial boundaries of the state against a health threat. If some- how the threat could be kept at bay outside of the given state’s borders, the population within would remain safe.

Many of the health issues that policy-makers face today remain, strictly speaking, international health issues. The threat of food-borne diseases from increased international trade, for example, in principle could be addressed by improved national, regional and multilateral regulation of food production and trade. Increased risk from infectious diseases as a result of highly mobile populations, at least those affecting individuals who enter and leave countries legally, could (theoretically) be regulated by customs authorities and public health officials at points of entry into a given country. In practice, as a number of chapters to this volume demonstrate, this is difficult to achieve given the limited capacity of many LMIC governments.

However, international health becomes global health when the causes or consequences of a health issue circumvent, undermine or are oblivious to the territorial boundaries of states and, thus, beyond the capacity of states to address effectively through state institutions alone. The illicit drug trade is conducted in a highly covert way, using global transporta- tion, communications, banking and financial infrastructures to directly challenge law-enforcement authorities worldwide. As Stares (1996) argues, the illicit drug industry has its own geographical rationalism of closely linked producing and consuming populations. The health effects of environmental degradation, such as global climate change or the Chernobyl nuclear accident, can also transcend state boundaries and directly challenge the capacity of the state alone to address its causes and consequences.

Global health is also concerned with factors that contribute to changes in the capacity of states to deal with the determinants of health. The global economic crisis of the late 1990s is recognised as having had pro- found impacts on public sector expenditure on health programmes such as family planning and basic health services (UNFPA/Australian National

6 Kelley Lee, Suzanne Fustukian and Kent Buse

University 1998). Cheaper and more widely available transportation tech- nologies, for example, have led to a significant increase in the number of people crossing national borders each week. While the sheer volume of international population movements challenges the logistical capacity of public health officials to cope with screening of travellers for health risks, the global movement of more vulnerable groups, such as economic migrants, refugees or trafficked individuals, places the inadequacy of in- ternational health (both conceptually and operationally) in starker relief.

One of the first premises of this book is that the scope of global health is expanding as a consequence of the processes of globalisation. Glob- alisation can be defined as ‘processes that are changing the nature of human interaction across a wide range of spheres including the socio- cultural, political, economic, technological and ecological’ (Lee 2001). These processes are global, in the sense that at least three types of bound- aries hitherto separating human interaction – spatial, temporal and cog- nitive – are being redefined. These are discussed in greater depth in Lee (2001) but can be summarised briefly as follows.

Spatial or geographical boundaries, in particular the territorial bor- ders of states, are becoming relatively less important as a consequence of globalisation. Perhaps more accurately, a reterritorialisation of geograph- ical boundaries is occurring by which globalising processes are redefin- ing geographical space in alternative and innovative ways. For example, global civil society, virtual communities and cyberspace increasingly defy the logic of territorially defined geography, giving rise to the importance of, on the one hand, aterritorial social arrangements and, on the other, competing loyalties and identities (Scholte 2000). Transnational activ- ities such as foreign-exchange trading and the Internet have become deterritorialised in the sense that geographical location matters little. Other transnational activities, although not deterritorialised as such, have intensified to such an extent that they are transforming societies around the world. Most fundamental of these is the ‘global shift’ of the world economy, which, through the interrelated actions of transnational cor- porations (TNCs) and states, is affecting local communities around the globe (Dicken 1998).

In the health field, this reterritorialisation of human interactions is impacting on both cause (health determinants) and effect (health status). As discussed above, globalisation in the economic, political, social, cul- tural, ecological and technological spheres of human activity needs to be taken into account as part of the broader determinants of health. The impacts of these processes of change, in turn, are leading to new patterns of human health and disease that do not necessarily conform to, or are revealed by, national boundaries alone.

