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1.  Cosmopolitanism and foreign policy for health: ethics for and beyond the state 
Background
Foreign policy holds great potential to improve the health of a global citizenship. Our contemporary political order is, in part, characterized by sovereign states acting either in opposition or cooperation with other sovereign states. This order is also characterized by transnational efforts to address transnational issues such as those featured so prominently in the area of global health, such as the spread of infectious disease, health worker migration and the movement of health-harming products. These two features of the current order understandably create tension for truly global initiatives.
Discussion
National security has become the dominant ethical frame underlying the health-based foreign policy of many states, despite the transnational nature of many contemporary health challenges. This ethical approach engages global health as a means to achieving national security objectives. Implicit in this ethical frame is the version of humanity that dichotomizes between “us” and “them”. What has been left out of this discourse, for the most part, is the role that foreign policy can play in extending the responsibility of states to protect and promote health of the other, for the sake of the other.
Summary
The principal purpose of this paper is to review arguments for a cosmopolitan ethics of health-based foreign policy. I will argue that health-based foreign policy that is motivated by security interests is lacking both morally and practically to further global health goals. In other words, a cosmopolitan ethic is not only intrinsically superior as a moral ideal, but also has potential to contribute to utilitarian ends. This paper draws on the cosmopolitanism literature to build robust support for foreign policies that contribute to sustainable systems of global health governance.
doi:10.1186/1472-698X-13-29
PMCID: PMC3717113  PMID: 23829176
2.  Understanding how and why health is integrated into foreign policy - a case study of health is global, a UK Government Strategy 2008–2013 
Background
Over the past decade, global health issues have become more prominent in foreign policies at the national level. The process to develop state level global health strategies is arguably a form of global health diplomacy (GHD). Despite an increase in the volume of secondary research and analysis in this area, little primary research, particularly that which draws directly on the perspectives of those involved in these processes, has been conducted. This study seeks to fill this knowledge gap through an empirical case study of Health is Global: A UK Government Strategy 2008–2013. It aims to build understanding about how and why health is integrated into foreign policy and derive lessons of potential relevance to other nations interested in developing whole-of-government global health strategies.
Methods
The major element of the study consisted of an in-depth investigation and analysis of the UK global health strategy. Document analysis and twenty interviews were conducted. Data was organized and described using an adapted version of Walt and Gilson’s policy analysis triangle. A general inductive approach was used to identify themes in the data, which were then analysed and interpreted using Fidler’s health and foreign policy conceptualizations and Kingdon’s multiples streams model of the policymaking process.
Results
The primary reason that the UK decided to focus more on global health is self-interest - to protect national and international security and economic interests. Investing in global health was also seen as a way to enhance the UK’s international reputation. A focus on global health to primarily benefit other nations and improve global health per se was a prevalent through weaker theme. A well organized, credible policy community played a critical role in the process and a policy entrepreneur with expertise in both international relations and health helped catalyze attention and action on global health when the time was right. Support from the Prime Minister and from the Foreign and Commonwealth Office was essential. The process to arrive at a government-wide strategy was complex and time-consuming, but also broke down silos. Significant negotiation and compromise were required from actors with widely varying perspectives on global health and conflicting priorities.
Conclusions
As primarily an exploratory study, this research sheds significant light on the global health policymaking process at the level of the state. It provides a useful and important starting point for further hypothesis driven empirical research that focuses on the integration of health in foreign policy, how and why this happens and whether or not it makes an impact on improving global health.
doi:10.1186/1744-8603-9-24
PMCID: PMC3680218  PMID: 23742130
Global health diplomacy; Health and foreign policy; Whole-of-government policymaking
3.  What’s in a word? The framing of health at the regional level: ASEAN, EU, SADC and UNASUR 
Global Social Policy  2015;15(3):229-260.
The Association of Southeast Asian Nations, the European Union, the Southern African Development Community and the Union of South American Nations have increasingly been involved in health diplomacy in the past decade, yet little is known about how they frame health as a foreign policy issue and how this has an impact on their prioritisation of policies. For this, we conducted a review of existing grey and peer-reviewed literature that address regional integration and health, as well as a documentary review according to security, development, trade, human rights, moral/ethical reasonings and global public goods frames identified in the literature. The policy frames identified responded to the challenges these regions currently face. The Association of Southeast Asian Nation’s struggle with re-emerging diseases has led to favouring a securitisation approach to health, the European Union approaches health as a cross-cutting policy issue, the Southern African Development Community presents health as a driver for development, and while the Union of South American Nations emphasises health as a human right and addresses the social determinants of health as an ethical imperative. Overall, these policy frames were useful in analysing the framing of health in foreign policy at the regional level. However, within our analysis, we identified a new frame that approaches health as an intersectoral issue. The impact of regional organisations’ forward will depend on their ability to harness their convening power and speak in a coherent voice on health matters.
doi:10.1177/1468018115599816
PMCID: PMC4639831  PMID: 26635496
Foreign policy; health policy; policy frames; regional organisations
4.  Global Health and Foreign Policy 
Epidemiologic reviews  2010;32(1):82-92.
