Understanding resilience, self-reliance and increasing country voice: a clash of ideologies in global health.

BACKGROUND: 'Resilience', 'self-reliance' and 'increasing country voice' are widely used terms in global health. However, the terms are understood in diverse ways by various global health actors. We analyse how these terms are understood and why differences in understanding exist. METHODS: Drawing on scholarship concerning ideology, framing and power, we employ a case study of a USAID-sponsored suite of awards called MOMENTUM. Applying a meta-ethnographic approach, we triangulate data from peer-reviewed and grey literature, as well as 27 key informant interviews with actors at the forefront of shaping these discourses and those associated with MOMENTUM, working in development agencies, implementing organisations, low-income and middle-income country governments, and academia. RESULTS: The lack of common understanding of these three terms is in part a result of differences in two perspectives in global health-reformist and transformational-which are animated by fundamentally different ideologies. Reformists, reflecting neoliberal and liberal democratic ideologies, largely take a technocratic approach to understanding health problems and advance incremental solutions, working within existing global and local health systems to effect change. Transformationalists, reflecting threads of neo-Marxist ideology, see the problems as inherently political and seek to overhaul national and global systems and power relations. These ideologies shape differences in how actors define the problem, its solutions and attribute responsibility, resulting in nuanced differences among global health actors in their understanding of resilience, self-reliance and increasing country voice. CONCLUSIONS: Differences in how these terms are employed and framed are not just linguistic; the language that is used is reflective of underlying ideological differences among global health actors, with implications for the way programmes are designed and implemented, the knowledge that is produced and engagement with stakeholders. Laying these distinct ideologies bare may be crucial for managing actor differences and advancing more productive discussions and actions towards achieving global health equity.

Political challenges to prioritizing gender in global health organisations.

BACKGROUND: Many global health organisations have adopted formal strategies to integrate gender in their programming. In practice, few prioritise the issue. Institutions with considerable global power therefore largely overlook fundamental drivers of adverse health outcomes: gender inequality and harmful gender norms. We analyse the factors shaping attention to gender in organisations involved in global health governance. METHODS: Drawing on scholarship from the fields of organisational behavior and management, sociology, international relations and the policy process, we undertook a thematic analysis of peer-reviewed scholarship and organisational documents. We also conducted 20 semi-structured interviews over Skype with individuals working at the cross-section of gender and health. RESULTS: In seeking to reform the policies and practices of global health organisations, gender proponents confront patriarchal organisational cultures, hostile political environments and an issue that is difficult to address as it requires upsetting existing power structures. Proponents also face three linked challenges internal to their own networks. First, there is little cohesion among champions themselves, as they are fragmented into multiple networks. Second, proponents differ on the nature of the problem and solutions, including whether reducing gender inequality or addressing harmful gender norms is the primary goal, the role of men in gender initiatives, which health issues to prioritise, and even the value of proponent cohesion. Third, there are disagreements among proponents on how to convey the problem. Some advance an instrumental case, while others believe that it should be portrayed as a human rights issue and using any other argument undermines that fundamental justification. CONCLUSIONS: Prospects for building more gender-responsive global health organisations will depend in part on the ability of proponents to address these disagreements and develop strategies for negotiating difficult organisational cultures and political environments.

Generating Global Priority for Addressing Rheumatic Heart Disease: A Qualitative Policy Analysis.

Background Rheumatic heart disease (RHD) poses a high burden in low-income countries, as well as among indigenous and other socioeconomically disadvantaged populations in high-income countries. Despite its severity and preventability, RHD receives insufficient global attention and resources. We conducted a qualitative policy analysis to investigate the reasons for recent growth but ongoing inadequacy in global priority for addressing RHD. Methods and Results Drawing on social science scholarship, we conducted a thematic analysis, triangulating among peer-reviewed literature, organizational documents, and 20 semistructured interviews with individuals involved in RHD research, clinical practice, and advocacy. The analysis indicates that RHD proponents face 3 linked challenges, all shaped by the nature of the issue. With respect to leadership and governance, the fact that RHD affects mostly poor populations in dispersed regions complicates efforts to coordinate activities among RHD proponents and to engage international organizations and donors. With respect to solution definition, the dearth of data on aspects of clinical management in low-income settings, difficulties preventing and addressing the disease, and the fact that RHD intersects with several disease specialties have fueled proponent disagreements about how best to address the disease. With respect to positioning, a perception that RHD is largely a problem for low-income countries and the ambiguity on its status as a noncommunicable disease have complicated efforts to convince policy makers to act. Conclusions To augment RHD global priority, proponents will need to establish more effective governance mechanisms to facilitate collective action, manage differences surrounding solutions, and identify positionings that resonate with policy makers and funders.

Gender equality and gender norms: framing the opportunities for health.