An introduction to global health policy 7

This reconfiguration of the geography of health determinants and status, along with other geographies (e.g. financial resources, production and trade, cultural identity), has called into question traditional ways in which we categorise health needs. The familiar dichotomy between developed and developing countries has long been recognised as overly crude but broadly useful in distinguishing the needs and realistic options of countries of different levels of wealth. Global health issues are thus those that are not confined to a specific country or groups of countries, but are transborder in cause or effect; this suggests that the ways in which we conceptualise the geographical boundaries of the world, and the health issues related to them, need to adapt to processes that are transborder in nature.

Importantly, this does not mean that we should ignore the often stark inequities in impact that are being experienced within and across pop- ulation groups. While global health, by definition, makes all individuals and groups potentially vulnerable given their transborder nature, those who have the necessary resources, skills and mobility to reduce or avoid the costs of globalisation are at a clear advantage over those who do not. Most agree that there are winners and losers arising from the processes of globalisation. The proportion of winners to losers, and the long-term distribution of costs and benefits among them, remain highly disputed. Supporters of neo-liberalism maintain that benefits will eventually ‘trickle down’ to more and more people, raising the overall standard of living for all (World Bank 2000). Others, however, disagree that these trickle-down benefits are occurring sufficiently or fast enough. Bauman (1998), for ex- ample, argues that a minority of extraterritorial elites are enjoying a dis- proportionate share of the benefits of globalisation, while the bulk of the world’s population, a ‘localised majority’, bears the brunt of its risks and problems. Similarly, Coburn (2000) writes that ‘the links between glob- alisation and health initially stemmed from concerns within the health sector that economic globalisation in its present form is having adverse impacts on human health, in particular worsening equity and health sta- tus within certain vulnerable populations’. Measures to redistribute costs and benefits more directly are thus advocated, such as the Jubilee 2000 initiative on debt relief or the Tobin Tax, to generate resources for ad- dressing global health inequalities.

Temporal boundaries, the way in which we perceive and experience time, are also changing as a result of globalisation. For the most part, globalisation has been characterised by an acceleration of the pace of our lives, a feeling of time compression created by what has become possible technologically and aspirationally. As Gleick (1999: 9–10) writes:

8 Kelley Lee, Suzanne Fustukian and Kent Buse

We are in a rush. We are making haste. A compression of time characterizes the life of the century now closing . . . We believe that we possess too little of it [time]: that is a myth we now live by. What is true is that we are awash in things, in information, in news, in the old rubble and shiny new toys of our complex civilization, and – strange, perhaps – stuff means speed. The wave patterns of all these facts and choices flow and crash about us at a heightened frequency. We live in the buzz. We wish to live intensely, and we wonder about the conse- quences.

The effects of this temporal change on health are again relevant to both the determinants of health and health status. Changes in certain health deter- minants can manifest more rapidly or operate within an altered timescale. Our destruction of the natural environment, for example, is happening at an unprecedented and accelerating rate with direct consequences for the survival of the human species (McMichael 1993). Lee and Dodgson (2000) observe that the seventh cholera pandemic began in 1963 and spread worldwide more quickly than the previous six. Furthermore, its duration of about 40 years is by far the longest cholera pandemic in his- tory, eluding public health efforts to definitively contain it because of its capacity to re-emerge in different parts of the world as a result of such features of globalisation as human hypermobility, political instability and the food trade.

Third, globalisation has a cognitive dimension that concerns the thought processes that shape our perceptions of ourselves and the world around us. Wallerstein (1991) refers to a globalising cognitive framework that he calls ‘geoculture’, in which ‘particular patterns of thought and behaviour – even language – inscribed in geoculture, are not only es- sential to ensure that the modern world-system functions effectively, but also provide much of its underlying legitimation’ (Murden 1997). Glob- alisation is changing how thought processes are produced and repro- duced, particularly through the spread of communication technologies in the mass media, research community and interpersonal communications (e.g. email), as well as what thoughts are being produced (e.g. values, beliefs, ideologies, ethics, cultural identity). There is disagreement as to whether these changes are integrating societies for good or bad. Liberal advocates of the ‘global village’ vision observe that: ‘The world is becom- ing a single place, in which different institutions function as parts of one system and distant peoples share a common understanding of living to- gether on one planet. This world society has a culture; it instills in many people a budding consciousness of living in a world society’ (Lechner and Boli 2000: xiii). Others are worried that dominant western-derived values, characterised by rampant consumerism, materialism and individ- ualism, are being replicated around the world:

An introduction to global health policy 9

onrushing economic, technological, and ecological forces that demand integra- tion and uniformity and that mesmerize peoples everywhere with fast music, fast computers, and fast food – MTV, Macintosh, and McDonald’s – pressing nations into one homogenous global theme park, one McWorld tied together by communications, information, entertainment and commerce. (Barber 2000: 21)

Most overtly, the impact of the cognitive dimension of globalisation on health is its direct consequences for diet and life style. Since the end of the Second World War, populations in high-income countries have be- come less physically active while at the same time consuming increased fat and sugar levels. Smoking rates have declined in many high-income countries, although the health consequences after many decades of high rates of smoking are now being experienced. The result is a steadily rising incidence of obesity, coronary heart disease, certain cancers and diabetes. Importantly, these changes can be linked to the multi-billion pound mar- keting of particular life styles via the mass media and other channels of advertising, promotion and sponsorship. According to Wallack and Montgomery (1992: 205), processed foods, soft drinks, cigarettes, alco- hol, drugs and toiletries account for 80–90 per cent of all international advertising expenditures. The aspirational messages that advertisers have conveyed for decades in high-income countries are becoming globalised, exported to the increasingly affluent in other parts of the world through global trade and production relations, information technologies (notably the mass media), and the liberalisation and privatisation of economies worldwide.

Along with the replication of life style choices on a global scale, the cog- nitive dimension of globalisation is shaping policy responses that facilitate or hinder their health effects. Individual life style choices are being made within a broader context of global capitalism. Many of the issues raised by this book stem from concerns that cognitive exchanges within current forms of globalisation are undertaken within highly inequitable circum- stances. Rather than a ‘meeting of minds’, health policy is being shaped foremost by a broader context of certain value systems, beliefs, aspirations and so on that seek to maintain a particular world order. This process is aptly captured in the French expression pensée unique, explained by Halimi (2000: 18) as follows:

It is the ideological translation of the interests of global capital, of the priorities of financial markets and of those who invest in them. It is the dissemination through leading newspapers of the policies advocated by the international economic in- stitutions which use and abuse the credit, data and expertise they are entrusted with: such institutions as the World Bank, the IMF, the OECD, the World Trade Organization.

10 Kelley Lee, Suzanne Fustukian and Kent Buse

This shifting cognitive landscape is clearly discernible in the health field where many of the policies discussed in this book derive. For example, Bettcher and Yach (1998) explore the ways in which public health ethics may be changing as a consequence of globalisation. Similarly, debates over how health should be defined are being reframed, from a concern with how to ensure health as a basic human right available to all and collectively provided, to health as a product whose attainment and con- sumption by individuals should be regulated by a marketplace. This shift is further reflected in the normative criteria, and resultant analytical tools (e.g. burden of disease, cost-effectiveness analysis), which are applied to translate certain values into decisions over, among other things, the allocation of limited health resources. The cognitive dimension relates to both how societies structure and deliver health care, from the underlying principles that guide health care to the specific technical interventions provided, and the deeper structural level which concerns how we act to mediate and direct globalisation towards agreed goals.

Collectively, changes to spatial, temporal and cognitive boundaries can be described as the dimensions of global change. Efforts to under- stand and respond effectively to these dimensions of change comprise the broad and growing fields of global health policy and governance (Lee 2001).

What is global health policy?