Health has long been intertwined with the foreign policies of states. In recent years, however, global health issues have risen to the highest levels of international politics and have become accepted as legitimate issues in foreign policy. This elevated political priority is in many ways a welcome development for proponents of global health, and it has resulted in increased funding for and attention to select global health issues. However, there has been less examination of the tensions that characterize the relationship between global health and foreign policy and of the potential effects of linking global health efforts with the foreign-policy interests of states. In this paper, the authors review the relationship between global health and foreign policy by examining the roles of health across 4 major components of foreign policy: aid, trade, diplomacy, and national security. For each of these aspects of foreign policy, the authors review current and historical issues and discuss how foreign-policy interests have aided or impeded global health efforts. The increasing relevance of global health to foreign policy holds both opportunities and dangers for global efforts to improve health.
doi:10.1093/epirev/mxq006
PMCID: PMC2898916  PMID: 20423936
commerce; disease outbreaks; economics; health policy; international cooperation; public health; security measures; world health
5.  Global Health and Foreign Policy 
Epidemiologic Reviews  2010;32(1):82-92.
Health has long been intertwined with the foreign policies of states. In recent years, however, global health issues have risen to the highest levels of international politics and have become accepted as legitimate issues in foreign policy. This elevated political priority is in many ways a welcome development for proponents of global health, and it has resulted in increased funding for and attention to select global health issues. However, there has been less examination of the tensions that characterize the relationship between global health and foreign policy and of the potential effects of linking global health efforts with the foreign-policy interests of states. In this paper, the authors review the relationship between global health and foreign policy by examining the roles of health across 4 major components of foreign policy: aid, trade, diplomacy, and national security. For each of these aspects of foreign policy, the authors review current and historical issues and discuss how foreign-policy interests have aided or impeded global health efforts. The increasing relevance of global health to foreign policy holds both opportunities and dangers for global efforts to improve health.
doi:10.1093/epirev/mxq006
PMCID: PMC2898916  PMID: 20423936
commerce; disease outbreaks; economics; health policy; international cooperation; public health; security measures; world health
6.  Past Fame, Present Frames and Future Flagship? An Exploration of How Health is Positioned in Canadian Foreign Policy 
Administrative sciences  2012;2(2):162-185.
Canada has been regarded as a model global citizen with firm commitments to multilateralism. It has also played important roles in several international health treaties and conventions in recent years. There are now concerns that its interests in health as a foreign policy goal may be diminishing. This article reports on a thematic analysis of key Canadian foreign policy statements issued over the past decade, and interviews with key informants knowledgeable of, or experienced in the interstices of Canadian health and foreign policy. It finds that health is primarily and increasingly framed in relation to national security and economic interests. Little attention has been given to human rights obligations relevant to health as a foreign policy issue, and global health is not seen as a priority of the present government. Global health is nonetheless regarded as something with which Canadian foreign policy must engage, if only because of Canada’s membership in many United Nations and other multilateral fora. Development of a single global health strategy or framework is seen as important to improve intersectoral cooperation on health issues, and foreign policy coherence. There remains a cautious optimism that health could become the base from which Canada reasserts its internationalist status.
doi:10.3390/admsci2020162
PMCID: PMC4072654  PMID: 24977037 CAMSID: cams3831
global health; foreign policy; Canada; security; trade; development; human rights; global health diplomacy
7.  Global Health Governance and the Commercial Sector: A Documentary Analysis of Tobacco Company Strategies to Influence the WHO Framework Convention on Tobacco Control 
PLoS Medicine  2012;9(6):e1001249.
Heide Weishaar and colleagues did an analysis of internal tobacco industry documents together with other data and describe the industry's strategic response to the proposed World Health Organization Framework Convention on Tobacco Control.
Background
In successfully negotiating the Framework Convention on Tobacco Control (FCTC), the World Health Organization (WHO) has led a significant innovation in global health governance, helping to transform international tobacco control. This article provides the first comprehensive review of the diverse campaign initiated by transnational tobacco corporations (TTCs) to try to undermine the proposed convention.
Methods and Findings
The article is primarily based on an analysis of internal tobacco industry documents made public through litigation, triangulated with data from official documentation relating to the FCTC process and websites of relevant organisations. It is also informed by a comprehensive review of previous studies concerning tobacco industry efforts to influence the FCTC. The findings demonstrate that the industry's strategic response to the proposed WHO convention was two-fold. First, arguments and frames were developed to challenge the FCTC, including: claiming there would be damaging economic consequences; depicting tobacco control as an agenda promoted by high-income countries; alleging the treaty conflicted with trade agreements, “good governance,” and national sovereignty; questioning WHO's mandate; claiming the FCTC would set a precedent for issues beyond tobacco; and presenting corporate social responsibility (CSR) as an alternative. Second, multiple tactics were employed to promote and increase the impact of these arguments, including: directly targeting FCTC delegations and relevant political actors, enlisting diverse allies (e.g., mass media outlets and scientists), and using stakeholder consultation to delay decisions and secure industry participation.
Conclusions
TTCs' efforts to undermine the FCTC were comprehensive, demonstrating the global application of tactics that TTCs have previously been found to have employed nationally and further included arguments against the FCTC as a key initiative in global health governance. Awareness of these strategies can help guard against industry efforts to disrupt the implementation of the FCTC and support the development of future, comparable initiatives in global health.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Every year, about 5 million people die worldwide from tobacco-related causes and, if current trends continue, annual deaths from tobacco-related causes will increase to 10 million by 2030. In response to this global tobacco epidemic, the World Health Organization (WHO) has developed an international instrument for tobacco control called the Framework Convention on Tobacco Control (FCTC). Negotiations on the FCTC began in 1999, and the international treaty—the first to be negotiated under the auspices of WHO—entered into force on 27 February 2005. To date, 174 countries have become parties to the FCTC. As such, they agree to implement comprehensive bans on tobacco advertising, promotion, and sponsorship; to ban misleading and deceptive terms on cigarette packaging; to implement health warnings on tobacco packaging; to protect people from tobacco smoke exposure in public spaces and indoor workplaces; to implement taxation policies aimed at reducing tobacco consumption; and to combat illicit trade in tobacco products.
