Shaping Global Health Policy

Global Social Policy Actors and Ideas about Health Care Systems

Alexandra Kaasch

• Publisher: Palgrave Macmillan
• Year: 2015
• ISBN:
  9781137308894
• Topic: Politics & International Relations
• Subtopic: Social Policy
• Index: Politics & International Relations

Using an approach that combines transnational and comparative social policy analysis with international relations, this book assesses various global social policy actors and compares their ideas and prescriptions about national health care systems. It highlights the importance of considering health policies across multiple scales.

1

Global Social Policy Actors and Health Care System Ideas

1.1 Introduction

Health is a significant global issue, and has become even more so in the past few decades owing to manifold globalisation processes. People all over the world struggle with similar health constraints. The search for curative and eradicative means to cure diseases is usually considered a common and global human challenge. Infectious diseases threaten people in a world of extensive worldwide cross-border exchanges. The dramatic social risks of the inability to work for health reasons affect the lives of people, without regard for age, social status or their place of residence. At the same time, the increasing transnationalisation of family structures and individual work and employment histories poses significant challenges to national and supranational health care provision and financing.

An important institution to tackle such challenges is the health care system (also referred to as “health system”).¹ While commonly set up at national policy levels, health care systems as concepts or strategies also form a central element of global social policy agendas and debates. They are considered important for the achievement of global health goals (such as the health-related Millennium Development Goals (MDGs) and the post-2015 goals (so-called Sustainable Development Goals (SDGs)), and they provide a key element of various other social development and global health strategies; for example, when it concerns the fight against specific diseases. In a speech to the United Nations (UN) General Assembly meeting on the Prevention and Control of Non-Communicable Diseases (2011), UN Secretary-General Ban Ki-moon stated:

Improving health systems improves health services. Involving all parts of government attacks all sides of a problem. And taking comprehensive action is the best way to protect against diseases.

The vital importance of well-functioning health care systems appears to be common knowledge among national and global policymakers, and a vital goal in high-, middle- and low-income countries alike. Nevertheless, the great challenges and considerable uncertainties with regard to building up, and maintaining, functioning health care systems seem to be equally shared in national and transnational policy arenas. One can find political efforts in various places, and at different levels of policymaking, to address issues such as long-term sustainable funding of health care systems, equal and adequate health provision and access to health care. At the same time demographic changes, technical innovation and different forms of crisis (such as global economic crises, disease outbreaks and natural catastrophes) create stresses on national health care systems.

In such situations, on the one hand, “health care systems” as a global health topic appear to be particularly important, and national and global actors alike call for increased attention on more comprehensive – or horizontal – approaches to health care systems that go beyond tackling specific diseases (so-called vertical approaches). On the other hand, however, the complexity and relative costs of health care systems frequently appear insurmountable. That often results in new initiatives to tackle specific problems in the short term, and just talking about the need to focus on health care systems more generally.

1.2 Global health policy and governance

The unquestionable importance of health care systems for the well-being of individual societies, together with the marked lack of straightforward solutions to major questions of health and social protection, has generated multi-scaled, transnational activities concerning national health care systems. The related initiatives partly connect to specific health issues (such as the fight against malaria or tuberculosis). Partly, however, they also reflect global ideational discourse as a somewhat independent sphere of global social and health policy. Some of these discourses relate to particular groups of countries or regions; while others are supposed to apply in general and globally.

More generally, global governance of health care systems, or global health governance, is characterised by a typical multi-layered, polyarchic and pluralistic institutional architecture. We can observe a variable geometry in the sense of varying political significance and regulatory capacities in different parts of the world, or by different actors (on global social governance more specifically, see Kaasch and Martens, 2015). This architecture is, in addition, in a process of continuous change; and ever new configurations of actors, as well as a continuously growing number of different kinds of actors, activities, overlapping jurisdictions, power resources and competencies result in a growing complexity (Held and McGrew, 2002: 5; Wilkinson, 2002: 2; Hein and Kohlmorgen, 2008).