The focus of this book is on health policy and the ways in which global- isation is affecting how policy-making is being carried out in the health sector (and in other sectors and issue areas that impact on health). Health policy is broadly defined as ‘goals and means, policy environments and instruments, processes and styles of decision-making, implementation and assessment. It deals with institutions, political power and influence, people and professionals, at different levels from local to global’ (Leppo 1997). Global health policy can thus be understood as the ways in which globalisation may be impacting on health policy and, alternatively, what health policies are needed to respond to the challenges raised by global- ising processes.

Interest in global health policy can be seen as an extension of a desire, in more recent literature on globalisation, to understand the knock-on effects of current neo-liberal and market-driven forms of globalisation, on public policy especially in relation to social policy. While much of the globalisation literature remains heavily focused on the economic and fi- nancial sectors (World Bank 2000), many of the policy areas neglected until recently are now being addressed. Initially, these efforts have come

An introduction to global health policy 11

from scholars in social policy who observe the often adverse effects that globalisation is having on the social sectors such as education, housing and health. Deacon (1997) argues, for example, that national social pol- icy is increasingly determined by global economic competition and cer- tain international organisations. Social policy must thus be understood in terms of global social redistribution, social regulation, social provision and empowerment (Deacon 1997). Alternatively, Kaul et al. (1999: 452) conceptualise the shortfalls of globalisation in terms of the undersup- ply of global public goods defined as exhibiting characteristics which are ‘nonexcludable, [and produce] nonrival benefits that cut across borders, generations and populations’.

More recently, attention to the social sectors has come from economic analyses, prompted by externalities of the global financial crisis of the late 1990s, revealing the interconnectedness and mutual vulnerability of national economies and societies. As well as eliciting extensive reflection of the need to strengthen global economic governance (e.g. banking regu- lation) (Stiglitz 1999), the links between economic and social policy were brought more sharply into focus. As Reinicke (1998: 1) writes:

without a greater effort to understand the origin and nature of the current global transformation and its implications for public policy, we will continue to react to events rather than act to shape the future course of world politics. Such passivity will leave our societies vulnerable to the risks that change will undoubtedly bring, while forgoing the gains that a more active policymaking could realize.

In relation to the health sector, concerns for nascent global public policy has initially centred on threats to national security or at least the security of high-income countries. In the context of reframing post-cold war for- eign and defence policy, this perspective has focused on selected health threats such as infectious diseases, biological and chemical weapons, human migration, and illicit drug trafficking. The global health policy agenda in the US, in particular, has sought to channel the so-called ‘peace dividend’ to health risks arising from globalisation (Institutes of Medicine 1997; Raymond 1997).

Internationally, global health policy has been cast to emphasise the links between health and economic development led by the World Health Organisation (WHO). Recognising economic integration as a key driver of current forms of globalisation, WHO has strengthened its efforts to understand issues such as multilateral trade agreements, capital flows and macroeconomic policy and their implications for public health. In this respect, Director-General Gro Harlem Brundtland has frequently sought to argue that the protection and promotion of public health is a core requirement of sustainable globalisation (Brundtland 1999a).

12 Kelley Lee, Suzanne Fustukian and Kent Buse

The intention of this book is to bring these concerns together. A number of questions occur in relation to health policy: is globalisation changing the way health policies are being made? How effectively are so- cieties able to address the risks and benefits of globalisation to human health? Is globalisation broadening or narrowing involvement in priority- setting in health? Is our collective ability to address global health issues strengthened or undermined by the globalisation process? These ques- tions, which are framed by what Held et al. (1999: 18) describe as the decisional and institutional impacts of globalisation, are addressed. De- cisional impacts are ‘the degree to which the relative costs and benefits of the policy choices confronting governments, corporations, collectivities and households are influenced by global forces and conditions’. Institu- tional impact refers to ‘the ways in which organizational and collective agendas reflect the effective choices or range of choices available as a result of globalization’. In short, the volume seeks to advance understanding of the interplay between the dynamics of globalisation and the health policy.