Why Was This Study Done?
Transnational tobacco corporations (TTCs) are sometimes described as “vectors” of the global tobacco epidemic because of their drive to maximize shareholder value and tobacco consumption. Just like conventional disease vectors (agents that carry or transmit infectious organisms), TTCs employ a variety of tactics to ensure the spread of tobacco consumption. For example, various studies have shown that TTCs have developed strategies that attempt to limit the impact of tobacco control measures such as the FCTC. However, to date, studies investigating the influence of TTCs on the FCTC have concentrated on specific countries or documented specific tactics. Here, the researchers undertake a comprehensive review of the diverse tactics employed by TTCs to undermine the development of the FCTC. Such a review is important because its results should facilitate the effective implementation of FCTC measures and could support the development of future tobacco control initiatives and of global initiatives designed to control alcohol-related and food-related disease and death.
What Did the Researchers Do and Find?
The researchers analyzed documents retrieved from the Legacy Tobacco Documents Library (a collection of internal tobacco industry documents released as a result of US litigation cases) dealing with the strategies employed by TTCs to influence the FCTC alongside data from the websites of industry, consultancy, and other organizations cited in the documents; the official records of the FCTC process; and previous studies of tobacco industry efforts to influence the FCTC. Their analysis reveals that the strategic response of the major TTCs to the proposed FCTC was two-fold. First, the TTCs developed a series of arguments and “frames” (beliefs and ideas that provide a framework for thinking about an issue) to challenge the FCTC. Core frames included claiming that the FCTC would have damaging economic consequences, questioning WHO's mandate to develop a legally binding international treaty by claiming that tobacco was not a cross-border problem, and presenting corporate social responsibility (the commitment by business to affect the environment, consumers, employees, and society positively in addition to making money for shareholders) as an alternative to the FCTC. Second, the TTCs employed multiple strategies to promote and increase the impact of these arguments and frames, such as targeting FCTC delegations and enlisting the help of diverse allies including media outlets and scientists.
What Do These Findings Mean?
These findings illustrate the variety and complexity of the tobacco industry's efforts to undermine the FCTC and show the extent to which TTCs combined and coordinated tactics on a global stage that they had previously used on a national stage. Indeed, “the comprehensiveness and scale of the tobacco industry's response to the FCTC suggests that it is reasonable to speak of a ‘globalisation of tobacco industry strategy’ in combating the development of effective tobacco control policies,” write the researchers. Awareness of the strategies employed by TTCs to influence the FCTC should help guard against industry efforts to disrupt the implementation of the FCTC and should support the development of future global tobacco control initiatives. More generally, these findings should support the development of global health initiatives designed to tackle cardiovascular disease, cancer, chronic respiratory diseases and diabetes – non-communicable diseases that together account for 60% of global deaths and are partly driven by the commercial activities of food, alcohol, and tobacco corporations.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001249.
The World Health Organization provides information about the dangers of tobacco (in several languages) and about the Framework Convention on Tobacco Control
For information about the tobacco industry's influence on policy, see the 2009 World Health Organization report Tobacco interference with tobacco control
The Framework Convention Alliance provides more information about the FCTC
The Legacy Tobacco Documents Library is a public, searchable database of tobacco company internal documents detailing their advertising, manufacturing, marketing, sales, and scientific activities
The UK Centre for Tobacco Control Studies is a network of UK universities that undertakes original research, policy development, advocacy, and teaching and training in the field of tobacco control
SmokeFree, a website provided by the UK National Health Service, offers advice on quitting smoking and includes personal stories from people who have stopped smoking
Smokefree.gov, from the US National Cancer Institute, offers online tools and resources to help people quit smoking and not start again
doi:10.1371/journal.pmed.1001249
PMCID: PMC3383743  PMID: 22745607
8.  Turning dread into capital: South Africa’s AIDS diplomacy 
Background
In much of the world, President George W. Bush was not admired for his foreign policy and diplomacy. It is therefore ironic that Bush’s single most uncontested foreign policy triumph was an instance of what has now become known as “health diplomacy”. In 2003 Bush launched the President’s Emergency Plan for AIDS Relief, a five-year $15 billion initiative to fight HIV/AIDS, mostly in Africa. The president’s pragmatic health diplomacy may well save his foreign policy legacy. This article argues that a middle power such as South Africa should consider a similar instrumental AIDS diplomatic strategy, to rehabilitate its public health as well as foreign policy images.
Discussion
This article reflects on the emergence and contemporary practice of health diplomacy. In particular, it explores the potential of niche areas within health diplomacy to become constructive focal points of emerging middle powers’ foreign policies. Middle powers often apply niche diplomacy to maximise their foreign policy impact, particularly by pursuing a multilateral agenda. The literature on middle powers indicates that such foreign policy ambitions and concomitant diplomacy mostly act to affirm the global status quo. Instead, this paper argues that there may well be niches within health diplomacy in particular that can be used to actually challenge the existing global order. Emerging middle powers in particular can use niche areas within health diplomacy in a critical theoretical manner, so that foreign policy and diplomacy become a project of emancipation and transformation, rather than an affirmation of the world as it is.