The Sustainable Development Goals offer the global health community a strategic opportunity to promote human rights, advance gender equality, and achieve health for all. The inability of the health sector to accelerate progress on a range of health outcomes brings into sharp focus the substantial impact of gender inequalities and restrictive gender norms on health risks and behaviours. In this paper, the fifth in a Series on gender equality, norms, and health, we draw on evidence to dispel three myths on gender and health and describe persistent barriers to progress. We propose an agenda for action to reduce gender inequality and shift gender norms for improved health outcomes, calling on leaders in national governments, global health institutions, civil society organisations, academic settings, and the corporate sector to focus on health outcomes and engage actors across sectors to achieve them; reform the workplace and workforce to be more gender-equitable; fill gaps in data and eliminate gender bias in research; fund civil-society actors and social movements; and strengthen accountability mechanisms.

Early childhood development coming of age: science through the life course.

Early childhood development programmes vary in coordination and quality, with inadequate and inequitable access, especially for children younger than 3 years. New estimates, based on proxy measures of stunting and poverty, indicate that 250 million children (43%) younger than 5 years in low-income and middle-income countries are at risk of not reaching their developmental potential. There is therefore an urgent need to increase multisectoral coverage of quality programming that incorporates health, nutrition, security and safety, responsive caregiving, and early learning. Equitable early childhood policies and programmes are crucial for meeting Sustainable Development Goals, and for children to develop the intellectual skills, creativity, and wellbeing required to become healthy and productive adults. In this paper, the first in a three part Series on early childhood development, we examine recent scientific progress and global commitments to early childhood development. Research, programmes, and policies have advanced substantially since 2000, with new neuroscientific evidence linking early adversity and nurturing care with brain development and function throughout the life course.

Setting the global health agenda: The influence of advocates and ideas on political priority for maternal and newborn survival.

This study investigates a puzzle concerning global health priorities-why do comparable issues receive differential levels of attention and resources? It considers maternal and neonatal mortality, two high-burden issues that pertain to groups at risk at birth and whose lives could be saved with effective intrapartum care. Why did maternal survival gain status as a global health priority earlier and to a greater degree than newborn survival? Higher mortality and morbidity burdens among newborns and the cost-effectiveness of interventions would seem to predict that issue's earlier and higher prioritization. Yet maternal survival emerged as a priority two decades earlier and had attracted considerably more attention and resources by the close of the Millennium Development Goals era. This study uses replicative process-tracing case studies to examine the emergence and growth of political priority for these two issues, probing reasons for unexpected variance. The study finds that maternal survival's grounding as a social justice issue spurred growth of a strong and diverse advocacy network and aligned the issue with powerful international norms (e.g. expectations to advance women's rights and the Millennium Development Goals), drawing attention and resources to the issue over three decades. Newborn survival's disadvantage stems from its long status as an issue falling under the umbrellas of maternal and child survival but not fully adopted by these networks, and with limited appeal as a public health issue advanced by a small and technically focused network; network expansion and alignment with child survival norms have improved the issue's status in the past few years.

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

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

Global Health as a Field of Power Relations: A Response to Recent Commentaries.

Actors working in global health often portray it as an enterprise grounded in principled concerns, advanced by individuals and organizations who draw on scientific evidence to pursue health equity. This portrait is incomplete. It is also a field of power relations-a social arena in which actors claim and draw on expertise and moral authority to gain influence and pursue career, organizational and national interests. A clear understanding of how power operates in this field is necessary to ensure that it is used productively to serve the aims of health equity and improved population health. Responding to commentaries on an editorial published in this journal, I offer 3 ideas toward this end: (1) be skeptical of the global health rationality project-the effort to rescue the field from the alleged indignities of politics through the application of scientific methods; (2) analyze global health as a field of power relations, a concept developed by sociologist Pierre Bourdieu; and (3) elevate the place of input legitimacy-inclusive deliberation, fair process and transparency-to address legitimacy and knowledge deficits in this field.

Advancing the newborn and stillbirth global agenda: priorities for the next decade.

Remarkable advances have been made over the past decade in defining the burden of newborn mortality and morbidity and stillbirths, and in identifying interventions to address the major risk factors and causes of deaths. However, progress in saving newborn lives and preventing stillbirths in countries lags behind that for maternal mortality and for children aged 1-59 months. To accelerate progress, greater focus is needed on improving coverage, quality and equity of care at birth-particularly obstetric care during labour and childbirth, and care for small and sick newborns, which gives a triple return on investment, reducing maternal and newborn lives as well as stillbirths. Securing national-level political priority for newborn health and survival and stillbirths, and implementation of the Every Newborn Action Plan are critical to accomplishing the unfinished global agenda for newborns and stillbirths beyond 2015.

Holding health providers in developing countries accountable to consumers: a synthesis of relevant scholarship.