Accordingly, we find a great number and variety of transnational policy actors dedicating (part of) their attention and resources to the topic of health care systems. “Health care systems” have found their way into the world’s major international meetings, such as the World Economic Forum and G20 Summits. International (governmental) organisations such as the World Health Organization (WHO) and the World Bank commit substantial resources to analyse and support health care systems in various ways. Numerous civil society organisations (CSOs), including philanthropic organisations, provide significant support to health care systems by advocacy, donations and direct provision of health care. In their exchange of ideas, their interrelatedness and their collaborations, these global social and health policy actors represent a global sphere, or level, of policymaking on the issue of health care systems.

This book is concerned with questions such as: What do global actors do in order to guide national health care systems? What are their ideas? How do these ideas compare? And how can they be related to national health policies?

1.3 Global health policy as global social policy

The literature on global social policy and governance (for example, Deacon et al., 1997; Yeates, 2001, 2008; Orenstein, 2005, 2008; Deacon, 2007; Kaasch and Stubbs, 2014; Kaasch and Martens, 2015) and global health governance (for example, Lee et al., 2002; Hein and Kohlmorgen, 2003, 2008; Lee, 2003; Kickbusch, 2004) have revealed, illustrated and explained many of the characteristics just described. This book intends to contribute to the global social policy literature in reporting a detailed study in a social policy field that has been rather neglected within the past years, namely health care systems. It draws on the insights provided in that literature, but it also challenges and updates some of the information and accounts. Apart from Koivusalo and Ollila (1997), the existing contributions have either focused on global social policy, or social policy and globalisation more generally, or primarily on the field of pensions (for example, Müller, 2003; Brooks, 2005, 2007; Ervik, 2005; Orenstein, 2005, 2008, 2011; Weyland, 2005). Other contributions are rather organisation-driven, and study the role of the World Bank (for example, St Clair, 2006), the WHO (for example, Siddiqi, 1995; Lee, 2009) or the Organisation for Economic Co-operation and Development (OECD) (for example, Mahon and McBride, 2008b; Martens and Jakobi, 2010). By drawing on a broad picture of various global social policy actors, this book follows the approach used to study international actors and their social policy ideas as developed and employed by Bob Deacon, but with a focus on a particular social policy field (for example, Deacon et al., 1997). Such a contribution will enable us to better understand some of the nuances of global social policy discourses and struggles over positions, going beyond a general take on the issue that merely offers broad and general accounts of global social policy, without considering the potential differences between social policy fields.

The issues and discussions addressed in this book are conceptualised as a form of global social policy and governance. Health care systems as an issue of global policies and governance matter in different ways. Following Deacon’s (2007) understanding of global social policy, a distinction can be made between “truly” or genuinely global social policies, and prescriptions for national social policy generated and disseminated by global social policy actors. The dimension of a genuinely global social policy involves mechanisms of global social redistribution, the formulation of global social rights and the enactment of global social regulation. Theoretically, related to health care systems, this could add up to something approaching a “global health care system”. Indeed, global social redistribution happens predominantly through the field of health. Many of the innovative financing facilities are connected to health issues (such as the International Finance Facility for Immunisation (IFFIm), or the International Drug Purchasing Facility (IDPF)). There are further global funds for supporting health development, most importantly the Global Fund to Fight Aids, Tuberculosis, and Malaria (Global Fund) (discussed in Chapter 5). In terms of international organisations, there is, for example, the ILO Ghana-Luxembourg Social Trust project scheme (2009–2014) that provided families in Ghana with health care coverage through subsidisation of their premiums.² Apart from the funding to fight particular diseases and/or supporting health care systems, such organisations, initiatives and programmes also carry particular ideas about health care systems and in that way influence national health policy reforms. Another issue within this global social policy dimension is connected to the definition and potential provision of global public goods (Kaul et al., 1999, 2003). Health plays an important role, as a number of health issues have been identified as having a “global public good” character, such as the global surveillance of infectious diseases (as through the WHO) or the global control of tobacco consumption and illicit drugs (the WHO’s Framework Convention on Tobacco Control is an important document in this context (Jha and Chaloupka, 2000; WHO, 2005 (updated reprint); see also, for example, Gilmore et al., 2007).

