Analysing power and politics in health policies and systems

ABSTRACT

This special issue of Global Public Health presents a collection of articles that analyse power and its mechanisms in health systems and health policy processes. Researchers have long noted that the influence of power is implicated throughout the global health field, yet theories and methods for examining power—its sources, workings, and effects—are rarely applied in health policy and systems research. By engaging with the social sciences and humanities, contributors to this collection aim to analytically sharpen and thematically broaden the study of power and politics in global health. Contributors analyse the exercise of power by actors typically considered powerful on the global stage as well as actors across the health system who may be powerful in national or local contexts. Additionally, the papers draw attention to actors, interest groups, and practices not usually viewed as politically salient in health policy and systems research in low- and middle-income countries. The papers not only analyse power but also identify ways to counteract it, such as by using human rights-based frameworks to investigate and challenge power asymmetries. Collectively, they show how researchers working on global health issues can theorise power and deepen political analysis of health policy and systems.

KEYWORDS:

• Power
• politics
• political determinants of health
• health policy and systems
• social science

Researchers have increasingly drawn attention to the influence of power implicated throughout the global health field, noting that biomedical approaches in public health, which emphasise scientific evidence to guide decision-making, tend to ignore the distribution and exercise of power in health policy and systems (Lee, 2015; Shiffman, 2014). They have argued that in failing to explicitly recognise the normative premises that undergird global health efforts (Ooms, 2015), we overlook why and how actors holding power may steer health efforts in particular directions.

Power, moreover, is relative and relational, and manifests at levels ranging from policy decision-making to the local implementation of interventions. Scholars have highlighted that the exercise of power occurs not only among actors typically considered powerful on the global stage, such as international agencies whose institutional roles, resources, and alliances can shape global action on health (Brown, Cueto, & Fee, 2006), or actors at the national level, such as political parties whose ideologies can influence the equity and universality of public policy (Mackenbach, 2014; Navarro et al., 2006), but also actors across the health system who may be powerful in particular local contexts. Administrators, bureaucratic agents, and frontline health workers may exercise power in the course of everyday health service delivery, with negative or positive consequences for the people they serve (Erasmus & Gilson, 2008; Gilson, Schneider, & Orgill, 2014). In these cases, too, when researchers overlook the practice of power, they can misattribute reasons why policy decisions and policy implementation obtain particular outcomes. Failing to critically analyse political context, including political rights, institutions, ideologies, and norms, can lead researchers to methodologically bias their studies, such as when interlocutors do not or cannot offer comprehensive, critical views, and to thus misrepresent the success of health programmes (Østebø, Cogburn, & Mandani, 2018).

Despite growing recognition of the role of power in shaping global health initiatives and health outcomes, social scientific theories and methods for examining power—its sources, workings, and implications—are rarely applied in health policy and systems research. This observation is not new. Scholars noted that advances in knowledge about technical aspects of primary health care programmes in the early 1980s were not accompanied by research into political influences on their implementation and effectiveness (Bossert & Parker, 1984). A review of policy analysis literature focused on low- and middle-income countries covering the period 1994–2007 found that politics and power were broadly discussed but rarely explicitly assessed or rigorously studied (Gilson & Raphaely, 2008). In making the case to invigorate a political debate on health systems, Storeng and Mishra (2014) observed that studies of health systems strengthening—an issue that rose in importance in the global health field in the mid-2000s (Hafner & Shiffman, 2013)—had emphasised technical and managerial issues of health service delivery, ‘with little attention to the politics and social relations that shape health systems’ (p. 858).