Summary
The article first describes the emergence and contemporary practice of health diplomacy; this is followed by a discussion of niche diplomacy, in particular as it applies to the foreign policy agendas of emerging middle powers. It then reviews South African foreign policy and diplomacy, before situating these policies within the context of emerging mechanisms of south-south multilateralism. The article concludes by synthesizing these elements and advocating for a South African AIDS diplomacy, emphasizing its potential to galvanize a global project of emancipation.
doi:10.1186/1744-8603-9-8
PMCID: PMC3599770  PMID: 23497509
HIV; AIDS; South Africa; Niche diplomacy; Foreign policy; Middle power
9.  Prioritizing Surgical Care on National Health Agendas: A Qualitative Case Study of Papua New Guinea, Uganda, and Sierra Leone 
PLoS Medicine  2016;13(5):e1002023.
Background
Little is known about the social and political factors that influence priority setting for different health services in low- and middle-income countries (LMICs), yet these factors are integral to understanding how national health agendas are established. We investigated factors that facilitate or prevent surgical care from being prioritized in LMICs.
Methods and Findings
We undertook country case studies in Papua New Guinea, Uganda, and Sierra Leone, using a qualitative process-tracing method. We conducted 74 semi-structured interviews with stakeholders involved in health agenda setting and surgical care in these countries. Interviews were triangulated with published academic literature, country reports, national health plans, and policies. Data were analyzed using a conceptual framework based on four components (actor power, ideas, political contexts, issue characteristics) to assess national factors influencing priority for surgery.
Political priority for surgical care in the three countries varies. Priority was highest in Papua New Guinea, where surgical care is firmly embedded within national health plans and receives significant domestic and international resources, and much lower in Uganda and Sierra Leone. Factors influencing whether surgical care was prioritized were the degree of sustained and effective domestic advocacy by the local surgical community, the national political and economic environment in which health policy setting occurs, and the influence of international actors, particularly donors, on national agenda setting. The results from Papua New Guinea show that a strong surgical community can generate priority from the ground up, even where other factors are unfavorable.
Conclusions
National health agenda setting is a complex social and political process. To embed surgical care within national health policy, sustained advocacy efforts, effective framing of the problem and solutions, and country-specific data are required. Political, technical, and financial support from regional and international partners is also important.
Gavin Yamey and colleagues discuss the factors that affect priority setting for surgical care in LMICs and how this important treatment can be prioritised.
Editors' Summary
Background
Improving human health is a key global concern. Three of the eight Millennium Development Goals agreed to by world leaders in 2000 and designed to eradicate extreme poverty globally by 2015 were directly concerned with public health improvement. And health is central to the Sustainable Development Goals adopted in 2015. But despite health being a global concern, individual countries are largely responsible for addressing the health needs of their populations. All countries have to weigh the health challenges that face their populations and decide which programs and services to prioritize within their national health systems. The allocation of scarce public resources to competing health and other priorities is a complex social and political process, especially in low- and middle-income countries (LMICs). Little is known about why governments channel resources towards some health challenges and not others or about why some health issues become embedded within national health policy while others—including those responsible for a large burden of illness—are largely ignored by national health systems.
Why Was This Study Done?
Surgical care provision is given low priority in the health systems of most LMICs. Only 6.3% of the world’s surgical procedures are undertaken in the poorest countries, where more than a third of the world’s population lives, and most premature deaths from untreated surgical conditions (diseases, illnesses, or injuries in which surgery can potentially improve the outcome) occur in LMICs. Moreover, surgical conditions kill more people every year than HIV/AIDS, tuberculosis, and malaria combined. Understanding why surgical care is a low priority within national health systems in LMICs could provide insights into the social and political processes that drive health agenda setting and resource allocation. In this qualitative case study, the researchers examine the factors influencing the position of surgical care in the national health agendas of Papua New Guinea, Uganda, and Sierra Leone. Although the provision of surgical care has recently improved in Papua New Guinea, all three of these LMICs have a high burden of surgical conditions and inadequate surgical services. A qualitative study examines peoples’ opinions, explanations, and motivations for a particular issue, in order to understand the “why” and “how” of decision-making.
What Did the Researchers Do and Find?
For their study, the researchers used “process tracing,” a qualitative approach that uses two or more methods to analyze change and causation. Specifically, the researchers conducted semi-structured interviews with surgeons, politicians, and other stakeholders to elicit information about how and why different health issues, including surgical care, are prioritized in each study country. They “triangulated” (combined) the information collected in the interviews with information about national health plans and policies and data from country reports and the academic literature. Finally, they analyzed the data using a conceptual framework with four components (actor power, ideas, political context, and issue characteristics) to identify the factors that influence surgical care prioritization. The researchers report that the priority of surgical care varied between countries but was highest in Papua New Guinea. In Papua New Guinea, surgical care was firmly embedded within the health system and received significant domestic and international resources. Notably, three dominant factors influenced whether surgery was prioritized—the level of advocacy by the local surgical community, the national political and economic environment, and the influence of donors and other international actors on national agenda setting.
What Do These Findings Mean?
