Owain David Williams

Frames, Paradigms and Power: Global Health Policy-Making under Neoliberalism

The study of global health governance has developed rapidly over recent years. That literature has identified a range of factors which help explain the “failure” of global health governance, but it has largely neglected the global public policy processes which perpetuate that failure. In this paper we argue that there is such a thing as “global health policy” and set out a new framework for analyzing the processes through which it is made, highlighting the mixture of power and ideas, agency and structure, which impact upon the policy cycle. The framework rests upon four pillars: framing; paradigms; power; and the “deep core” of neoliberalism. Through integrating insights from a range of literatures, in particular from the global health governance and public policy analysis fields, we seek to enrich the conceptual basis of current work on global health governance.

Framing global health: The governance challenge

Abstract With the emergence of global health comes governance challenges which are equally global in nature. This article identifies some of the initial limitations in analyses of global health governance (GHG) before discussing the focus of this special supplement: the framing of global health issues and the manner in which this impacts upon GHG. Whilst not denying the importance of material factors (such as resources and institutional competencies), the article identifies how issues can be framed in different ways, thereby creating particular pathways of response which in turn affect the potential for and nature of GHG. It also identifies and discusses the key frames operating in global health: evidence-based medicine, human rights, security, economics and development.

Global Health Governance: Crisis, Institutions and Political Economy

Acknowledgements Notes on Contributors Introduction: The International Political Economy of Global Health Governance A.Kay & O.Williams PART I: THE POLITICS OF GLOBAL HEALTH GOVERNANCE Understandings of Global Health Governance: The Contested Landscape K.Lee National Security and Global Health Governance C.McInnes Global Governance Capacities in Health: WHO and Infectious Diseases S.Rushton The International Political Economy of Global Responses to HIV/AIDS A.Ingram Chronic Diseases and Global Health Governance: The Contrasting Cases of Food and Tobacco S.Barraclough PART II: THE ECONOMY OF GLOBAL HEALTH GOVERNANCE Unpacking Economism and Remapping the Terrain of Global Health M.Sparke The Power of Money: Global Financial Markets, National Politics, and Social Determinants of Health T.Schrecker Trade and Health R.Labonte, C.Blouin & L.Forman IMF Policies and Health in Sub-Saharan Africa R.P.Buckley & J.Baker The World Bank and Health S.Harman The Competition State and the Private Control of Health Care H.Lofgren Index

Introduction: The International Political Economy of Global Health Governance

In this chapter we seek to provide an overarching theoretical and conceptual framework for the analysis of global health and contemporary global health governance by means of an international political economy (IPE) approach. The chapter, and indeed this volume, is the first major attempt to generate an IPE of global health governance, wherein explanations of contemporary crises in global health and the contested space of global health policies are explicitly rooted in IPE. We seek to offer a corrective to what is a striking poverty of IPE approaches to this fundamental area of globality and human life, an absence which has persisted despite the almost routine linkage of new disease patterns and resource scarcity in healthcare with key features of globalisation (Fidler, 2001 and 2004; Lee et al., 2002). Works on global health governance regularly footnote the centrality of economic globalisation, including how such factors as increased volumes of international trade, investment and finance are having direct and indirect effects on human health, not least in the more rapid transmission of infectious diseases resulting from trade flows and spatial compression. Similarly, and in political terms, scholars and health policy communities are increasingly sensitive to the fact that global health governance is also changing (and has arguably changed from a system of ‘international’ health governance) because of the increasing influence of a range of International Organisations (IOs) and economic actors with little or no previous health remit (Brown et al., 2006).

New life in old frames: HIV, development and the 'AIDS plus MDGs' approach

Abstract There have been recent indications that the primacy of AIDS among global health issues may be under threat. In this article we examine one response to have emerged from the AIDS policy community as a result of this perceived threat: the ‘AIDS plus Millennium Development Goals (MDGs)’ approach, which argues that the AIDS response (the focus of MDG6) is essential to achieving the other MDG targets by 2015, stressing the two-way relationship between AIDS and other development issues. By framing AIDS in this way, the AIDS plus MDGs approach draws on an established narrative of a ‘virtuous circle’ between health and development, but at the same time makes some important concessions to critics of the AIDS response. This article – the first critical academic analysis of the AIDS plus MDGs approach – uses this case to illuminate aspects of the utilisation of framing in global health, shedding light both on the extent to which new framings draw upon established ‘common sense’ narratives as well as the ways in which framers must adapt to the changing material and ideational context in which they operate.