The WHO Commission on the Social Determinants of Health (CSDH) recognised that health inequities resulted from ‘a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics’ (CSDH, 2008, p. 1). It conceptualised and assembled evidence on a wide range of social forces and casual processes that affect health inequity. But it was less clear or analytical about political strategies, competing political priorities, contested political ideologies, and other ‘battle[s] of values and ideas’ that advocates of health equity inevitably confront in moving forward policy agendas (Lee, 2010, p. 5). Building on the CSDH report, the 2014 report of The Lancet-University of Oslo Commission on Global Governance for Health (Ottersen et al., 2014) further drew attention to the role of power asymmetries in shaping health inequities. The report defined the ‘global political determinants of health’ as the norms, policies, and practices that arise from global interactions among entities (states, transnational corporations, and civil society organisations, among others) with ‘different interests and degrees of power’ (Ottersen et al., 2014, p. 630). However, it did not ‘consider the need to better understand empirically how power is expressed in global health governance’ (Marten, Hanefeld, & Smith, 2014, p. 2207).

More generally, health policy and systems analyses have been found to be more descriptive than explanatory (Adam et al., 2012; Gilson & Raphaely, 2008) and weakly grounded in theory. Scholars have commented on health security policy recommendations lacking theoretical foundations, making their suggestions ‘incoherent and difficult to integrate into foreign policy strategies’ (Youde, 2005, p. 205). Others have found global health scholarship lacking in theories that can generate ‘durable intellectual frameworks’ to analyse health problems in different contexts, anticipate future situations, and educate practitioners (Kleinman, 2010, p. 1518). Building such frameworks entails drawing on the humanities and social sciences to develop interdisciplinary research that can systematically investigate inequity, make structural power visible, generate dialogue between empirically and normatively focused global health researchers (Ooms, 2014), and obtain greater reflexivity among individuals and institutions about their own position in the field of global health (Forman, 2016).

The past few years have seen a rise in social-scientific scholarship on questions of power and politics in global health (Gomez, 2016; Hansen, Holmes, & Lindemann, 2013; Parker & Garcia, 2019; Storeng & Mishra, 2014). Yet this literature has also highlighted the substantial potential for expanding the scope and profile of such inquiry. Gomez (2016) writes that the discipline of political science ‘needs to take global health policy issues more seriously, while the global public health community needs to do the same for political science, specifically on issues of institutional design and governance’ (p. 4). While Hansen et al. (2013) illuminate the contribution that medical anthropology and sociology, specifically ethnographic research, stands to make to shape public discourse and policy, Storeng and Mishra (2014) observe that in the main, ethnographic research on political dynamics in health policies and systems has ‘been off the radar of the global health research community’ (p. 859). The call for research to investigate power and politics, and to make this research speak to both social science and health research communities, remains significant and current.

This special issue takes up that call with a focus on applying and extending theories to investigate power, demonstrating methods to discern power and its mechanisms, and expanding our understanding of politically salient issues in health policy and systems research. It approaches the study of politics, broadly defined as the making and implementation of collective decisions, through the trope of power. By engaging with approaches from the social sciences and humanities, contributors to this collection aim to analytically sharpen and thematically broaden the study of power in health policy and systems research in three ways: by showing how interdisciplinarity contributes to the study of power, by identifying power and its mechanisms in national health policy and systems, and by identifying power and its mechanisms in transnational processes.

Interdisciplinarity and the study of power

Academic inquiry into questions of power and politics entails bridging disciplines, bringing into global and domestic health policy and systems research concepts and analytical approaches from the social sciences and humanities.

In this issue, Lisa Forman argues for such a dialogue between human rights law and health policy. Forman makes the case for incorporating insights from normative scholarly traditions, such as international law, philosophy, ethics, and political science, not only as a conceptual lens to understand how actors exercise power, but also as a practical and rhetorical device to interpret power asymmetries, challenge policies and their underlying rationales, and remediate inequities. Forman finds that discussions of power in the global health field—such as in the Commission on the Social Determinants of Health, The Lancet-Oslo Commission on Global Governance for Health, and task forces preceding the Sustainable Development Goals—acknowledge the normative component of power and view human rights as supplying a normative counterpoint. The right to health has been codified in international and regional legal instruments and used by individuals and civil society organisations to challenge health policy decisions.