These findings provide insights into the process of national health agenda setting in Papua New Guinea, Uganda, and Sierra Leone and highlight the complex interplay of social and political factors underpinning this process. In particular, they identify three dominant factors that have influenced whether surgery is prioritized as a health issue in these three LMICs. Notably, the results from Papua New Guinea show that a strong surgical community can generate priority from the ground up, even when other factors are unfavorable for the prioritization of surgical care. These findings may not apply to other LMICS, and certain aspects of the study design may affect their accuracy. For example, the interviewers were surgeons or surgical trainees, which raises the possibility of interviewer bias. Overall, however, these findings suggest that sustained advocacy effort, effective framing of the problem of inadequate surgical care and of the solution to this problem, accurate country-specific data on surgical care indicators, and political, technical, and financial support from regional and international partners will all be needed to ensure that surgical care becomes a priority issue in national health agendas in LMICs.
Additional Information
This list of resources contains links that can be accessed when viewing the PDF on a device or via the online version of the article at http://dx.doi.org/10.1371/journal.pmed.1002023.
A brief description of the need for global surgery, the provision of high-quality surgical care in all countries, is available
The World Health Organization briefly explains the need for global surgery and provides links to a research paper that details how people in LMICs are missing out on essential surgery and to a short article on recent initiatives that aim to correct this deficit
The Lancet Commission on Global Surgery provides information (including videos) on the need for all people to have access to safe, high-quality surgical and anesthesia care, outlines what is needed to achieve global surgical goals, and quantifies the costs of failure if these essential services are not provided
The Disease Control Priorities project summarizes and synthesizes evidence of the effectiveness of global health interventions and provides comparative economic evaluation of policies to implement those interventions; its 2015 publication Essential Surgery shows that surgical services are among the most cost-effective of all health interventions
Wikipedia has a page on process tracing (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
Brief overviews of qualitative research are provided by Northeastern University and by the University of Surrey
doi:10.1371/journal.pmed.1002023
PMCID: PMC4871553  PMID: 27186645
10.  Responding to the public health consequences of the Ukraine crisis: an opportunity for global health diplomacy 
Introduction
Peace and stability in Eastern Europe is now at a crossroads with the rapidly deteriorating foreign policy crisis continuing to unfold in the Ukraine. However, largely overlooked in the context of other foreign policy and diplomatic priorities are the serious public health consequences for the region following the annexation of Crimea and the subsequent decision to ban opioid substitution therapy in the disputed territory.
Discussion
On 1 May 2014, the Republic of Crimea officially announced it would end access to opioid substitution therapy, an essential harm reduction tool recognized by international organizations and virtually all other European countries. The policy development marks a critical reversal in the region’s fight against its growing HIV epidemic and also threatens years of public health gains aimed at providing evidence-based and integrated treatment approaches to combat drug dependence and HIV. Beyond these risks, the Ukrainian conflict could also negatively impact control of other infectious diseases that are converging with HIV and injection drug use, such as multidrug-resistant tuberculosis and hepatitis C virus. The continuing conflict is also likely to have a significant negative impact on Ukraine’s fragile public health system leading to even worse population health outcomes than currently experienced by the country.
Conclusions
In response to this crisis, the application of global health diplomacy principles represents a possible route of advocacy to ensure that HIV prevention, humane treatment of substance using populations, and improving public health outcomes in the region are pursued among concerned international stakeholders. In order to be effective, global health diplomacy efforts must be coordinated and advocated in all forms of diplomatic engagement, including at the core, multistakeholder and informal levels and through existing channels such as the different human rights bodies of the United Nations as well as amongst other actors. Hence, the Ukraine crisis represents a critical moment for the practice and advancement of global health diplomacy in order to ensure global public health priorities are given their rightful place in foreign policy making to hopefully help in bringing resolution to the current conflict.
doi:10.7448/IAS.18.1.19410
PMCID: PMC4365104  PMID: 25787347
health diplomacy; syndemic; health policy; international relations; foreign affairs; opioid substitution therapy; Ukrainian conflict; harm reduction
11.  Regional health governance: A suggested agenda for Southern African health diplomacy 
Global Social Policy  2015;15(3):278-295.
Regional organisations can effectively promote regional health diplomacy and governance through engagement with regional social policy. Regional bodies make decisions about health challenges in the region, for example, the Union of South American Nations (UNASUR) and the World Health Organisation South East Asia Regional Office (WHO-SEARO). The Southern African Development Community (SADC) has a limited health presence as a regional organisation and diplomatic partner in health governance. This article identifies how SADC facilitates and coordinates health policy, arguing that SADC has the potential to promote regional health diplomacy and governance through engagement with regional social policy. The article identifies the role of global health diplomacy and niche diplomacy in health governance. The role of SADC as a regional organisation and the way it functions is then explained, focusing on how SADC engages with health issues in the region. Recommendations are made as to how SADC can play a more decisive role as a regional organisation to implement South–South management of the regional social policy, health governance and health diplomacy agenda.
doi:10.1177/1468018115599817
PMCID: PMC4639828  PMID: 26635498
Global South; health diplomacy; health governance; regionalism; SADC; social protection
12.  Reflections on the ethics of recruiting foreign-trained human resources for health 
Background
Developed countries' gains in health human resources (HHR) from developing countries with significantly lower ratios of health workers have raised questions about the ethics or fairness of recruitment from such countries. By attracting and/or facilitating migration for foreign-trained HHR, notably those from poorer, less well-resourced nations, recruitment practices and policies may be compromising the ability of developing countries to meet the health care needs of their own populations. Little is known, however, about actual recruitment practices. In this study we focus on Canada (a country with a long reliance on internationally trained HHR) and recruiters working for Canadian health authorities.