The adverse impacts of globalisation on health, and the seeming in- capacity of existing institutions and systems to address them, illustrate the need for, and current weaknesses of, global health governance. Kaul et al. (1999), for example, attribute the undersupply of global public goods to three existing weaknesses or ‘gaps’ in the current institutions of international policy-making:

(a) jurisdictional gap – ‘the discrepancy between a globalized world and national, separate units of policy-making’;

(b) participation gap – the continued focus of international co-operation on inter- governmental actors and marginalisation of new global actors, civil society and private sector; and

(c) incentive gap – the over reliance of the operationalisation of international agree- ments on aid mechanisms while ignoring ‘many other practical policy options that could make co-operation a preferred strategy for both developing and industrial countries’.

Similarly, Kickbusch (1999) explores the possible characteristics of global health governance and the necessary changes in how policy-making is carried out.

In summary, global health policy is concerned with the ways in which globalisation is affecting the ‘goals and means, policy environments and instruments, processes and styles of decision making, implementation and assessment’ (Leppo 1997) in the health field. This may eventually lead to the development of global-level policy-making, but global health policy may embrace those aspects of local, national, regional and inter- national policy-making needed to address the impacts of globalisation on

An introduction to global health policy 13

health. As described above, the global health policy agenda has thus far been narrowly circumscribed, with selected costs and benefits of globali- sation focused upon. It is argued here that global health policy is a broad area encompassing the different spheres of human activity (i.e. economic, political, ecological, technological, cultural) being changed by the pro- cesses of globalisation at any level – from the individual to the global.

Conceptual framework of the book

There are admittedly many different models for conceptualising how policy-making takes place, what the most important influences are, and how we should study them. The field is multidisciplinary, offering a di- verse and at times incompatible array of theories and approaches. Rather than seek to reconcile differences in disciplinary, epistemological and nor- mative starting points, this book begins with the broad approach taken by Walt and Gilson (1994) that describes health policy in terms of policy actors, processes, context and content. This framework is used, not as a methodological tool, but as a conceptual list to prompt and organise possible analytical questions.

First, how are policy actors in health changing as a consequence of globalisation? This question concerns both who is making policy and their changing power in relation to other actors to influence decision- making. Policy actors may be individuals or groups of individuals with the capacity to influence, either formally or informally, the policy-making process. As well as understanding who participates, it is important to recognise those under-represented by decision-making. Globalisation, as described above, suggests that different actors have gained power over others, notably actors with transnational links and resources. Globali- sation is often described as an era of big business and big government. Above all, the book will argue that conventional analyses of health policy, as for other areas of public policy, that narrowly focus on the national level and on state actors alone are becoming increasingly obsolete. This is not to imply that national/local contexts are not important, but that these need to be integrated into a much wider framework of analysis.

Second, how is globalisation affecting the processes by which policy- making is carried out? Much of the criticism of globalisation, from both the political left and right, is that it is an alienating phenomenon that takes power away from individuals and their local communities, and lo- cates it somewhere referred to as the ‘global’. Political responsibility and political power are seen to be becoming more separated with the result that an exclusive global elite is able to exert unrivalled power without, to some extent, accountability to those they affect. Decisions taken in the

14 Kelley Lee, Suzanne Fustukian and Kent Buse

boardrooms of large TNCs can have implications for people around the world. Governments, in turn, theoretically remain responsible to their citizenry but have diminished power to provide for their needs. Large groups of individuals and communities worldwide feel even more dis- empowered by the globalising forces that seem to be changing modern societies in so many ways. Many writers argue that foremost is the need to democratise globalisation (Amin 2000; Sen 2000).

An alternative vision of policy-making amidst globalisation is what Castells (1996: 469–71) dubs ‘the rise of the network society’. He writes that ‘dominant functions and processes in the information age are increasingly organized around networks . . . A network-based social struc- ture is a highly dynamic, open system, susceptible to innovating without threatening its balance . . . Yet the network morphology is also a source of dramatic reorganization of power relationships.’ In this sense, the pro- cesses of globalisation are potentially democratising, opening up political spaces for a wider range of actors and new interconnections among them. This book explores the extent to which processes of policy-making in the health sector are changing as a consequence of globalisation, and in what ways. Our examples seem to suggest that networks are indeed forming, bringing new configurations of power relations, but that these networks are still relatively exclusive.