Forman cautions, however, that human rights advocacy may not translate into actual commitments in domestic and global health contexts, suggesting that the right to health is also suffused with power and can sustain power dynamics. Drawing attention to the mostly marginal position of human rights education in the health professions, Forman calls for redressing the disconnect between law, health, and social science, so that scholars and advocates can use rights-based normative and strategic frameworks to identify and challenge power asymmetries in health policy, as well as analyse how power may influence human rights outcomes.

Nathan Paxton and Jeremy Youde examine the intersection of international relations theory and global health. Finding persistently limited communication between the two fields, Paxton and Youde argue that international relations theory can help social scientists who study global health and international politics better explain the failures and successes of global health policy. They focus on the contribution that four theoretical orientations—realism, neoliberal institutionalism, constructivism, and feminism—make to the analysis of global health politics.

Paxton and Youde discuss foundational concepts, assumptions, and arguments in each theoretical orientation, which offer alternative understandings of power and its effects on global politics and global health. To illustrate, the authors examine the case of the Global Health Security Agenda (GHSA), a partnership of states, international organisations, and nongovernmental actors that builds national and global capacity and acts to detect, prevent, and respond to infectious disease threats. They suggest that from a realist perspective we might view the GHSA as an alliance of nations against the threat of a global pandemic. Institutionalism would likely stress the ‘global’ and ‘agenda’ portions of the GHSA, constructivism the idea of ‘health security,’ and feminist theory the externalities of the GHSA process. Paxton and Youde show how different theories diversify and deepen analysis of power and politics in global health, enabling analysts to be consider, in theoretically grounded ways, a range of factors—national security; economic gain; ideas, identities, interests, and norms and how these shift over time; gender dynamics and social exclusion; among others—that help us make sense of the roles and actions of states, non-state actors, international institutions, and individuals in global health.

Identifying power and its mechanisms in national health policy and systems

Three contributions in this issue illuminate the workings of power within national health policy-making and health systems. Although transnational and non-state actors play powerful roles in global health, states are sovereign entities in the international system and remain central to national policy decision-making and implementation (Ricci, 2009). State institutions and political history, relations between state and society, and relations within society are among the factors that critically shape national health policy and systems. Aligned with that premise, these three contributions extend our understanding of actors who hold power, how they derive, exercise, and experience power, and with what effects for national health policy and health care services.

Devaki Nambiar and Arima Mishra investigate how practitioners of traditional medicine in India’s health system exercise power. The authors note that certain alternative systems of medicine, such as Ayurveda, yoga, and homeopathy, are officially recognised in India’s health system, though they are subservient to biomedicine. Policy documents additionally refer to Local Health Traditions (LHT)—practices such as bone setting, home remedies, and spiritual healing—as undocumented knowledge possessed by individuals, communities, and tribal groups. Although the state views LHT as marginal, substantial proportions of Indian households report using local health traditions. The state and civil society organisations have launched efforts to revitalise LHT, but traditional healers remain marginal in the system.

In this context, Nambiar and Mishra show how LHT practitioners exercise power to redefine and recast their positions relative to the state and other actors. The authors report findings from their ethnographic research in three South Indian states. They identify four sites and sources of power for LHT practitioners: interaction with and recognition from ‘accomplished others,’ such as doctors, artists, lawyers, judges, ministers, and, government functionaries; the state, though selectively, such as through endorsement of individual healers by state actors and invitations by state agencies outside the health sector (e.g. forestry, biodiversity, tribal affairs) requesting LHT practitioners to share their knowledge; collective organising, such as through unions and boards; and divine providence. Nambiar and Mishra thus discern the complexity of power relations among systems of medicine and the state. Notably, they show how actors in marginal positions in the health system may nonetheless ascribe to power, with the state implicated as a potential source of power.

