Jesse B. Bump

Priority-Setting Institutions in Health: Recommendations from a Center for Global Development Working Group

The rationing problem is common to all health systems-the challenge of managing finite resources to address unlimited demand for services. In most low- and middle-income countries, rationing occurs as an ad hoc, haphazard series of nontransparent choices that reflect the competing interests of governments, donors, and other stakeholders. Yet in a growing number of countries, more explicit processes, with strengths and limitations, are under development that merit better support. Against this background, the purpose of the Center for Global Development Working Group, which is to examine how priorities are set currently, and to propose institutional arrangements that promote country ownership and improve health outcomes by more systematically managing this complex process of politics and economics, is discussed. Current global and national priority-setting practices in low- and middle-income countries, the potential for strengthened national institutions, and increased global support are reviewed. Recommendations for action are provided.

Partnership and promise: evolution of the African river-blindness campaigns.

Abstract This article describes the evolution of the partnership, between various health and developmental agencies, that has sustained the campaign against river blindness in Africa. The international community was oblivious to the devastating public-health and socio–economic consequences of onchocerciasis until towards the end of the 1960s and the beginning of the 1970s. Then a ‘Mission to West Africa’, supported by the United Nations Development Programme, and a visit to the sub-region by the president of the World Bank culminated, in 1974, in the inauguration of the Onchocerciasis Control Programme in West Africa (OCP). OCP was a landmark event for the World Bank as it represented its first ever direct investment in a public-health initiative. The resounding success of the OCP is a testimony to the power of the partnership which, with the advent of the Mectizan Donation Programme, was emboldened to extend the scope of its activities to encompass the remaining endemic regions of Africa outside the OCP area. The progress that has been made in consolidating the partnership is discussed in this article. The prospects of adapting the various strategies of the African Programme for Onchocerciasis Control, to entrench an integrated approach that couples strong regional co-ordination with empowerment of local communities and thereby address many other health problems, are also explored.

Political economy analysis for tobacco control in low- and middle-income countries

Tobacco is already the worlds leading cause of preventable death, claiming over 5 million lives annually, and this toll is rising. Even though effective tobacco control policies are well researched and widely disseminated, they remain largely unimplemented in most low- and middle-income countries (LMICs). For the most part, control attempts by advocates and government regulators have been frustrated by transnational tobacco companies (TTCs) and their supporters. One reason tobacco is so difficult to control is that its political economy has yet to be adequately understood and addressed. We conducted a review of the literature on tobacco control in LMICs using the databases PubMed, EconLit, PsychInfo and AGRICOLA. Among the over 2500 papers and reports we identified, very few explicitly applied political economy analysis to tobacco control in an LMIC setting. The vast majority of papers characterized important aspects of the tobacco epidemic, including who smokes, the effects of smoking on health, the effectiveness of advertising bans, and the activities of TTCs and their allies. But the political and economic dynamics of policy adoption and implementation were not discussed in any but a handful of papers. To help control advocates better understand and manage the process of policy implementation, we identify how political economy analysis would differ from the traditional public health approaches that dominate the literature. We focus on five important problem areas: information problems and the risks of smoking; the roles of domestic producers; multinational corporations and trade disputes in consumption; smuggling; the barriers to raising taxes and establishing spatial restrictions on smoking; and incentive conflicts between government branches. We conclude by discussing the political economy of tobacco and its implications for control strategies.

Implementing pro-poor universal health coverage.

Universal health coverage (UHC) - the availability of quality affordable health services for all when needed without financial impoverishment - can be a vehicle for improving equity health outcomes and financial wellbeing. It can also contribute to economic development. In its Global Health 2035 report the Lancet Commission on Investing in Health (CIH) set forth an ambitious investment framework for transforming global health through UHC. The CIH endorsed pro-poor pathways to UHC that provide access to services and financial protection to poor people from the beginning and that include people with low income in the design and development of UHC health financing and service provision mechanisms.

The Long Road to Universal Health Coverage: Historical Analysis of Early Decisions in Germany, the United Kingdom, and the United States

Abstract—Over the last several years the once-obscure idea of Universal Health Coverage (UHC) has blossomed into a movement embraced by leading authorities in global health. Both the World Bank and the World Health Organization have designated UHC as a core objective, but many details of this concept have yet to be specified, including the political economy process by which countries can increase financial protection to move toward UHC. Using an analysis of historical literature, this paper examines the development of the two common mechanisms for providing financial risk protection: national social health insurance as developed in Germany, and general tax revenue as used by the United Kingdom to launch the National Health Service. Because of the prominence of organized labor groups in demanding increased financial protection in these two cases, the paper then considers a comparison case from the Progressive Era in the United States where labor groups were far less engaged. Based on the categories used in the historical literature, I develop a framework for comparing the cases in six areas: related legal and cultural heritage; macro-historical conditions; demand for increased social protection; politics of expanding government role in health; financing and delivery systems; and UHC-related outcomes. The paper concludes with some reflections from this analysis for low- and middle-income countries attempting to move toward UHC.