Methods
We conducted interviews with health human resources recruiters employed by Canadian health authorities to describe their recruitment practices and perspectives and to determine whether and how they reflect ethical considerations.
Results and discussion
We describe the methods that recruiters used to recruit foreign-trained health professionals and the systemic challenges and policies that form the working context for recruiters and recruits. HHR recruiters' reflections on the global flow of health workers from poorer to richer countries mirror much of the content of global-level discourse with regard to HHR recruitment. A predominant market discourse related to shortages of HHR outweighed discussions of human rights and ethical approaches to recruitment policy and action that consider global health impacts.
Conclusions
We suggest that the concept of corporate social responsibility may provide a useful approach at the local organizational level for developing policies on ethical recruitment. Such local policies and subsequent practices may inform public debate on the health equity implications of the HHR flows from poorer to richer countries inherent in the global health worker labour market, which in turn could influence political choices at all government and health system levels.
doi:10.1186/1478-4491-9-2
PMCID: PMC3032656  PMID: 21251293
13.  Corporate Social Responsibility and Access to Policy Élites: An Analysis of Tobacco Industry Documents 
PLoS Medicine  2011;8(8):e1001076.
Gary Fooks and colleagues undertook a review of tobacco industry documents and show that policies on corporate social responsibility can enable access to and dialogue with policymakers at the highest level.
Background
Recent attempts by large tobacco companies to represent themselves as socially responsible have been widely dismissed as image management. Existing research supports such claims by pointing to the failings and misleading nature of corporate social responsibility (CSR) initiatives. However, few studies have focused in depth on what tobacco companies hoped to achieve through CSR or reflected on the extent to which these ambitions have been realised.
Methods and Findings
Iterative searching relating to CSR strategies was undertaken of internal British American Tobacco (BAT) documents, released through litigation in the US. Relevant documents (764) were indexed and qualitatively analysed. In the past decade, BAT has actively developed a wide-ranging CSR programme. Company documents indicate that one of the key aims of this programme was to help the company secure access to policymakers and, thereby, increase the company's chances of influencing policy decisions. Taking the UK as a case study, this paper demonstrates the way in which CSR can be used to renew and maintain dialogue with policymakers, even in ostensibly unreceptive political contexts. In practice, the impact of this political use of CSR is likely to be context specific; depending on factors such as policy élites' understanding of the credibility of companies as a reliable source of information.
Conclusions
The findings suggest that tobacco company CSR strategies can enable access to and dialogue with policymakers and provide opportunities for issue definition. CSR should therefore be seen as a form of corporate political activity. This underlines the need for broad implementation of Article 5.3 of the Framework Convention on Tobacco Control. Measures are needed to ensure transparency of interactions between all parts of government and the tobacco industry and for policy makers to be made more aware of what companies hope to achieve through CSR.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
In the past, companies and multinational corporations were judged on the profits they made. Nowadays, though, much is made of corporate social responsibility (CSR). CSR is the commitment by business to behave ethically and to contribute to economic development while improving the quality of life of the workforce, their families, the local community, and society at large. Put simply, companies and corporations now endeavor to show that they have a positive impact on the environment, consumers, employees, and society in addition to making money for their shareholders. Large tobacco companies are no exception. British American Tobacco (BAT, the world's second largest publicly traded tobacco company), for example, began working on a wide-ranging CSR program more than a decade ago. Given that tobacco is responsible for an estimated 5.4 million deaths worldwide annually, this program was initially met with hostility and dismissed as an image management exercise. However, large parts of the investment and CSR communities now approve of BAT's CSR program, which has won numerous awards.
Why Was This Study Done?
But what do BAT and other tobacco companies actually hope to achieve through their CSR initiatives and how successful have they been in achieving these aims? Few studies have addressed these important questions. In particular, there has been little research into the extent to which tobacco companies use CSR initiatives as a form of corporate political activity that can help them gain “access” to policymakers and define the legitimate concerns and optimal alternatives of public policy (“issue definition”). Access is defined as taking place when policymakers consider the views of policy advocates such as tobacco company employees and is a crucial component of issue definition, which refers to the strategies adopted by bodies such as multinational corporations to influence the policy agenda by defining what issues public policy should concern itself with and how it should approach them. In this case study, the researchers explore whether BAT's CSR program works as a form of corporate political activity by systematically examining internal BAT documents made publicly available as a result of US litigation. Specifically, the researchers examine BAT's efforts through its CSR program to reestablish access with the UK Department of Health following the department's decision in the late 1990s to restrict contact with major tobacco companies.
What Did the Researchers Do and Find?
Using iterative searching, the researchers identified 764 documents in the Legacy Tobacco Documents Library (a large collection of internal tobacco company documents released as a result of US litigation cases) that contain information relevant to BAT's CSR strategies. Their analysis of these documents indicates that one of the key aims of the CSR program actively developed over the past decade by BAT was to help secure access to policymakers and shows how BAT used CSR to renew and maintain dialogue with policymakers at a time when contact between government and tobacco companies was extremely restricted. The documents also show that BAT employees used CSR initiatives as a means of issue definition to both optimize the probability of subsequent discussions taking place and to frame their content. Finally, the documents illustrate how BAT used its CSR program to expand the number of access points across government, thereby providing BAT with more opportunities to meet and talk to officials.