Health care providers in low-income countries often treat consumers poorly. Many providers do not consider it their responsibility to listen carefully to consumer preferences, to facilitate access to care, to offer detailed information, or to treat patients with respect. A lack of provider accountability to health consumers may have adverse effects on the quality of health care they provide, and ultimately on health outcomes. This paper synthesizes relevant research on health provision in low-, middle- and high-income countries with the aim of identifying factors that shape health provider accountability to consumers, and discerning promising interventions to enhance responsiveness. Drawing on this scholarship, we develop a framework that classifies factors into two categories: those concerning the health system and those that pertain to social influences. Among the health systems factors that may shape provider accountability are oversight mechanisms, revenue sources, and the nature of competition in the health sector-all influences that may lead providers to be accountable to entities other than consumers, such as governments and donors. Among the social factors we explore are consumer power, especially information levels, and provider beliefs surrounding accountability. Evidence on factors and interventions shaping health provider accountability is thin. For this reason, it is not possible to draw firm conclusions on what works to enhance accountability. This being said, research does suggest four mechanisms that may improve provider responsiveness: 1. Creating official community participation mechanisms in the context of health service decentralization; 2. Enhancing the quality of health information that consumers receive; 3. Establishing community groups that empower consumers to take action; 4. Including non-governmental organizations in efforts to expand access to care. This synthesis reviews evidence on these and other interventions, and points to future research needs to build knowledge on how to enhance health provider accountability to consumers.

Has aid for AIDS raised all health funding boats?

Global health analysts have debated whether donor prioritization of HIV/AIDS control has lifted all boats, raising attention and funding levels for health issues aside from HIV/AIDS. We investigate this question, considering donor funding for 4 historically prominent health agendas-HIV/AIDS, health systems strengthening, population and reproductive health, and infectious disease control-over the decade 1998-2007. We employ funding data from the Development Assistance Committee of the Organization for Economic Cooperation and Development, which tracks donor aid. The data indicate that HIV/AIDS may have helped to increase funding for the control of other infectious diseases; however, there is no firm evidence that other health issues beyond the control of infectious diseases have benefited. Between 1998 and 2007, funding for HIV/AIDS control rose from just 5.5% to nearly half of all aid for health. Over the same period, funding for health systems strengthening declined from 62.3% to 23.9% of total health aid and that for population and reproductive health declined from 26.4% to 12.3%. Also, even as total aid for health tripled during this decade, aid for health systems strengthening largely stagnated. Overall, the data indicate little support for the contention that donor funding for HIV/AIDS has lifted all boats.

Has donor prioritization of HIV/AIDS displaced aid for other health issues?

Advocates for many developing-world health and population issues have expressed concern that the high level of donor attention to HIV/AIDS is displacing funding for their own concerns. Even organizations dedicated to HIV/AIDS prevention and treatment have raised this issue. However, the issue of donor displacement has not been evaluated empirically. This paper attempts to do so by considering donor funding for four historically prominent health agendas--HIV/AIDS, population, health sector development and infectious disease control--over the years 1992 to 2005. The paper employs funding data from the Organization for Economic Cooperation and Development's (OECD) Development Assistance Committee, supplemented by data from other sources. Several trends indicate possible displacement effects, including HIV/AIDS' rapidly growing share of total health aid, a concurrent global stagnation in population aid, the priority HIV/AIDS control receives in US funding, and HIV/AIDS aid levels in several sub-Saharan African states that approximate or exceed the entirety of their national health budgets. On the other hand, aggregate donor funding for health and population quadrupled between 1992 and 2005, allowing for funding growth for some health issues even as HIV/AIDS acquired an increasingly prominent place in donor health agendas. Overall, the evidence indicates that displacement is likely occurring, but that aggregate increases in global health aid may have mitigated some of the crowding-out effects.

Donor funding priorities for communicable disease control in the developing world.

Prior research has considered donor funding for developing world health by recipient and donor country but not by disease. Examining funding by disease is critical since diseases may be in competition with one another for priority and donors may be making allocation decisions in ways that do not correspond to developing world need. In this study I calculate donor funding for 20 historically high-burden communicable diseases for the years 1996 to 2003 and examine factors that may explain variance in priority levels among diseases. I consider funding for developing world health from 42 major donors, classifying grants according to the communicable disease targeted. Data show that funding does not correspond closely with burden. Acute respiratory infections comprise more than a quarter of the burden among these diseases but receive less than 3% of direct aid. Malaria also stands out as a high-burden neglected disease. The evidence indicates that neither developing world need nor industrialized world interests explain all funding patterns, and that donors may be imitating one another in ways that do not take into account problems in the developing world. There is an urgent need for a major increase in funding for communicable disease control in the developing world, and for more balanced allocation of the resources already provided.

Norms in tension: democracy and efficiency in Bangladeshi health and population sector reform.

Spurred on by donors, a number of developing countries are in the midst of fundamental health and population sector reform. Focused on the performance-oriented norms of efficiency and effectiveness, reformers have paid insufficient attention to the process-oriented norms of sovereignty and democracy. As a result, citizens of sovereign states have been largely excluded from the deliberative process. This paper draws on political science and public administration theory to evaluate the Bangladeshi reform experience. It does so with reference to the norms of efficiency, effectiveness, sovereignty and democracy as a means of making explicit the values that need to be considered in order to make health and population sector reform a fair process.