Radhika Gore studies the workings of power in frontline health service delivery. Gore observes that although an emerging scholarship examines this, most studies either focus on a specific, often newly instituted, programme, which can miss the conditions that structure pre-existing power relations, or else weakly theorise power, tending to categorize forms of power rather than propose how power functions. Gore’s study attends to ‘macro-institutional factors’ that impact frontline actors’ everyday work. Further, in contrast to studies of frontline actors’ exercise of discretionary power, Gore directs us to observe how frontline actors experience, make sense of, and respond to power over them, specifically to popular opinion, representing citizens’ power to voice perspectives on and claims over state services in a democracy.

To show this, Gore conducts an ethnographic study of everyday primary care provision in municipal government-run clinics and hospitals in Pune, India. She finds that, in the municipal doctors’ perspectives, people preferred private over public sector health care, a choice the doctors felt was misinformed but that they could do little to shift. In discussing systemic factors that sustain strained relations between municipal doctors and communities, Gore notes the long-standing policy neglect of urban primary care; the dominance of an avid, unregulated private sector; and medical education and practice norms that do not equip or encourage doctors to address patients’ social circumstances. Gore’s study suggests how, without institutional resources for doctors to deliver high-quality care and participatory institutions for communities to deliberate and articulate their views to state agencies, power relations in frontline service delivery can sustain a deficient status quo.

Sarah Dalglish, Veena Sriram, Kerry Scott, and Daniela Rodríguez examine the power of medical professionals in health policy-making, which, they observe, is not well understood in low- and middle-income countries. Taking the case of child survival in Niger and emergency medicine specialisation in India, the authors use document review, semi-structured interviews, and non-participant direct observation to study how medical professionals exercise power in policy-making. They first separately collected and analysed data for the two cases and then jointly contrasted them.

Although the cases concern different policy issues, the analysis shows that in both countries, medical professionals, mostly specialists, sought policy solutions focused on curative care rather than population health even as they acknowledged the need for health system improvements. In both countries, a small number of medical professionals comprised the group of influential doctors. In Niger the group included clinicians holding positions in government and international agencies. In India it included clinicians from metropolitan areas and members of the diaspora, working mostly in hospitals, not policy-making bodies. The groups were geographically concentrated and connected through informal networks, professional associations, and common medical education and work experiences. The authors find that, relative to high-income countries, the groups in Niger and India are small and fragmented, but nonetheless exercised power in policy-making such as by dominating discussions during stakeholder consultations (Niger), resisting proposals to extend the rural health system using non-clinical workers (Niger), using their networks to gain access to regulatory institutes and committees (India), and arranging medical training and conferences to promote policy interests (India).

Identifying power and its mechanisms in transnational processes

Authors of the final three contributions to this special issue examine power in global processes involving states, development agencies, and multinational corporations.

Katerini Storeng, Jennifer Palmer, Judith Daire, and Maren Kloster study how international non-governmental organisations (INGOs) engaged in political advocacy and navigated national policy processes for safe abortion and family planning in Malawi and South Sudan (both conservative contexts for reproductive health policy) on behalf of donors. The INGOs worked through local intermediaries to develop partnerships with government and civil society actors, thereby helping to shape national regulations, laws, and policy in line with global norms on reproductive health and rights. The authors conducted extensive ethnographic research of two INGOs, Ipas in Malawi and Marie Stopes International in South Sudan, both funded by the UK Department for International Development to influence reproductive health policy in the two countries.

The authors find that staff at the INGOs emphasised their role as providing technical advice on human rights standards, evidence, and guidelines on abortion to inform national policy processes, but this ‘effaces’ the political nature of their and their donors’ practices. For instance, the INGOs brokered alliances and mobilised expert and moral authority, financial resources, and discursive frames to gain access to policy decision-makers and help shape policy options. The study underscores relations, workings, and effects of power in global health: the invisibility of bilateral donors who provide financial support and influence programme design; differences in financial, normative, and epistemic power between INGOs and their national counterparts; consequences for grassroots mobilisation as policy is shaped by local elites; potential displacement of rights-based and feminist discourses by frames emphasising technical public health knowledge; and calls for scrutiny of not only donors’ and INGOs’ messages but also their practices.