What Do These Findings Mean?
These findings suggest that CSR is a form of corporate political activity that potentially has important implications for public health given the documented impact of the political activity of tobacco companies in delaying and blocking health-related tobacco control policies. In practice, the impact of the political use of CSR is likely to be context specific and will depend on factors such as whether senior policymakers regard companies as reliable sources of information. Importantly, these findings underline the need for broad implementation of Article 5.3 of the World Health Organization's Framework Convention on Tobacco Control (FCTC), an international treaty that calls for the introduction of multiple measures to reduce tobacco consumption, including tobacco advertizing bans and relevant taxation policies. Article 5.3 aims to protect public-health policies on tobacco control from tobacco industry influence. The findings of this study indicate that implementation of Article 5.3 will require measures that ensure transparency in interactions between all parts of government and the tobacco industry and will need an increased awareness across government of what tobacco companies hope to achieve through CSR.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001076.
The Corporate Responsibility (CORE) coalition, an alliance of voluntary organizations, trade unions, and companies, maintains a Web site that contains useful material on corporate social responsibility
The European Coalition for Corporate Justice (ECCJ) promotes corporate accountability by bringing together national platforms of civil society organizations (including NGOs, trade unions, consumer advocacy groups, and academic institutions) from all over Europe
The Legacy Tobacco Documents Library is a public, searchable database of tobacco company internal documents detailing their advertising, manufacturing, marketing, sales, and scientific activities
The World Health Organization provides information about the dangers of tobacco (in several languages), details of the Framework Convention on Tobacco Control (in several languages), and guidelines for the implementation of Article 5.3 of the FCTC
The Framework Convention Alliance provides more information about the FCTC
For information about tobacco industry influence on policy, see the 2009 World Health Organization report Tobacco interference with tobacco control
doi:10.1371/journal.pmed.1001076
PMCID: PMC3160341  PMID: 21886485
14.  Diplomatic advantages and threats in global health program selection, design, delivery and implementation: development and application of the Kevany Riposte 
Background
Global health programs, as supported by organizations such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and the President’s Emergency Plan for AIDS Relief (PEPFAR), stand to make significant contributions to international medical outcomes. Traditional systems of monitoring and evaluation, however, fail to capture downstream, indirect, or collateral advantages (and threats) of intervention selection, design, and implementation from broader donor perspectives, including those of the diplomatic and foreign policy communities, which these programs also generate. This paper describes the development a new métier under which assessment systems designed to consider the diplomatic value of global health initiatives are described and applied based on previously-identified “Top Ten” criteria.
Methods
The “Kevany Riposte” and the “K-Score” were conceptualized based on a retrospective and collective assessment of the author’s participation in the design, implementation and delivery of a range of global health interventions related to the HIV/AIDS epidemic. Responses and associated scores reframe intervention worth or value in terms of global health diplomacy criteria such as “adaptability”, “interdependence”, “training,” and “neutrality”. Response options ranged from “highly advantageous” to “significant potential threat”.
Results
Global health initiatives under review were found to generate significant advantages from the diplomatic perspective. These included (1) intervention visibility and associations with donor altruism and prestige, (2) development of international non-health collaborations and partnerships, (3) adaptability and responsiveness of service delivery to local needs, and (4) advancement of broader strategic goals of the international community. Corresponding threats included (1) an absence of formal training of project staff on broader political and international relations roles and responsibilities, (2) challenges to recipient cultural and religious practices, (3) intervention-related environmental concerns, and (4) a lack of prima facie consideration of intervention diplomatic and foreign policy consequences.
Conclusions
Global health interventions stand to generate significant diplomatic advantages for donor and recipient countries and organizations when appropriately selected, designed, targeted, and delivered. Conversely, in the absence of the application of standards such as those developed under the Kevany Riposte, threats to diplomacy and international relations may occur. With the application of related systems to other global health programmes and settings, comparative results on the relative worth of alternate approaches from the diplomatic perspective may be generated to better inform political, strategic, and global health policy and programmatic decisions.
Electronic supplementary material
The online version of this article (doi:10.1186/s12992-015-0108-x) contains supplementary material, which is available to authorized users.
doi:10.1186/s12992-015-0108-x
PMCID: PMC4470080  PMID: 26013278
Global health diplomacy; foreign policy; PEPFAR; HIV/AIDS; the Global Fund to Fight AIDS; Tuberculosis and Malaria; ‘smart power’
15.  “Working the System”—British American Tobacco's Influence on the European Union Treaty and Its Implications for Policy: An Analysis of Internal Tobacco Industry Documents 
PLoS Medicine  2010;7(1):e1000202.
Katherine Smith and colleagues investigate the ways in which British American Tobacco influenced the European Union Treaty so that new EU policies advance the interests of major corporations, including those that produce products damaging to health.
Background
Impact assessment (IA) of all major European Union (EU) policies is now mandatory. The form of IA used has been criticised for favouring corporate interests by overemphasising economic impacts and failing to adequately assess health impacts. Our study sought to assess how, why, and in what ways corporations, and particularly the tobacco industry, influenced the EU's approach to IA.
