When Do Governments Support Common Goods for Health? Four Cases on Surveillance, Traffic Congestion, Road Safety, and Air Pollution

Abstract

Common goods such as air, water, climate, and other resources shared by all humanity are under increasing pressure from growing population and advancing globalization of the world economy. Safeguarding these resources is generally considered a government responsibility, as common goods are vulnerable to market failure. However, governments do not always fulfill this role, and face many challenges in doing so. This observation—that governments only sometimes address common goods problems—informs the central question of this paper: when do governments act in support of common goods? We structure our inquiry using a framework derived from three theories of agenda setting, emphasizing problem perception, the role of actors and collective action patterns, strategies and policies, and catalyzing circumstances. We used a poll of experts to identify important common goods for health: disease surveillance, environmental protection, and accountability. We then chose four historical cases for analysis: the establishment of the Epidemic Intelligence Service in the US, transport planning in London, road safety in Argentina, and air quality control in urban India. Our analysis of the collective evidence of these cases suggests that decisions to advance government action on common goods require a concisely articulated problem, a well-defined strategy for addressing the problem, and leadership backed by at least a few important groups willing to cooperate. Our cases reveal a variety of collective action patterns, suggesting that there are many routes to success. We consider that the timing of an intervention in support of common goods depends on favorable circumstances, which can include a catalyzing event but does not necessarily require one.

Keywords:

• collective action
• common goods
• global health history
• government failure
• public health

Introduction

Air, water, climate, and other resources shared by all humanity are under increasing pressure from growing population and advancing globalization of the world economy. Despite their necessity for all human life, actions to safeguard these resources are inadequate. For instance, air pollution is now the fourth largest threat to human health, with deleterious effects for individuals and societies including respiratory infections, lung cancer, and heightened cardiovascular disease risks.¹ The stewardship of air and other common goods for heath (CGH) is essential to wellbeing and development. As defined in this special issue, CGH are population-based functions or interventions that contribute to the health and economic progress and require public financing either because they are susceptible to market failure—that is, they are public goods—or they have large externalities.

Despite their importance, acting in support of common goods is difficult. Individuals and private actors generally cannot coordinate to protect common goods. At the dawn of modern economic thought in the late 1700s, Adam Smith argued that the responsibility for the best societal outcomes is held by the “invisible hand,” or free market forces.^2-4 However, the early days of the Industrial Revolution soon exposed the inability of markets to safeguard common goods. With reference to shared grazing areas, the now well-known term “tragedy of the commons” was developed in the 1830s to explain how individuals have incentives to increase their herds, leading to the destruction of the shared resource.⁵ This line of inquiry led in the nineteenth century to the conceptualization of “market failure” to indicate important societal objectives that cannot be achieved through markets,^6,7 although that term was not used until the 1950s.⁸

In economic and political thought, the idea of market failure became a major justification for government, which can rectify markets through regulation, taxation, and other interventions, and is therefore better able to manage CGH.⁹ However, governments are susceptible to many of the same failures as markets. For example, both face allocation problems, which are challenging for governments because revenues and costs are disconnected.^10,11 Also, “government failure” can mean that some or all of the government may act in self-interest, such as via corruption or rent seeking, and thus does not perform its public duties.¹²

In addition to standard problems of government failure, governments face other challenges in addressing CGH. As observed in many areas of preparedness and prevention, the political incentives for stewardship are much weaker than those for responding to issues more readily perceived as urgent.^13,14 Many CGH are underpinned by challenging collective action problems,¹⁵ meaning that their solutions require the cooperation of multiple groups. Additionally, many CGH must be managed across various levels and sectors of government, which can raise many within-government coordination and accountability issues.¹⁶ Some of the challenges applicable to CGH were partially articulated by the World Bank in its 2004 World Development Report, which characterized “short” and “long” routes to accountability. The more direct—“short”—routes between people and providers could be considered as market transactions. These do not apply to CGH, as they are defined by market failures. The “long” routes involve appeals to political processes by citizens and then governments’ use of policy, regulatory, and financing authority over the private sector. Action on CGH involves these less certain “long” routes, which are susceptible to government failure and other problems.¹⁷

In spite of many challenges, at times governments do act in support of CGH, as when they implement universal vaccination programs, communicable disease control programs, and many other public health efforts, for instance. This observation motivated us to examine the conditions under which governments decide to intervene in CGH. To generate hypotheses about these occurrences, we decided to analyze historical cases, believing that different examples might help us understand their common themes. Choosing historical cases—ours date from the mid-20th century to the present—allows us to assess action on CGH on a long timescale; this matches the extended periods required to bring the need for CGH management to public attention. Additionally, historical cases allow us to interrogate various influential contextual factors that may be less apparent in contemporary examples.