Concerning global social regulation, critical issues are international or global labour and social standards, trade matters, voluntary codes of conduct by business, global tax regulation and migration. In contrast to the dimension of redistribution where health issues are a key field of activity, this is less so for regulation. However, an important discussion in this context is that of the implications of trade agreements and the World Trade Organization’s (WTO) role in the health sector. The concern here is that through facilitating trade also in social and health services, detrimental effects on the health of people and social security systems can arise (for example, Koivusalo, 1999, 2003a, 2003b, 2003c; Pollock and Price, 2000; Sexton, 2001; Holden, 2003, 2005) (for a related discussion see Chapter 3). Another issue, connected to migration and particularly relevant to health, is “brain drain”, which refers to the weakening of health care systems through staff shortages caused by migration (for example, Martineau et al., 2004; Kapur and McHale, 2005). Further, global food standards are also related to health issues (see for example Post, 2005).

As the third element of a global social policy, global social rights have to be considered. These represent a particular type of rights as – compared to civil and political rights – they require resources in order to be met (Deacon, 2007: 136; Kaasch, forthcoming). Such social rights have been formulated, amongst others, in the International Covenant on Economic, Social and Cultural Rights (ICESCR) of 1976, the Universal Declaration of Human Rights of 1948, the Convention on the Rights of the Child (CRC) of 1990 and the International Covenant on Civil and Political Rights (ICCPR) of 1976. Rights issues are particularly important in the context of gender, ethnicity or other issues that are prone to discriminatory practices; and include health-related rights (see for example Mishra, 1999; Deacon, 2007; Tarantola, 2008). Tarantola shows how health as a social right came into focus in the context of dealing with HIV/AIDS, because of the belief that “human rights were [ … ] a prerequisite for open access to prevention and care by those who needed them most; away from fear, discrimination and other forms of human rights violations” (Tarantola, 2008: 15). On a similar topic, Hein and Kohlmorgen (2008) engage with new institutional structures in global health governance with a focus on HIV/AIDS and global social rights. These issues are also important for the organisation of health care systems.

Even when taking all these forms of a truly global social policy that relate to health policies and health care systems together, we are far from a truly global health care system. These forms of global social and health policy are only examples of what is happening at the global level with regard to health. Particularly regarding the second form of global social policy as supranational social policy, this is also connected to a potential future global welfare state, as discussed by Leisering (2007), or a global health care system, as envisaged by Kickbusch (2003).

From a normative perspective, despite valid claims about reducing global inequalities on health, it might still not be desirable or feasible to work towards such an institution, given great differences in health needs and cultural expectations.

Turning to the global prescriptions for health care systems, numerous global health actors provide information and recommendations in the form of models and suggestions for reforms of health care systems. As such, prescriptions are only comprehensive in some cases; they are seldom complete and coherent. This often makes it complicated to capture and characterise them. Different perspectives on national health care systems play a role, as well as the different contexts within which health care systems are being addressed by specific actors. However, it needs to be taken into account that the discussion in this book about global actors in health care system issues is less about empirical, national health care systems and experiences, but mainly concerns global ideas and models (with the exception of Chapter 7, which makes the move towards implications for national health care systems, namely Poland).

1.4 Approaches to study global prescriptions for health care systems

Analytically and methodologically, the following approaches have been employed to understand global social policy actors and ideas, and their application at the national policy level. Studies of policy diffusion and transfer in general, as well as case studies for specific (groups of) countries or policy fields have shown that national social and health policy is being influenced by external factors; and these studies have analysed such processes between states as they relate to national policymaking in a single country. Usually, diffusion studies include, amongst other things, findings that relate to policy change through the creation and spread of new ideas; and geographical clustering. They look at the “spread of commonality amid diversity”, and often concentrate on mechanisms of diffusion (Orenstein, 2003; Meseguer, 2004). Interdependence of decisions taken in different places is an important characteristic of diffusion processes (Braun and Gilardi, 2006). Elkins and Simmons (2005: 39) define this interdependence as uncoordinated; thus, “the actions and choices of one country affect another but not through any collaboration, imposition or otherwise programmed effort on the part of any of the actors”.