A model for evaluating the sustainability of community‐directed treatment with ivermectin in the African Program for Onchocerciasis Control

Onchocerciasis is controlled by mass treatment of at-risk populations with ivermectin. Ivermectin is delivered through community-directed treatment (CDTI) approach. A model has been developed to evaluate the sustainability of the approach and has been tested at 35 projects in 10 countries of the African Program for Onchocerciasis Control (APOC). It incorporates quantitative and qualitative data collection and analysis, taking account of two factors identified as crucial to project sustainability. These are (i) the provision of project performance information to partners, and (ii) evidence-based support for project implementation. The model is designed to provide critical indicators of project performance of the model to implementing, coordinating, and funding partners. The models participatory and flexible nature makes it culturally sensitive and usable by project management. This model is able to analyze the different levels involved in project implementation and arrive at a judgment for the whole project. It has inbuilt mechanisms for ensuring data reliability and validity. The model addresses the complex issue of sustainability with a cross-sectional design focusing on how and at which operational level of implementation to strengthen a CDTI project. The unique attributes and limitations of the model for evaluating the sustainability of projects were described.

Can Trade Help Poor People? The Role of Trade, Trade Policy and Market Access in Tanzania

Many development economists prescribe trade as a poverty-reducing formula. But how is this elixir supposed to work? This article contributes to the lively debate on this topic with household evidence from Tanzania - a poor country even within sub-Saharan Africa, the poorest region. About 81% of the poor work in agriculture, which accounts for 88% of the export bundle. The article describes existing poverty and then evaluates the poverty-reduction potential of trade, trade policy and market access. The article extends the analysis by simulating tariff changes and four switching scenarios that swap some poor households into trade-related sectors, such as cash cropping or tourism, to project national poverty reductions of up to 5.6% and household income increases of up to 21.5%. Copyright 2007 Blackwell Publishing Ltd.

Accounting for Technical, Ethical, and Political Factors in Priority Setting

Abstract—This article investigates two cases of priority setting to explore how, in addition to technical considerations, ethical and political factors shape the allocation of health resources. First, we discuss how Thai authorities adjudicated a coverage decision for HLA-B*1502 screening, which meets the national cost-effectiveness threshold for only some of the conditions it can detect. Second, we consider Englands Cancer Drugs Fund to investigate the interplay of technical decision making and political reality. Our findings suggest four concluding observations for policy makers and others considering priority-setting processes. First, we observe that different methods can produce conflicting recommendations, which makes priority setting very complex. Second, we suggest that robust processes for generating and weighing political, ethical, and technical evidence are essential because there is no absolute standard by which resource allocation decisions can be made. Third, priority setting is inherently political, and improving its technical and ethical validity means constructing political importance for these other factors. Fourth, we argue that transparency in the trade-offs required to set priorities is important ethically and can help build support politically.

Political Strategies for Health Reform in Turkey: Extending Veto Point Theory

Abstract—This qualitative case study uses primary interview data to investigate the political processes of how Turkey established a unified and universal health coverage system. The goal of providing health coverage to all citizens through a unified system has been adopted by many low- and middle-income countries, but few have achieved it; Turkey is a notable exception. We use institutional veto point theory to identify four institutional obstacles to a unified and universal coverage system in Turkey between 2003 and 2008: (1) the Ministry of Finance and Treasury, (2) the Ministry of Labor and Social Security, (3) the Office of the President, and (4) the Constitutional Court. Our analysis shows how Minister of Health Recep Akdağ and his team of advisors used political strategies to address and overcome opposition at each veto point. Where possible they avoided institutional veto points by using ministerial authority to adopt policies. When adoption required approval of others with veto power, they delayed putting forward legislation while working to facilitate institutional change to remove opposition; persuaded or made strategic compromises to gain support; or overpowered opposition by calling on the prime minister to intervene. Our findings propose an extension to institutional veto point theory by showing how the exercise of political strategies can overcome opposition at institutional veto points to facilitate policy adoption.

Your Call Could Not Be Completed as Dialled: Why Truth Does Not Speak to Power in Global Health; Comment on 'Knowledge, Moral Claims and the Exercise of Power in Global Health'

This article contends that legitimacy in the exercise of power comes from the consent of those subject to it. In global health, this implies that the participation of poor country citizens is required for the legitimacy of major actors and institutions. But a review of institutions and processes suggests that this participation is limited or absent. Particularly because of the complex political economy of non-communicable diseases, this participation is essential to the future advancement of global health and the legitimacy of its institutions. More analysis of power and legitimacy provides one entry point for fostering progress.