In this paper, we begin by examining relevant theories, deriving a framework for analysis, and discussing our case selection process. We then turn to analyses of the four cases: the establishment of the Epidemic Intelligence Service in the US, transport planning in London, air quality improvement in urban India, and road safety efforts in Argentina, and air quality improvement in urban India. Following presentations of the cases, we discuss their common themes to suggest conditions under which governments act on CGH. We conclude with some synthetic observations and their implications for advocates seeking to promote government action on CGH.

Agenda Setting Theories

To guide our investigation of government action on CGH, we turned to the literature on agenda setting. This sub-field of political science examines how issues ascend on the policy agenda. At its core, agenda setting theory understands government processes as products of competitive influences, reflecting contests between different actors seeking to advance their issues and interests. This view emphasizes the politics of perception, public support, and interest groups, to explain why some issues and actors triumph over others. We reasoned that insights into how issues become politically salient and theories about the structure of the process would help us identify the most important elements of the historical cases of government decisions on CGH. Also, we felt that the competitive lens used in agenda setting would help explain decisions, whether positive or negative.

We considered drawing primary theoretical support from the literature on government failure but we found it less intuitive for our purposes. This literature seeks to explain why governments do not achieve their aims, or do not do so efficiently. Applied to common goods, this implies a normative position that governmental aims should include protecting common goods. We strongly support this position in general, but we felt it was not a helpful presumption for investigating our main questions, which concern how and when governments decide to support common goods, as opposed to why they should do so. Also, for the purposes of our inquiry, we did not want to disconnect the normative issues from the political processes that adjudicate government actions. Nonetheless, we note that the government failure literature identifies explanations that are compatible with those we find in agenda setting, although from a negative perspective. For example, governments would provide support for common goods but they have difficulty because of uncertain accountabilities, limited incentives, and weak feedback from performance to rewards. In this context, rent-seeking and corruption are more likely. In general, governments do not invest in CGH because the harms are dispersed and they lack political salience.

Perhaps the most widely applied agenda setting theory in global health has been John Kingdon’s, which focuses on the “streams” of problems, politics, and policies.¹⁸ The problem stream assesses how some issues become perceived as important and urgent. The politics stream focuses on the struggles among specialists to advance their preferred solutions as possible policies. The policy stream refers to the contests between competing policies, which is often a process dominated by interest groups that stand to benefit from particular policy options. According to Kingdon’s theory, when any two of the three streams are well-defined and combine during a window of opportunity, an issue can reach the policy agenda. This theory of agenda setting was informed by research on the US Commerce Department conducted in the 1980s, and accordingly reflects democratic change, government stability, and leadership by policy makers.

Common goods are characterized by collective action challenges involving competing interests and non-democratic power dynamics, which is not completely aligned with processes and institutions that inform Kingdon’s model. To capture how policies may be advanced based on the interests of a few influential groups operating in relative isolation from democratic mechanisms, we also considered the theory of the power elite, first proposed by Mills in the 1950s.¹⁹ The “power elite” include prominent families, rich business people, leading corporate executives, the most senior military officers, top executives in government, and other famous people.²⁰ In the power elite model, agendas are set according to how the interests of these groups align.

Finally, we also consulted punctuated equilibrium theory advanced by Baumgartner and colleagues since the 1990s, which holds that long periods of incremental change (“policy stasis”) are interrupted by sudden shifts, or “punctuations.”^21-23 This happens because bureaucracies have limited decision space and cannot always advance policy as rapidly as societal changes can occur. As the divergence between society and policy reaches a tipping point, long periods of stability or incremental change are punctuated by major changes. Punctuated equilibrium highlights both the limited decision space of normal policy making and the potential for episodic large shifts. We reasoned that these elements could be germane to decisions on CGH, some of which require large changes in policy.

To develop our categories of analysis, we compared the primary elements of these theories, beginning with Kingdon’s streams model, which we believe to be the most commonly used for analyzing agenda setting. We then adapted its categories to incorporate elements of the other theories. As our final step, we applied each category to one element of decision-making on CGH, thereby producing four categories for analyzing historical case evidence. “Perceptions of CGH problems” includes how influential individuals and institutions view CGH issues (such as their urgency or their importance relative to other potential policy issues). The “role of engaged actors and their willingness to collaborate for CGH” assesses the alignment of stakeholders, interest groups, or other actors. “Strategies for addressing CGH problems” refers to the possible policy choices under discussion. “Catalyzing circumstances” refers to contextual factors or events that bring attention to CGH issues. The results of this exercise are shown in Table 1. We used these categories to organize and assess the evidence in our cases. We then employed these categories to compare the cases to make synthetic observations and draw conclusions.

