Health policy and planning
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Comparative Study
Comparing global alcohol and tobacco control efforts: network formation and evolution in international health governance.
Smoking and drinking constitute two risk factors contributing to the rising burden of non-communicable diseases in low- and middle-income countries. Both issues have gained increased international attention, but tobacco control has made more sustained progress in terms of international and domestic policy commitments, resources dedicated to reducing harm, and reduction of tobacco use in many high-income countries. The research presented here offers insights into why risk factors with comparable levels of harm experience different trajectories of global attention. ⋯ What sets the tobacco case apart was the ability of tobacco control advocates to create and maintain a consensus on policy solutions, expand their reach in low- and middle-income countries and combine evidence-based research with advocacy reaching beyond the public health-centered focus of the core network. In contrast, a similar network in the alcohol case struggled with expanding its reach and has yet to overcome divisions based on competing problem definitions and solutions to alcohol harm. The tobacco control network evolved from a group of dedicated individuals to a global coalition of membership-based organizations, whereas the alcohol control network remains at the stage of a collection of dedicated and like-minded individuals.
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Globally 2.9 million babies die each year before reaching 28 days of life. Over the past quarter century, neonatal mortality has declined at a slower pace than post-neonatal under-five mortality: in consequence newborns now comprise 44% of all deaths to children under five years. Despite high numbers of newborn deaths, global organizations and national governments paid little attention to the issue until 2000, and resources, while growing since then, remain inadequate. ⋯ The network's relatively recent emergence, its predominantly technical rather than political composition and strategies, and its inability to date to find a framing of the issue that has convinced national political leaders of the issue's urgency, in part explain the insufficiency of resources. However, since 2010 a number of non-health oriented inter-governmental organizations have begun to pay attention to the issue, and several countries with high neonatal mortality have created national plans, developments which augur well for the future. The study points to two broader implications concerning how neglected global health issues come to attract attention: priority emerges from a confluence of factors, rather than any single cause; and growth in priority may depend on the creation of a broader political coalition that extends beyond the largely technically oriented actors who may first press for attention to a problem.
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Where once global health decisions were largely the domain of national governments and the World Health Organization, today networks of international organizations, governments, private philanthropies and other entities are actively shaping public policy. However, there is still limited understanding of how global networks form, how they create institutions, how they promote and sustain collective action, and how they adapt to changes in the policy environment. Understanding these processes is crucial to understanding their effectiveness: whether and how global networks influence policy and public health outcomes. ⋯ Presently, however, tensions have become more apparent within the network as it struggles with changing internal political dynamics and the evolution of the disease. While centralization and stability helped to launch and grow the network, the institutionalization of governance and strategy may have constrained adaptation. Institutionalization and centralization may, therefore, facilitate short-term success for networks, but may end up complicating longer-term effectiveness.
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Global efforts to address alcohol harm have significantly increased since the mid-1990 s. By 2010, the World Health Organization (WHO) had adopted the non-binding Global Strategy to Reduce the Harmful Use of Alcohol. This study investigates the role of a global health network, anchored by the Global Alcohol Policy Alliance (GAPA), which has used scientific evidence on harm and effective interventions to advocate for greater global public health efforts to reduce alcohol harm. ⋯ The analysis reveals a need to transform the network into a formal coalition of regional and national organizations that represent a broader variety of constituents, including the medical community, consumer groups and development-focused non-governmental organizations. Considering the growing harm of alcohol abuse in LMICs and the availability of proven and cost-effective public health interventions, alcohol control represents an excellent 'buy' for donors interested in addressing non-communicable diseases. Alcohol control has broad beneficial effects for human development, including promoting road safety and reducing domestic violence and health care costs across a wide variety of illnesses caused by alcohol consumption.