Third, how is globalisation changing the context in which policy- making takes place? Policy context concerns the surrounding social, in- stitutional and natural environment that shapes policy-making at a given time. One of the most significant changes to the health policy context in a globalising world is the realisation that the determinants of health are more complex and wide-ranging as a consequence of globalisation. Glob- alisation brings home the message that the health sector is directly and indirectly affected by other sectors such as trade and finance, environ- ment, labour, communications and transportation. Of course, these con- nections have long been recognised, but what has become more evident is the increased interrelatedness of these policy areas to an extent unprece- dented. Furthermore, there has been what Kaul et al. (1999) describe as the blurring of the dividing line between the spheres of domestic and foreign policy, leading to the need ‘to review the fundamental princi- ples of policy-making’. National policy-makers have experienced a rela- tive decline in their capacity to control health determinants of domestic populations because globalisation, by its very nature, concerns processes that transcend state boundaries. For example, the global financial crisis of the late 1990s had significant impacts on resources available to health policy-makers in the hardest hit countries (UNFPA/Australian National University 1998). Economic instability from volatile financial markets has

An introduction to global health policy 15

been accompanied by political instability in many parts of the world, in turn adversely affecting the capacity to make effective health policies. The worldwide spread of affordable information and communication tech- nologies is changing the evidence base upon which health policies can be made. All of these developments are creating policy contexts influenced by diverse and complex forces, that are rapidly and steadily in flux, and that do not conform to familiar national boundaries.

Finally, is globalisation influencing the content of policies being made? Many of the chapters in this book examine particular policies and locate them within the context of globalisation. Underlying these chapters is the question of why certain policies become globalised, in the sense that poli- cies originating in particular countries, organisations or even individuals are eventually adopted by others as legitimate and useful. Of particular note is what Leppo (1997: 3) describes as ‘an epidemic of reforms based on various forms of market principles’. It may be argued that such poli- cies are simply ‘good’ policies in that they successfully achieve agreed and desired goals. The variable success of policies such as private health insurance, user fees, contracting out and competitive tendering suggests that other factors have influenced their acceptance worldwide.

Structure of the book

We have organised the chapters of this book into three parts. Part I deals with how health policy-making takes place in a globalising world. In so doing, the authors address, among other things, the transfer of val- ues, technologies, practices and policies across a variety of boundaries (e.g. local, national, regional, global). They also explore how policy actors and their interactions are changing as a result of globalising forces. Ranson and colleagues, in their analysis of the public health implications of multi- lateral trade agreements, explore the shifting patterns of influence among states, multilateral organisations (particularly the WTO) and commer- cial interests over health policy. The chapter sheds light on the powerful effect that formalised intergovernmental rules enshrined in treaty obliga- tions in one sector (in this case liberalised and harmonised trading rules) can have on public health. Buse and Walt discuss the hybrid institutional form for health policy-making that is embodied in global public–private partnerships. They draw attention to the increasing emphasis placed on such collaboration for health policy and to the need for improved ways of governing these institutions. The chapter by Brugha and Zwi, which reviews the evidence base of policies relating to the regulation of private providers in LMICs, reveals a number of disturbing features. In particu- lar, the authors argue that advice provided by leading donor agencies to