TABLE 1. Framework for Analyzing Agenda-setting Processes

Three Streams	Power Elite	Punctuated Equilibrium	Major Categories	Our Framework for Analyzing CGH Decisions
Problem	Various interests of elite groups	Issue definition	Problem and perception	Perception of CGH problems
Politics	Distribution of power among elite	Divergence of circumstances from institutional bounded decision space	Actors	Role of engaged actors and willingness to collaborate for CGH
Policy	Interaction of power groups	Interaction of political institutions and bounded decision-making	Solutions	Strategies and policies for CGH
Window of Opportunity	Conditions for alliances	Conditions for rapid change	Historical & Political Context	Catalyzing circumstances

Sources: Refs. 18–22.

Cases Selection and Methods

Each of the four cases for analysis concerns a different CGH and a different national context: disease surveillance in the United States, transport planning in the United Kingdom, road safety legislation in Argentina, and air quality improvement in India.

We chose the cases using the following process. As a starting point, we had conducted a poll of the members of the World Health Organization’s technical expert group on Financing Common Goods for Health (JBB and AS are members). The web-based poll was conducted during a technical expert group meeting to help the group understand the range of opinions on which CGH were believed to be most important. Each member entered three free-text responses, all of which were then reviewed by the full group and placed in general categories. The leading areas of concern identified by members were surveillance and environmental issues; after those there was little consensus on specific common goods. Later we decided to use these results to guide this article. To reflect the concern for surveillance, we chose the establishment of the US Centers for Disease Control and Prevention and its Epidemic Intelligence Service, the world’s leading surveillance program. This example was selected to illuminate some dynamics about the historical decision to provide this CGH. To reflect the many concerns for environment-linked CGH, we looked for recent examples that would reveal variation in outcome, including cases where actions were or were not taken. We narrowed our focus to urban issues because they are common around the world and we believed that would help us identify cases with some common characteristics. We then chose India as a case for analysis because air pollution in several cities has made international headlines but not yet provoked a solution. As a comparison case with a positive outcome we chose transport planning and the adoption of congestion charges in London. The third-most frequently mentioned issue by technical expert group members was accountability, which is extremely important but is not specific or unique to a single issue area. We began identifying possible cases in which responsibility is unclear but accountabilities are enforced, reasoning that more complex cases would reveal more about the challenges of CGH. We chose road safety as an area of analysis in which the responsibilities themselves are uncertain—vehicle manufacturers, those who build and maintain road infrastructure, those who make or enforce traffic laws, and drivers themselves all share responsibility in degrees that are open to debate. We selected the case of Argentina for analysis because there had been major road safety improvements there in the relatively recent past.

Following the selection of our cases, we searched the internet via Google and Google Scholar using keywords related to our examples. We searched with English-language terms in all cases and also Spanish-language terms for the Argentine case. We reviewed the citations in those publications we found most helpful to identify more sources. We repeated the searches using additional keywords, such as the names of organizations and individuals, as our research unfolded. We searched the websites of relevant institutions to identify grey literature and used Google’s news filter to find news accounts. We used the literature we collected this way to build a narrative account of each case, guided by our categories for analysis to review sources and present each case. Once we had initial drafts of the narratives, we reviewed the evidence in each case, assessed our confidence in its sources, and conducted additional research until we believed we had identified the main elements germane to each decision on CGH. With the four cases completed, we reviewed the main themes to identify how each CGH decision had unfolded and synthesize common factors to inform our discussion and conclusions.

In our analysis of the cases, we pay particular attention to how collective action emerged in the category on actors and their willingness to collaborate on CGH. We define collective action as the collaboration of groups or individuals toward outcomes they cannot achieve independently. We reasoned that understanding patterns of collective action might be useful in identifying the impetus for a positive decision on CGH and why action was not taken in other cases. For this categorization, we used the common typology of outside-initiation, inside-initiation, mobilization, and consolidation.^24,25 Outside-initiation relates to how social actors in combination with public support can force governments to act. Inside-initiation relates to how actors with vested interests and direct access to government can influence the agenda without the public. Mobilization refers to generating public buy-in and support after agendas have been set. Consolidation refers to action undertaken by the government on issues with existing public support. In interpreting our cases, we use these categories to characterize the collective action observed around government decisions for CGH.

We recognize several important limitations to our approach. First, four cases drawn from different times and settings are a reasonable basis for hypothesizing but inadequate for making definitive claims. Second, our analysis rests largely on secondary sources. It is possible we would reach different interpretations if we consulted more primary materials. Third, beyond the methods we used, we were unable to identify any consensus on which CGH would be the best subject for our analysis. It is possible that the ones we chose do not share many similarities with other CGH. It is also possible that historical evidence has limited applicability for understanding current dynamics around present-day decisions on these or other common goods.

CGH Cases for Analysis

Case 1: Disease Surveillance, United States

Surveillance is both fundamental to disease control and an extremely important CGH that suffers from chronic under-investment.^26,27 To assess a positive example of government decision-making in this area, we investigated the establishment of the Centers for Disease Control and Prevention (CDC; at the time the Communicable Diseases Center) and its surveillance arm, the Epidemic Intelligence Service. The development of this surveillance capacity is linked with growing appreciation of two key threats to US military and strategic interests in the early and mid-20th century: malaria and the possibility of biowarfare.

