Eduardo J. Gómez

An alternative approach to evaluating, measuring, and comparing domestic and international health institutions: Insights from social science theories

OBJECTIVES This article introduces the benefits of applying social science theories discussing institutional stasis and change to better measure, explain, and compare elite behavior within health administration and decentralization processes. A new comparative method based on these theories is introduced, as well as methods for collecting and analyzing data. METHODS A literature review of health governance, health system governance, and path dependency and institutional change theory was conducted to reveal the limitations of health governance approaches explaining elite behavior. Next, path dependency and institutional change theory was applied to case studies in order to demonstrate their utility in explaining institutional stasis and change. RESULTS Current approaches to analyzing and comparing elite behavior in the health governance frameworks are limited in their ability to accurately explain the willingness of elites to pursue more efficient institutional and policy designs. Current indicators measuring elite behavior are also too static, failing to account for periodic resistance to change and the conditions for it. CONCLUSIONS By applying path dependency and institutional change theory, the policy community can obtain greater insight into the willingness and thus capacity of institutions to pursue innovations while developing alternative analytic frameworks and databases that better measure and predict this process.

What the United States can learn from Brazil in response to HIV/AIDS: international reputation and strategic centralization in a context of health policy devolution

Contrary to what many may expect, this article argues that Brazil did a better job than the USA when it came to responding to HIV/AIDS. Because of the Brazilian governments concern about its international reputation and the partnerships it has forged with international donors and civil society, the government has been committed to strengthening decentralization processes by introducing both formal and informal re-centralization measures that strengthen health policy devolution, while effectively targeting the biggest at-risk groups. The US, in contrast, has not achieved these objectives, due to its lack of interest in increasing its international reputation and its focus on bi-lateral aid rather than investing in domestic policy. The paper closes by explaining the lessons that Brazil can teach the US and other large federations seeking to ensure that decentralization and prevention policy work more effectively.

Political repression, civil society and the politics of responding to AIDS in the BRICS nations

The policy responses to human immunodeficiency virus/acquired immune deficiency syndrome (AIDS) in the Brazil, Russia, India, China and South Africa (BRICS) nations have played out amid radically different political environments that have shaped state-civil society relations in critical ways. In contrasting these different environments, this article offers the first comparison of the policy response to AIDS in the BRICS nations and seeks to understand the way in which political context matters for conditioning the response to a major epidemic. Using a comparative historical approach, we find that while collaborative state-civil society relations have produced an aggressive response and successful outcomes in Brazil, democratic openness and state-civil society engagement has not necessarily correlated with an aggressive response or better outcomes in the other cases. Response to the epidemic has been worst by far in democratic South Africa, followed by Russia, where in the former, denialism and antagonistic state-civil society relations fuelled a delayed response and proved extremely costly in terms of human lives. In Russia, a lack of civil societal opportunity for mobilization and non-governmental organization (NGO) growth, political centralization and the states unwillingness to work with NGOs led to an ineffective government response. Top-down bureaucratic rule and a reluctance to fully engage civil society in democratic India substantially delayed the states efforts to engage in a successful partnership with NGOs. Nevertheless, China has done surprisingly well, in spite of its repressive approach and narrow engagement with civil society. And in all cases, we find the relationship between state and civil society to be evolving over time in important ways. These findings suggest the need for more research on the links between democratic openness, political repression and policy responses to epidemics.

Emergence of multilateral proto-institutions in global health and new approaches to governance: analysis using path dependency and institutional theory

The role of multilateral donor agencies in global health is a new area of research, with limited research on how these agencies differ in terms of their governance arrangements, especially in relation to transparency, inclusiveness, accountability, and responsiveness to civil society. We argue that historical analysis of the origins of these agencies and their coalition formation processes can help to explain these differences. We propose an analytical approach that links the theoretical literature discussing institutional origins to path dependency and institutional theory relating to proto institutions in order to illustrate the differences in coalition formation processes that shape governance within four multilateral agencies involved in global health. We find that two new multilateral donor agencies that were created by a diverse coalition of state and non-state actors, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and GAVI, what we call proto-institutions, were more adaptive in strengthening their governance processes. This contrasts with two well-established multilateral donor agencies, such as the World Bank and the Asian Development Bank, what we call Bretton Woods (BW) institutions, which were created by nation states alone; and hence, have different origins and consequently different path dependent processes.

The effects of Global Fund financing on health governance in Brazil

ObjectivesThe impact of donors, such as national government (bi-lateral), private sector, and individual financial (philanthropic) contributions, on domestic health policies of developing nations has been the subject of scholarly discourse. Little is known, however, about the impact of global financial initiatives, such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria, on policies and health governance of countries receiving funding from such initiatives.MethodsThis study employs a qualitative methodological design based on a single case study: Brazil. Analysis at national, inter-governmental and community levels is based on in-depth interviews with the Global Fund and the Brazilian Ministry of Health and civil societal activists. Primary research is complemented with information from printed media, reports, journal articles, and books, which were used to deepen our analysis while providing supporting evidence.ResultsOur analysis suggests that in Brazil, Global Fund financing has helped to positively transform health governance at three tiers of analysis: the national-level, inter-governmental-level, and community-level. At the national-level, Global Fund financing has helped to increased political attention and commitment to relatively neglected diseases, such as tuberculosis, while harmonizing intra-bureaucratic relationships; at the inter-governmental-level, Global Fund financing has motivated the National Tuberculosis Programme to strengthen its ties with state and municipal health departments, and non-governmental organisations (NGOs); while at the community-level, the Global Fund’s financing of civil societal institutions has encouraged the emergence of new civic movements, participation, and the creation of new municipal participatory institutions designed to monitor the disbursement of funds for Global Fund grants.ConclusionsGlobal Fund financing can help deepen health governance at multiple levels. Future work will need to explore how the financing of civil society by the Global Fund and other donors influence policy agenda-setting and institutional innovations for increased civic participation in health governance and accountability to citizens.