Benjamin Hawkins, Chris Holden, and Sophie Mackinder investigate how transnational tobacco companies (TTCs) coordinate their activities to influence global debates and national policy decisions and policy implementation. The authors observe that while TTCs’ activities have been studied in country-specific case studies, TTCs operate at multiple levels, navigating global, regional, and national jurisdictions. Country-level studies provide insufficient analytical insight into the tobacco industry’s challenges, opportunities, and adaptive responses in a globalised policy environment. The authors theorise TTC activities in terms of policy transfer, multi-level governance, and venue shifting, and use document review and interviews to examine policy developments on tobacco packaging requirements in Uruguay, Australia, the UK, Ireland, and at EU level.

The authors show that TTCs defined standardised (‘plain’) packaging as a trade and intellectual property issue rather than a health issue, aiming to shift tobacco’s policy image and venues for its regulation. TTCs initiated concurrent disputes in domestic courts, at the EU level, at the WTO, and via bilateral investment treaties, which in part served to deter resource-limited governments from investing time, money, and effort to innovate and enact policy measures. The authors note that TTCs failed to block strong packaging requirements in the countries studied, but policy implementation was delayed in the UK and diluted in the EU Tobacco Products Directive, suggesting a ‘chilling effect’ on policy induced by TTCs’ coordinated actions. The study suggests that corporations can access multiple venues (domestic, regional, global) to exercise power, but these same venues present tobacco control advocates the imperative to draft international agreements and establish norms prioritising health considerations that may counteract that power.

Robert Marten considers the power exercised by states in the creation of the Millennium Development Goals (MDGs) in 2000. Marten observes that the MDGs were influential and contested in global health: they represented a new narrative on people-centred poverty reduction and human development, yet proposed a ‘vertical’ disease-specific approach that dominated the development agenda, shaping priorities and investments that favoured health issues included in the MDGs. Scholarship on the MDGs emphasises the role of civil society, non-governmental actors, and individuals within the United Nations, but as Marten shows, states critically supported, enabled, and leveraged other actors, institutions, and processes to conceptualise and institute the MDGs.

To analyse states’ engagement in shaping the MDGs, Marten applies a conception of power from global governance scholarship that emphasises social relations. Based on a review of published literature and unpublished policy materials, the study shows how states exerted power during three phases of the MDGs: first (2000-2005), developed states set the agenda, leveraged financial and human resources to ensure other states adopted their policy guidance, and sacrificed some power as they worked with international institutions to gain legitimacy. Second (2005-2010), emerging economies began to question the MDG approach even as they engaged with the MDGs within the UN system, and began to contribute to shaping the global health field away from a ‘verticalised’ to a systemic approach. Third (2010-2015), emerging economies negotiated to broaden the post-2015 Sustainable Development Goals (SDGs) and incorporate objectives related to environmental sustainability, labour, and governance, while developed states sought to institutionalise the MDGs within the SDGs. Among the lessons that the study posits for our understanding of power are that states continue to be decisive actors in global health policymaking, but need to ensure their legitimacy to effectively wield power.

Through these interventions, contributors to this special issue encourage a theoretically grounded investigation of the workings and effects of power in health policies and systems at national, regional, and global levels. The papers draw attention to actors not typically considered powerful, such as practitioners of local health traditions in India; interest groups rarely considered in policy analysis in low- and middle-income countries, such as medical professionals in Niger and India; actors overlooked in analysis of global health and development initiatives, such the role of states in influencing the creation of the MDGs; and processes not often analysed as political, such as the practices of donor-funded international NGOs working to provide technical advice to inform reproductive health policy in Malawi and South Sudan. The studies not only analyse power but also identify ways to counteract it, such as by using human rights-based normative and strategic frameworks to investigate and challenge power asymmetries. Authors show how integrating perspectives from the social sciences and humanities can help researchers working on global health issues to theorise power and deepen political analysis of health policy and systems.

Disclosure statement

No potential conflict of interest was reported by the authors.