The humid, swampy southern US had long been plagued by endemic malaria,²⁸ but as the American military expanded during World War I, the interwar period, and World War II, the disease took on new strategic importance for national security. By 1942, early in World War II, there were over 600 military bases and critical wartime industrial centers in the South, and all those stationed at them were at risk of malaria.²⁹ Additionally, the widespread adoption of automobiles provided ready—if unintended—transportation for the vector, mosquitoes. This expansion of mosquitoes’ effective flight range meant that mosquito control was required within a 30-mile radius of each strategic site, compared with the one-mile radius that sufficed in World War I.²⁹

In 1942, the US government created the Malaria Control in War Areas (MCWA) program, which focused on larviciding mosquito breeding grounds and entomological surveillance to monitor disease transmission risks.³⁰ At its peak late in the war, MCWA operations covered nearly 2,200 areas of military importance in 19 states.³⁰ As the war wound down, MCWA’s leadership stressed to Congress the importance of maintaining malaria control and related activities indefinitely.³¹ In 1946 the Communicable Disease Center was established in Atlanta to continue anti-malaria works.³²

As interest in malaria waned thanks to the control efforts, perception of the need for continued epidemic surveillance, and thus the fate of the CDC, came into question. Established government bodies with responsibilities for disease surveillance and management, including the National Institutes of Health and the Public Health Service, were not receptive to the CDC, bridling at its newcomer status and disapproving of its tendency to override the authority of the older bodies.²⁹ However, the Army’s chief malariologist, Dr. Justin Andrews, believed that the CDC, which was a stronghold for the malariology profession, remained relevant and needed more trained personnel.

In 1949 CDC recruited Alexander Langmuir, an epidemiologist who had worked in public health in New York State and with the US Army during the war.³³ Langmuir believed that controlling infectious disease was a matter of laboratory surveillance and field work to detect problems and trace their sources, which stood in some contrast to the entomological and broader environmental focus of CDC’s malaria work.³⁴ Langmuir faced various challenges in building support for extending epidemiological surveillance beyond the CDC’s traditional focus on malaria. In particular, there were too few adequately trained people available—there were not many to begin with and most went to work at National Institute of Health.³⁵ Langmuir employed a technical approach to build the perception of CDC’s importance. He began requiring laboratory confirmation of all malaria cases—the more rigorous methods revealed that malaria was disappearing from the US. Citing this success, Langmuir argued for more generalized surveillance capacity, emphasizing the ongoing threats of other infectious diseases and also raising the specter of biological attack to further make his point.³⁶

Langmuir’s strategy gained further traction as the Cold War made these concerns even more relevant to US national priorities and those of influential stakeholders within the government. In December 1949, the National Security Resources Board emphasized the importance of preparing for biological and other enemy attacks, and the Truman administration was eager to fund military readiness, including disease surveillance, as a matter of national defense.³⁷ Public awareness initiatives by the Federal Civil Defense Administration further stoked fears of biological attack, and this, in turn, instigated public support for investment in surveillance.³⁸ The outbreak of the Korean War in mid-1950 provided a catalyzing factor that further heightened perceptions of biowarfare risk. As a result of these pressures, the Epidemic Intelligence Service (EIS) was established in 1951, charged with disease surveillance nationally and in areas of US interest internationally.³⁵

We interpret the establishment of the EIS as a reflection of leadership by Langmuir, with the patronage of the Truman administration, thereby reflecting an outside-initiation process. The Cold War context and popular support, fostered by mobilization from the government, helped legitimize Langmuir’s ideas. The June 1950 commencement of hostilities in Korea lent urgency and immediacy to the perceived need for surveillance capacity. Finally, outbreaks of several epidemics early in its existence showcased the EIS’s capacities, further strengthening its legitimacy in identifying and containing disease outbreaks.

Case 2: Transport Planning, London, United Kingdom

Traffic regulation is an important function of national and urban government with significant implications for economic activity, environmental pollution, public safety, health, and quality of life.^39,40 However, traffic regulation is very challenging. It has a long history involving competing economic and political interests, as well as complex conflicts between entitlements to use public roads and the need to reconcile demand and capacity.^41-45 We focused on the 2003 introduction of a congestion charge in central London as one of the largest and most successful government-led initiatives to reduce traffic.

By the turn of the 21st century, London was “suffering from the worst congestion in the United Kingdom,”^46(p1) with the costs of added commuting time estimated between £2 and £4 million per week.⁴⁶ On an average workday morning, more than one million people entered central London between 7:00 AM and 10:00 AM.^39(p157) Beyond the economic costs, the public also perceived congestion as a major quality-of-life concern. An independent survey in 1999 showed that London residents considered transport and congestion as the two “most important problems” and 90% felt “there is too much traffic in London.”^39(p157)

These were long-standing issues, as was the perception that transport planning was needed. In 1964, the Smeed Report concluded that a congestion charge would be a sensible approach to reducing London traffic.^39(p158) Thirty-one years later, in 1995, the London Congestion Research Program reached the same conclusion, as did the 2000 Review of Charging Options for London. These reports provided evidence for use by policy makers. All three considered a variety of congestion charge schemes, and all concluded in favor of “road pricing.” Despite this consensus, the political process of introducing congestion charges was difficult.