16 Kelley Lee, Suzanne Fustukian and Kent Buse

privatise health care provision preceded the systematic gathering and analysis of empirical evidence and was instead predicated upon the ideo- logical preferences of powerful external actors. Their case illustrates the hegemony of certain ideas associated with dominant ideologies in a glob- alising world. A review of the regulation of emerging global health markets by Kumaranayake and Lake highlights the need for more effective regu- lation and the important role that might be played by non-state actors. Lee and Goodman challenge the orthodox assumption that globalisation opens up political spaces for greater participation in policy development by demonstrating how a small global elite, linked through an epistemic community, came to frame both the terms and the content of health care financing (HCF) reform worldwide. McPake takes up the challenge of understanding policy learning across countries, also in the area of HCF, as well as the promotion of autonomous hospitals, and argues for more sophisticated approaches to policy adaptation. Finally, Kumaranayake and Walker describe the globalisation of specific technical methodology for priority-setting and question its utility in many settings. Collectively, these chapters take a critical look at policy-making within the context of current forms of globalisation.

The chapters in Part II examine selected impacts of globalisation on the content of health policy. These chapters are concerned with how globalising forces are changing the agenda faced by policy-makers, be- cause the determinants of relatively familiar challenges are more complex and multifaceted, or new linkages are emerging between health issues and other areas, or new constellations of interest groups have captured the policy process. Mayhew and Watts demonstrate the critical role that the global women’s movement has played in framing the debates on violence against women and reproductive health; using modern commu- nications technology, this movement has formed powerful coalitions to influence global agendas on these issues, despite the often tepid support of state actors. They go on to argue that translating the global rhetoric into national programmes will require pragmatic links to be developed between the services and for them to be context-appropriate. The chapter by Porter et al. explores the globalisation of tuberculosis and the role of DOTS (directly observed therapy short course) as a ‘global strategy’. Lloyd-Sherlock examines the dynamics behind the ageing agenda; he re- veals the global dominance of particular ideological models with grave consequences on equity of health care access. Fustukian et al. tackle the neglected area of occupational health and safety as an area of health pol- icy directly affected by the emerging global economy. Finally, Zwi et al. consider the implications of collective violence on health policy agendas. They argue that the new forms of collective violence which have emerged

An introduction to global health policy 17

since the end of the cold war, notably complex political emergencies (CPEs), are linked to structural features of globalisation. Humanitarian responses to such conflicts, in an appropriate and timely manner, re- quire us to address the root causes of conflict – widening socio-economic inequalities, competition for control of natural resources in a global econ- omy, global arms trade, and privatisation of armed conflict. While these chapters are by no means intended to be a comprehensive discussion of health issues related to globalisation, they seek to demonstrate the need to better integrate consideration of globalising forces into health policy agendas.

In Part III, Buse et al. draw conclusions regarding the impact of glob- alisation on health policy-making. We return to the topic of globalisation and questions of actors, processes, context and content to explore further how globalisation is changing all of these features. However, the editors of this volume are keenly aware that this book only begins to open a corridor to better understanding global health policy. The issues dealt with here to explore global health are necessarily selective and omit, for example, such key areas as global environmental change and non-communicable dis- ease. None the less, in keeping with the multidisciplinary nature of the subject matter, the contributors to this volume approach globalisation from a variety of disciplinary perspectives, including anthropology, devel- opment studies, economics, organisation studies, epidemiology, politics and social policy. The chapters illustrate the multiple boundaries being crossed as a result of globalisation – spatial, temporal and cognitive – as well as the need to cross boundaries analytically and operationally to address the health consequences arising from global change.

KEY READINGS

Deacon, B. 1997, Global social policy, international organizations and the future of welfare, London: Sage Publications.

Held, D., McGrew, A., Goldblatt, D. and Perraton, J. 1999, Global transforma- tions: politics, economics and culture, Stanford University Press.

Kaul, I., Grunberg, I. and Stern, M. (eds.) 1999, Global public goods: international cooperation in the 21s t Century, Oxford University Press.

Lee, K. 2001, ‘Globalisation – a new agenda for health?’, in McKee, M., Garner, P. and Stott, R. (eds.) International co-operation and health, Oxford University Press.

UNDP 1999, Human development report 1999, New York: United Nations Devel- opment Programme.