Private actors in global health governance

The landscape of global health governance has undergone a radical transformation. Perhaps the most striking change has been the rise of private actors and their incorporation into what was previously a publicly dominated governance system. Their rise to prominence in global health has brought many benefits, not least in the vast resources that they have harnessed for addressing key global health problems. Yet they have attracted criticism as well as praise. The fact that there have often been heated debates surrounding the roles of global health partnerships (GHPs) and philanthropic foundations is testament to the simple fact that something fundamental has taken place in the field of global health. In a relatively short period of time, beginning in the mid-1990s, these actors have revolutionised the health governance architecture to an extent that the wider international system has not witnessed since the creation of the modern multilateral system, in the aftermath of the Second World War. In contrast to those earlier seismic shifts in international governance, the entrance of private actors in global health governance has not been the result of a carefully planned process. There has been no equivalent of the San Francisco or Bretton Woods Conferences. Rather, the change in global health governance has been a gradual and often ad hoc process. There are no clear lines of authority, either politically or legally. Mandates often overlap and compete. Traditional governance actors, from states to the World Health Organization (WHO), have been forced to adapt to this new reality.

The transformation of global health governance

The authors examine how health governance is being transformed amid globalization, characterized by the emergence of new actors and institutions, and the interplay of competing ideas about global health. They explore how this has affected the governance of specific health issues and how it relates to global governance more broadly.

The new political economy of pharmaceuticals : production, innovation and trips in the global south

1. The New Political Economy of Pharmaceuticals: Conformity and Resistance in the Global South Owain David Williams and Hans Lofgren 2. The Political Economy of Pharmaceutical Production in Brazil Cassandra M. Sweet 3. Pharmaceuticals, Health Policy and Intellectual Property Rights in China Chee-Ruey Hsieh 4. Immunity to TRIPS? Vaccine Production and the Biotechnology Industry in Cuba Jens Plahte and Simon Reid-Henry 5. TRIPS and Access to Medicines in Egypt Dina Iskander 6. The Pharmaceutical Industry in India after TRIPS Sudip Chaudhuri 7. The Health Care System and the Pharmaceutical Industry in Indonesia Richard Husada and Raymond R. Tjandrawinata 8. TRIPS, Free Trade Agreements and the Pharmaceutical Industry in Malaysia Mohamed Azmi Hassali, Jayabalan Thambyappa, Shankaran Nambiar and Asrul Akmal Shafie 9. The Pharmaceutical Industry, Intellectual Property Rights and Access to Medicines in Pakistan: Zaheer-Ud-Din Babar, Shazia Jamshed, Ashar Malik and Anwarul-Hassan Gilani 10. TRIPS, Access to Medicines and Local Production in South Africa Andrew L. Gray and Yousuf A. Vawda 11. TRIPS and New Challenges for the Pharmaceutical Sector in South Korea Bong-min Yang and Hye-young Kwon 12. Intellectual Property Rights and Neoliberal Restructuring in Turkey: The Pharmaceutical Industry Ipek Eren Vural 13. Conclusion: TRIPS, Drug Production in the Global South, and Access to Medicines Hans Lofgren and Owain David Williams

Successes and challenges of the millennium development goals in Ethiopia: lessons for the sustainable development goals

We analysed the performance of Ethiopia in achieving the health-related millennium development goals (MDGs) with the aim of acquiring lessons for the sustainable development goals (SDGs). Ethiopia achieved most of the health MDGs: a 67% reduction in under-five mortality, a 71% decline in maternal mortality ratio, a 90% decline in new HIV infections, a decrease in malaria-related deaths by 73% and a more than 50% decline in mortality due to tuberculosis. We argue that these achievements are due to implementation of a mix of comprehensive strategies within the health system and across other sectors of the government. Scaling up of interventions by disease control programmes (including the health extension programme) and strengthening of the health system have played important roles towards the achievements. These health gains could not have been realised without progress in the other MDGs: poverty reduction, education, access to safe drinking-water and peace and stability of the country. However, the gains were not equitable, with differences between urban and rural areas, among regions and socioeconomic strata. Ethiopias remarkable success in meeting most of the targets of the health-related MDGs could be explained by its comprehensive and multisectoral approach for health development. The inequity gap remains a challenge that achieving the health-related SDGs requires the country to implement strategies, which specifically target more marginal populations and geographic areas. This also needs peace and stability, without which it is almost impossible to improve health.

Could international compulsory licensing reconcile tiered pricing of pharmaceuticals with the right to health

BackgroundThe heads of the Global Fund and the GAVI Alliance have recently promoted the idea of an international tiered pricing framework for medicines, despite objections from civil society groups who fear that this would reduce the leeway for compulsory licenses and generic competition. This paper explores the extent to which an international tiered pricing framework and the present leeway for compulsory licensing can be reconciled, using the perspective of the right to health as defined in international human rights law.DiscussionWe explore the practical feasibility of an international tiered pricing and compulsory licensing framework governed by the World Health Organization. We use two simple benchmarks to compare the relative affordability of medicines for governments – average income and burden of disease – to illustrate how voluntary tiered pricing practice fails to make medicines affordable enough for low and middle income countries (if compared with the financial burden of the same medicines for high income countries), and when and where international compulsory licenses should be issued in order to allow governments to comply with their obligations to realize the right to health.SummaryAn international tiered pricing and compulsory licensing framework based on average income and burden of disease could ease the tension between governments’ human rights obligation to provide medicines and governments’ trade obligation to comply with the Agreement on Trade-Related Aspects of Intellectual Property Rights.