Opposition was present on many fronts, including from automobile companies such as Porsche and Land Rover—the latter commissioned a report claiming a congestion charge could actually increase pollution and traffic.^47,48 London mayoral candidates supported by the Conservative Party questioned the organizational and technological capacities needed to implement a charge, and expressed skepticism about its potential to reduce traffic or pollution.⁴⁹ Additionally, many central London inhabitants feared increased costs and inconvenience, and shop owners opposed the charge claiming their businesses risked losing revenue.^47-50 Various protests prevented the government from enacting its plans for different pricing levels and including the London Ringway roads in the charging zones.^39(p174) Although opposition to the proposed charge existed, the issue of congestion and its economic and social implications were well established and the public recognized the large problems associated with congestion.

Plans and options for congestion charges in central London were debated further during the administration of Ken Livingstone, who was elected Mayor of London in 2000. Livingstone’s platform had included a commitment to introduce congestion charging. To address opposition and distrust, Livingstone used a four-fold strategy. First, he assumed personal responsibility for the results; second, he defined a short evaluation period to determine whether the charges were effective.⁵¹ Third, Livingstone blunted popular discontent by holding an 18-month public consultation to identify charges acceptable to most people and gather input on the area to be included.^39(p159) Finally, in the months before the charge was introduced, he initiated a campaign to inform Londoners and visitors of the coming charge.⁵² A £5.00 charge for entry into the congestion zone ultimately went into effect in early 2003.

The charge reduced traffic congestion and increased public transport use immediately. Pollution and road accidents were reduced as well. The most recent iteration of the charge (updated in 2017), which accounts for toxicity and carbon dioxide emissions, is approximately £11.50 per day per vehicle, with variation by vehicle type.⁵³

The establishment of the congestion charge reflected political leadership by Livingstone, who drew on long-simmering popular discontent with London’s traffic. We were not able to identify any additional catalyzing factors. We note that a change in administration does create some flexibility in the policy agenda, but this is the case after every election. We therefore interpret the introduction of the charge as an inside-initiation reflecting primary leadership from within the government.

Case 3: Road Safety Legislation, Argentina

Road traffic injuries are a major global public health problem,^54,55 accounting for about 30% of all injury deaths.⁵⁶ As such, road safety is a critical area for intervention by governments, involving coordination problems, regulatory challenges, and unclear accountabilities among drivers, those who build and maintain roads, vehicle manufacturers, law enforcement authorities, and others. We considered road safety to be an important common good for further investigation because of the complexity of these factors and the significance of injuries attributable to inadequate intervention. We selected a recent positive decision in Argentina for our third case.

Road safety in Argentina had been recognized as needing government action by several actors over recent decades. In the 1990s, national civil society organizations and groups representing victims of traffic accidents and their families organized to collectively demand government intervention. Over the past 15 years, traffic injuries have also received global attention from organizations such as the World Bank and the World Health Organization.⁵⁷ Calls for stronger government action on road safety have been issued at the World Health Assembly and via various UN resolutions.^58-64

Argentina’s government had been receptive to these demands. In 1995, after a significant increase in traffic-related deaths, the National Traffic Act was passed to “establish a common code of traffic and safety legislation across all provinces.”^65(p125) However, it largely failed in Argentina’s decentralized system due to inadequate coordination and oversight of enforcement.^65,66 Successful government action was not achieved until 2008, when the Federal Agreement on Traffic and Road Safety Law was passed. The goal of this legislation was to reduce mortality from traffic accidents and strengthen institutional capacity to coordinate road safety programs.⁶⁵ A key improvement in the 2008 law as compared with the 1995 act was the establishment of the National Road Safety Agency (ANSV in Spanish) empowered with both regulatory and coordination authority. In combination with a secure stream of funding from international agencies including the World Bank, this agency was able to sustain political commitment to road safety.⁶⁵

Impetus for the 2008 legislation creating the ANSV included several disasters, which can be interpreted as catalyzing events. In 1999, nongovernmental organizations that had been advocating for road safety legislation for years had received front-page coverage for their new seatbelt campaign.⁶⁷ This was by happenstance: then-President Raul Alfonsín was involved in a near-fatal crash and had not been wearing a seatbelt. A turning point came in 2006 when a drunk truck driver collided with a school bus in Santa Fe, killing nine children and a teacher. The horrific Santa Fe accident received extensive media coverage, and victims and their families used the incident to mobilize political support among policy makers.⁶⁵ The accident has been commemorated with an annual national day of student solidarity used by advocates as an occasion to pressure government officials for more stringent road legislation.