Understanding the United States and Brazil's response to obesity: institutional conversion, policy reform, and the lessons learned

BackgroundIn the United States (US) and Brazil, obesity has emerged as a health epidemic. This article is driven by the following research questions: how did the US and Brazil’s federal institutions respond to obesity? And how did these responses affect policy implementation? The aim of this article is therefore to conduct a comparative case study analysis of how these nations’ institutions responded in order to determine the key lessons learned.MethodsThis study uses primary and secondary qualitative data to substantiate causal arguments and factual claims.ResultsBrazil shows that converting preexisting federal agencies working in primary healthcare to emphasize the provision of obesity prevention services can facilitate policy implementation, especially in rural areas. Brazil also reveals the importance of targeting federal grant support to the highest obesity prevalence areas and imposing grant conditionalities, while illustrating how the incorporation of social health movements into the bureaucracy facilitates the early adoption of nutrition and obesity policies. None of these reforms were pursued in the US.ConclusionsBrazil’s government has engaged in innovative institutional conversion processes aiding its ability to sustain its centralized influence when implementing obesity policy. The US government’s adoption of Brazil’s institutional innovations may help to strengthen its policy response.

Exploring the utility of institutional theory in analysing international health agency stasis and change.

Of recent interest is the capacity of international health agencies to adapt to changes in the global health environment and country needs. Yet, little is known about the potential benefits of using social science institutional theory, such as path dependency and institutional change theory, to explain why some international agencies, such as the WHO and the Global Fund to Fight AIDS, Tuberculosis and Malaria, fail to adapt, whereas others, such as the World Bank and UNAIDS, have. This article suggests that these institutional theories can help to better understand these differences in international agency adaptive capacity, while highlighting new areas of policy research and analysis.

Responding to Obesity in Brazil: Understanding the International and Domestic Politics of Policy Reform Through a Nested Analytic Approach to Comparative Analysis

Why do governments pursue obesity legislation? And is the case of Brazil unique compared with other nations when considering the politics of policy reform? Using a nested analytic approach to comparative research, I found that theoretical frameworks accounting for why nations implement obesity legislation were not supported with cross-national statistical evidence. I then turned to the case of Brazils response to obesity at three levels of government, national, urban, and rural, to propose alternative hypotheses for why nations pursue obesity policy. The case of Brazil suggests that the reasons that governments respond are different at these three levels. International forces, historical institutions, and social health movements were factors that prompted national government responses. At the urban and rural government levels, receiving federal financial assistance and human resource support appeared to be more important. The case of Brazil suggests that the international and domestic politics of responding to obesity are highly complex and that national and subnational political actors have different perceptions and interests when pursuing obesity legislation.

The Global and Domestic Politics of Health Policy in Emerging Nations

In recent years, several emerging nations with burgeoning economies and in transition to democracy have pursued health policy innovations. As these nations have integrated into the world economy through bilateral trade and diplomacy, they have also become increasingly exposed to international pressures and norms and focused on more effective, equitable health care systems. There are several lessons learned from the case studies of Brazil, Ghana, India, China, Vietnam, and Thailand in this special issue on the global and domestic politics of health policy in emerging nations. For the countries examined, although sensitive to international preferences, domestic governments preferred to implement policy on their own and at their own pace. During the policy-making and implementation process, international and domestic actors played different roles in health policy making vis-à-vis other reform actors -- at times the state played an intermediary role. In several countries, civil society also played a central role in designing and implementing policy at all levels of government. International institutions also have a number of mechanisms and strategies in their tool box to influence a countrys domestic health governance, and they use them, particularly in the context of an uncertain state or internal discordance within the state.

An Interdependent Analytic Approach to Explaining the Evolution of Ngos, Social Movements, and Biased Government Response to AIDS and Tuberculosis in Brazil

The politics of government response to health epidemics is a new area of scholarly research. Nevertheless, to date scholars have not considered how social science theory can be used and interdependently linked to provide a more thorough discussion of civil societal and national government response to different types of health epidemics. Introducing what I call an interdependent analytic framework of government response to epidemics, this article illustrates how social science theories can be interdependently linked and applied to help explain the evolutionary role of interest groups and social movements in response to AIDS and tuberculosis in Brazil, and when and why the government eventually responded more aggressively to AIDS but not tuberculosis. Evidence from Brazil suggests that the policy influence of interest groups and social movements evolves over time and is more influential after the national government implements new policies; moreover, this response is triggered by the rise of international pressures and government reputation building, not civil society. I highlight new areas of research that the framework provides and provide examples of how this approach can help explain civil societal and biased government responses to different types of epidemics in other nations.