Also policy transfer analyses focus on external influences on national policy, though with a different approach. The basic assumption is that policymakers are increasingly looking at what is going on in other places, and thus, according to Dolowitz and Marsh (2000), the implementation of new policies includes an iterative process of policy transfer between different contexts. They define policy transfer as the process of bringing ideas, programmes, institutions, policies, administrative arrangements and so on from one place and/or time into another place and/or time (Dolowitz and Marsh, 2000).

While transfer and diffusion studies provide evidence and examples of national social policy being influenced by external factors, the emphasis on processes between societal units often neglects the importance of the – sometimes quite concrete – localities and instances of supranational policy actors. The role of international organisations in influencing national social policy has been emphasised by the literature on global social policy employing international actors approaches (for example, Deacon, 2007; Orenstein, 2008), analysing the activities and power of international organisations (and other actors at that policy level). This includes studying the content of policy advice given by international organisations and other actors, as well as their strategies or activities in disseminating those ideas at global level and towards nation states (Deacon et al., 1997).

In this book, the approach employed focuses on three analytical units to understand the global actors that are engaged in providing prescriptions for health systems. These are mandates, ideas and dissemination mechanisms. The following sections describe the meaning and use of these categories.

1.5 Organisations and mandates

Global health policy and governance in the form of ideas about, and prescriptions for, national health care systems sets the stage for quite a number of international governmental and non-governmental organisations that are developing and disseminating knowledge or ideas about the structure, performance and reform of health care systems. They do this, however, with different mandates, and some of these activities are an expression of a system of global governance that is not characterised by a clear division of labour, but by parallel processes resulting in overlapping and to some extent competing agencies (Deacon, 2007; Kaasch, 2007). That means that a number of international organisations and other actors have identified health care systems as an issue relevant to achieving their particular aims, be they supporting a particular group of people (such as the United Nations Children’s Fund (UNICEF) for children), tackling a specific problem or achieving broader development aims (such as the United Nations Development Programme (UNDP) or the World Bank).

Instead of discussing and questioning different global health actors from a normative perspective, concerning the ways in which they use their power and disseminate particular ideas, this book considers the type of involvement by a particular organisation on the basis of the mandate given to it, or the expressed purpose for its engagement. This allows us to understand the justification of a particular actor’s involvement in the topic area, and provides the basis for comparing involvement and ideas. Basically, following Orenstein (2005: 177), “global policy actors are defined by the scope of their policy activity, not their constitutional nature”. In order to contextualise this involvement and give appropriate justice to the scope or content of the ideas developed and disseminated, it is nevertheless crucial to understand their mandates when analysing their activities, but even more so when making claims about the justification of a particular organisation’s involvement in a specific policy issue. Such “mandates”, however, naturally take very different forms for different types of actor. In the global health literature, Koivusalo and Ollila (1997) have employed the approach to systematically trace global health organisations’ mandates.

1.6 Concepts and ideas

In order to illustrate the key actors in global social policies around health care systems, a...

Table of contents

• Cover
• Title Page
• Copyright
• Contents
• Acknowledgements
• List of Abbreviations and Acronyms
• 1. Global Social Policy Actors and Health Care System Ideas
• 2. UN Organisations: Health for All and All for Health Care Systems?
• 3. The OECD and the WTO: Outside the UN but Increasingly Important?
• 4. The New Centres of Power? G8, G20 and the BRICS and Health Care Systems
• 5. The Global Fund to Fight AIDS, Tuberculosis and Malaria: A Hybrid Organisation as the Best Health Care System Actor?
• 6. Non-Governmental Organisations and Health Care System Ideas
• 7. The Polish Health Care System Under Global Scrutiny
• 8. Conclusions: Multiple Actors, Uncertain Ideas, Nested Discourses
• Notes
• Bibliography
• Index