The Santa Fe crash coincided with efforts by the National Ombudsman to bring attention to the need for road traffic legislation and call for a national road safety coordinating agency. In 2005, the Ombudsman, together with 14 civil society organizations and the World Health Organization, had released a report that exposed the “high social costs of traffic crashes” and the “failure of the state to effectively regulate safety.”^65(p125) After the Santa Fe accident, the Ombudsman and several organizations launched a campaign in 2007 that framed road safety as a human rights issue and added further support for legislative and institutional reform.

Victims’ groups gained influence and in 2007 provided input into the legislative process through the Federal Road Safety Council, which had been charged by President Nestor Kircher with developing new road safety laws. Continuity for this process was further ensured with the election of Nestor Kirchner’s wife Cristina Kirchner, who succeeded him as President. In 2007, her first year in office, President Cristina Kirchner prioritized gaining congressional approval of the Federal Agreement on Traffic and Road Safety Law.

The media played an important role in this case. Beyond the extensive coverage of traffic accidents, media outlets put pressure on provincial authorities to adhere to the 2008 law by presenting daily updates on road deaths and by providing opportunities for road safety advocates to appear on television.

Bhalla and Shotten⁶⁵ place importance on the role of policy entrepreneurs and international bodies in creating conducive environments for road safety legislation in Argentina. They argue that policy entrepreneurs were alert to the opportunities provided by the accidents to pass legislation. International actors are suggested to have been important in influencing governmental perception of the issue and in building demand among the public.

With supporters coming from multiple sectors, opposition to road safety was virtually non-existent. However, for the bill’s successful ratification and eventual implementation, consensus and approval from nearly all provinces and municipalities was important. For reluctant provinces, the combination of media attention and periodic accidents provided the pressure needed to ratify. We note the importance of media, civil society and the public in providing opportunities for outside-initiation for road safety. The lack of opposition and the discrete demand for legislation also point to government action through consolidation.

Case 4: Air Quality Control, Delhi, India

Many major Indian cities have hazardous air pollution; 11 of the world’s 12 cities with the highest particulate pollution are in India. Delhi ranks sixth in that list.⁶⁸ In 2016, an estimated 140 million people in India were exposed to pollution that was ten times the maximum safe limit set by the World Health Organization, or worse.⁶⁹ A 2017 analysis estimated that air pollution directly caused 1.24 million deaths and lowered life expectancy by 1.7 years in the country.⁷⁰ This offers us a case of limited government action for CGH.

In spite of these seemingly patent facts, the hazardousness of Delhi’s air pollution has been the subject of debate. Air pollution measurements in several Indian cities are based on one monitoring station per city, which does not account for variation within cities.⁶⁸ Government officials have suggested that air pollution, while harmful, is not directly linked to deaths and may be risky only for those with existing lung conditions.⁶⁹ Government representatives in Delhi have downplayed the issue, suggesting that air quality in the city is not substantially worse than in other capital cities.⁶⁹ Other officials have called for more research to better measure the health impact of air pollution.⁶⁹ Overall, the discourse has emphasized uncertainty, thereby undermining the perception of potential harm from poor air quality.

However, pollution is perceived as a serious concern among some segments of the public, who call for government action.⁷¹ Their complaints have been echoed by physicians, who have issued warnings through the media about health hazards of air pollution.⁷¹ The media has also been influential in providing extensive coverage of what some call the “pollution crisis.”⁶⁸ Further attention has come from environmental activists and the Supreme Court, all of whom have called for research and government action.^69,71,72

Perceptions of the problem of air pollution have influenced potential strategies. Delhi’s air pollution problem in particular has been attributed to geographical features that limit circulation, high population density, and local preferences for burning coal and biomass.⁷³ Delhi has already shut down power plants and banned heavy trucks from the city.⁷⁴ Other strategies suggested to address air pollution have included bans on fireworks, plans to expand solar power generation, and the use of cooking gas cylinders.^69,71 However, workers in high polluting industries are reluctant to support mitigation efforts, farmers are unwilling to switch from crop burning, construction workers are averse to changing their practices,⁷¹ and the automotive industry and power plants are antagonistic to government regulation that could affect their operations.⁶⁹

Early in 2019, the Ministry of Environment, Forests, and Climate Change launched a National Clear Air Program that aims to prevent, control, and reduce unhealthy air pollution, expand monitoring networks, and raise public awareness through multi-sectoral coordination.⁷⁵ The program is part of an overall investment in measurement and reporting efforts. Increased enforcement capacity has also been cited as a potential solution to air quality control, especially as anti-pollution laws currently exist.

However, the effectiveness of government action to improve air quality has been limited. This may change with increasing internal pressure including organized demonstrations, the #MyRightToBreathe movement instigated by activists and students,⁷⁶ and growing discontent among the middle class, which potentially could become catalyzing factors. Nonetheless, the air quality problem persists largely unaddressed. Although at present we consider this to be a case of government inaction, in coming years it is possible that outside-initiation may be effective in prompting positive action.

Discussion of the CGH Cases

To facilitate a comparative discussion of the cases we distilled important elements of each one using the framework prepared for our analysis. The results are shown in Table 2.

TABLE 2. Comparison of the Four Cases

Category of Analysis	Surveillance: EIS, CDC, US	Transport Planning: Traffic Congestion, London	Road Safety: Legislation, Argentina	Air Quality: Delhi, India
Perception of CGH problems	• Importance of communicable disease control • Threat of biological warfare	• Insufferable traffic in central London	• Burden of disease due to road traffic injuries and poor government coordination	• High levels of air pollution • Comparisons and consequences unclear
Role of engaged actors and willingness to collaborate for CGH	• Medical epidemiologist with knowledge on biological warfare (through outside initiation) • President • Public (mobilized by government)	• Mayor of London (through inside initiation) • Ministry of Transport • Conservative Party • Central London shop owners and inhabitants • Industry representatives • Public	• CSOs and NGOs • Victims’ groups and families • Media International • Bodies (together provided grounds for consolidation) • Presidents • National Ombudsman • Policy Entrepreneurs	• Public • Media • Environmental Activists (could lead to outside-initiation) • Supreme Court • Farmers • Construction workers • Industry representatives • Government officials
Strategies and policies for CGH	• Use CDC infrastructure to switch from malaria control to epidemic surveillance • Training more epidemiologists who could be active in an epidemic	• Congestion charges • Improvement of public transport	• Road safety legislation accompanied by a national coordinating agency	• Banning fireworks • Investment in public transport • Investment in renewable energy • Investment in research and monitoring • Investment in enforcement capacities
Catalyzing circumstances	• Outbreak of Korean War	• Election of new mayor	• Road traffic accidents, elections	• None, but may be building with rising popular concern among middle classes
CGH Decision	US government institutionalized global surveillance capacity in CDC, EIS	London City government institutes congestion charge to reduce traffic, pollution	Argentina government establishes national road safety agency to reduce traffic injury	Indian national and Delhi city governments have declined to act on air pollution

The analysis of the cases presented in Table 2 leads us to five observations about government decisions on CGH. First, in each of the three cases that did produce government action (US, UK, and Argentina) there was a clearly defined, plainly articulated, and widely perceived problem—the need for surveillance to counter the threat of biowarfare (US) or the need for greater road safety to prevent future tragedies (Argentina). The problems fit within prevailing contextual themes, namely the Cold War in the US and the advancement of human rights in Argentina, respectively. The same was true in London. Mayor Livingstone was able to gain political momentum by framing the problem in terms of economic productivity and quality of life and placing it against a backdrop of nearly half a century of public concern about traffic congestion. In the one example that has not (yet) yielded a strategy to address CGH demands, the problem of air pollution in India is not well articulated, muddied by calls for additional research, denials of its existence or seriousness by influential actors, and lack of consensus on its consequences. In the successful cases, the framing and the perception of the problem fit into prevailing contemporary themes—this reflects both good choices made by advocates and happenstance.

Second, in each instance of a positive decision to provide a common good, the government and at least some other significant interest groups agreed to collaborate in support of strong leadership. For example, in Argentina coordination across civil society organizations, non-governmental organizations, victims’ and families’ groups, and the National Ombudsman brought political influence to support a solution that emerged from the personal experience of the president. Similarly, with the EIS in the US, the objective of disease surveillance gained traction among different stakeholder groups, including professional epidemiologists, the CDC, the military, the government, and the public at large. These various stakeholders were able to unite in support of general leadership from the US president and specific leadership and policy proposals from the CDC’s chief epidemiologist. In India, however, stakeholder coordination has been challenging. As of now, the government itself is uninterested and no other groups have developed sufficient influence with the public or industrial concerns to lead a successful push toward action.

Third, each case that led to a decision to act on CGH included clear strategies for advocates and a well-defined policy or policies for addressing the problem. In Argentina, the call for stronger legislation accompanied increased institutional capacity for regulation. In London, congestion charges were researched in depth and had been modeled at different levels, while the exact charge was negotiated through a lengthy public consultation process. With the EIS, surveillance was offered as a primary means to detect and contain biological attacks. By contrast, the strategy to address air pollution in Delhi is the subject of ongoing debate. Some actors, including within the government, are calling for research to corroborate allegations that air pollution causes hazards. The locus of accountabilities, among various government sectors and many private actors, has not been agreed. In sum, disparate views and positions have not coalesced behind any obvious strategy.

Fourth, our cases showed diverse collective action patterns. The advocacy for surveillance included professional and institutional groups successfully persuading the government to support their position, an outside-initiation example. The leadership for congestion charges from the Mayor of London showed inside-initiation, in which the government itself led the movement for supporting a common good. Argentina’s decision to establish a road safety agency reflected a consolidation pattern, in which many groups favored action and came together over time to realize it, among other patterns. With no positive decision on air quality in Delhi, we observed no decisive collective action pattern. However, in light of the government’s lack of interest in the problem, we speculate that there is potential for outside-initiation by advocacy groups drawing on and fostering the growing public perception of the problem. We had no a priori reason to expect that any specific pattern would be more commonly found, and four cases are too few to detect one. However, we conclude that action on CGH can be provoked by any of the patterns we observed.

Fifth, the examples show the importance of timing in efforts to manage CGH, both for capitalizing on short-term opportunities and fostering the longer-term development of perceptions of problems and their solutions. In the cases of road safety and surveillance, there were important and immediate catalyzing events that supported progress: car crashes involving school children and the president, and the outbreak of the Korean war, respectively. For congestion charges in London, we did not identify a catalyzing event beyond the election of a new mayor who had campaigned on the issue. However, this occurred after four decades of growing public concern about the problem and an equal period of research and policy development. Although one example is a very limited basis for inference, this case suggests that public pressure and governmental leadership can combine with long-term research and planning efforts to support action for common goods without first requiring a catastrophe. In India, the lack of a catalyzing event and the absence of leadership have thus far resulted in a status quo that is highly damaging to population health. Similarly, recognition of the issue of air quality is fairly recent, having only gained prominent media attention in the last few years, and with health consequences that remain unclear to the public. It is possible that over time research and strategies to address air quality will be developed; it is also possible that the government will show greater leadership. Taken together, the four cases presented suggest that positive decisions for action on CGH may require time to gain momentum, and even then, that concrete action may be contingent on specific catalyzing factors or events.

Conclusions and Recommendations

The analysis of our four cases suggests that decisions to advance government action on common goods requires: the articulation of a defined problem; a well-defined strategy for addressing the problem; and leadership that is backed by at least a few important groups willing to cooperate. Such coalitions can initiate change and bring the majority of the society along with them. We found that the timing of intervention in support of common goods is dependent on favorable circumstances—this may include a catalyzing event but does not necessarily require one.

Each conclusion has implications for advocates of increased action in support of CGH. First, advocates can articulate a clear and consistent description of “the problem.” Our evidence shows that the threat of biowarfare, as opposed to an actual attack, was adequate to spur the embracement of expanded surveillance capacity. Economic modeling and common-sense appeals underpinned the definition of traffic congestion as a problem. However, a real road traffic tragedy was ultimately required to create a widespread perception that traffic safety was an important problem.

Second, each problem was articulated to fit intuitively with well-defined policy strategies presented as solutions. The problem of the prospect of biowarfare matched the solution of building epidemiologic surveillance capacity to safeguard the nation. Likewise, the previously proposed congestion charges were an intuitive approach to reducing the number of vehicles in central London. Additionally, these solutions included measurement strategies that would show if they worked. In the cases we examined, the formulation of problems and strategies reflected relatively long-term investments in building capacity and gathering evidence. Similarly, as advocates develop ways to frame a problem, they should consider which policy strategies they prefer and gather evidence to support their preferred perception of both the problem and solution.

Third, government progress on CGH did not occur in any case without leadership within the government itself. This is consistent with the conceptualization of CGH as caused by market failure (and susceptible to government failure). Advocates should therefore focus on building support among political leadership, not just at the technical levels of government. We also note the diversity of successful advocacy patterns. This suggests that advocates have a chance of success from many different starting positions, such as building citizen pressure on government or exercising leadership from within government.

Fourth, the three cases that led to action on CGH had a heritage of at least a quarter century of direct attention. This indicates that understanding common goods problems builds slowly and solutions emerge at a modest pace. In London, it took 40 years of increasing traffic problems to motivate action on an essentially unchanged policy solution. At the CDC, surveillance capacity was connected to anti-malaria efforts that had not only been expanded in the World Wars but stretched back to the invasion of Cuba in 1898 and drew heavily on methods developed by statistician William Farr in the 1840s.⁷⁷

These observations cast action for common goods in historical perspective, showing that however obvious the path of societal progress may appear to some, coordinating action on CGH is challenging. Further, successful action is dependent on: the long-term development of evidence; public awareness of a problem with a clear framing; and determined and strong leadership both within and outside of official government players. Thus, advocates for CGH should feel encouraged and inspired to maintain their efforts over the long term even if progress is difficult to discern in the short term.

Disclosure of potential conflicts of interest

No potential conflicts of interest were disclosed.

Additional information

Funding

This article was supported by the World Health Organization. Funding from Finland’s Ministry of Social Affairs and Health, the UK Department for International Development, and the European Commission is gratefully acknowledged.