Methods and Findings
In order to identify whether industry played a role in promoting this system of IA within the EU, we analysed internal documents from British American Tobacco (BAT) that were disclosed following a series of litigation cases in the United States. We combined this analysis with one of related literature and interviews with key informants. Our analysis demonstrates that from 1995 onwards BAT actively worked with other corporate actors to successfully promote a business-oriented form of IA that favoured large corporations. It appears that BAT favoured this form of IA because it could advance the company's European interests by establishing ground rules for policymaking that would: (i) provide an economic framework for evaluating all policy decisions, implicitly prioritising costs to businesses; (ii) secure early corporate involvement in policy discussions; (iii) bestow the corporate sector with a long-term advantage over other actors by increasing policymakers' dependence on information they supplied; and (iv) provide businesses with a persuasive means of challenging potential and existing legislation. The data reveal that an ensuing lobbying campaign, largely driven by BAT, helped secure binding changes to the EU Treaty via the Treaty of Amsterdam that required EU policymakers to minimise legislative burdens on businesses. Efforts subsequently focused on ensuring that these Treaty changes were translated into the application of a business orientated form of IA (cost–benefit analysis [CBA]) within EU policymaking procedures. Both the tobacco and chemical industries have since employed IA in apparent attempts to undermine key aspects of European policies designed to protect public health.
Conclusions
Our findings suggest that BAT and its corporate allies have fundamentally altered the way in which all EU policy is made by making a business-oriented form of IA mandatory. This increases the likelihood that the EU will produce policies that advance the interests of major corporations, including those that produce products damaging to health, rather than in the interests of its citizens. Given that the public health community, focusing on health IA, has largely welcomed the increasing policy interest in IA, this suggests that urgent consideration is required of the ways in which IA can be employed to undermine, as well as support, effective public health policies.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
The primary goal of public health, the branch of medicine concerned with the health of communities, is to improve lives by preventing disease. Public-health groups do this by assessing and monitoring the health of communities, by ensuring that populations have access to appropriate and cost-effective health care, and by helping to formulate public policies that safeguard human health. Until recently, most of the world's major public-health concerns related to infectious diseases. Nowadays, however, many major public-health concerns are linked to the goods made and marketed by large corporations such as fast food, alcohol, tobacco, and chemicals. In Europe, these corporations are regulated by policies drawn up both by member states and by the European Commission, the executive organ of the European Union (EU; an economic and political partnership among 27 democratic European countries). Thus, for example, the tobacco industry, which is widely recognized as a driver of the smoking epidemic, is regulated by Europe-wide tobacco control policies and member state level policies.
Why Was This Study Done?
Since 1997, the European Commission has been required by law to assess the economic, social (including health), and environmental consequences of new policy initiatives using a process called an “impact assessment” (IA). Because different types of IA examine the likely effects of policies on different aspects of daily life—a health impact assessment, for example, focuses on a policy's effect on health—the choice of IA can lead to different decisions being taken about new policies. Although the IA tool adopted by the European Commission aims to assess economic, environmental and social impacts, independent experts suggest this tool does not adequately assess health impacts. Instead, economic impacts receive the most attention, a situation that may favour the interests of large businesses. In this study, the researchers seek to identify how and why the EU's approach to IA developed. More specifically, the researchers analyze internal documents from British American Tobacco (BAT), which have been disclosed because of US litigation cases, to find out whether industry has played a role in promoting the EU's system of IA.
What Did the Researchers Do and Find?
The researchers analyzed 714 BAT internal documents (identified by searching the Legacy Tobacco Documents Library, which contains more than 10 million internal tobacco company documents) that concerned attempts made by BAT to influence regulatory reforms in Europe. They also analyzed related literature from other sources (for example, academic publications) and interviewed 16 relevant people (including people who had worked at the European Commission). This analysis shows that from 1995, BAT worked with other businesses to promote European regulatory reforms (in particular, the establishment of a business-orientated form of IA) that favor large corporations. A lobbying campaign, initiated by BAT but involving a “policy network” of other companies, first helped to secure binding changes to the EU Treaty that require policymakers to minimize legislative burdens on businesses. The analysis shows that after achieving this goal, which BAT described as an “important victory,” further lobbying ensured that these treaty changes were translated into the implementation of a business-orientated form of IA within the EU. Both the tobacco industry and the chemical industry, the researchers argue, have since used the IA to delay and/or weaken EU legislation intended to protect public health.
What Do These Findings Mean?
These findings suggest that BAT and its corporate allies have fundamentally altered the way in which EU policy is made by ensuring that all significant EU policy decisions have to be assessed using a business-orientated IA. As the authors note, this situation increases the likelihood that the EU will produce policies that favor big business rather than the health of its citizens. Furthermore, these findings suggest that by establishing a network of other industries to help in lobbying for EU Treaty changes, BAT was able to distance itself from the push to establish a business-orientated IA to the extent that Commission officials were unaware of the involvement of the tobacco industry in campaigns for IA. Thus, in future, to safeguard public health, policymakers and public-health groups must pay more attention to corporate efforts to shape decision-making processes. In addition, public-health groups must take account of the ways in which IA can be used to undermine as well as support effective public-health policies and they must collaborate more closely in their efforts to ensure effective national and international policy.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/0.1371/journal.pmed.1000202.
Wikipedia has a page on public health (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
More information on the European Union (in several languages), on public health in the European Union, and on impact assessment by the European Commission is available
The Legacy Tobacco Documents Library is a public, searchable database of tobacco company internal documents detailing their advertising, manufacturing, marketing, sales, and scientific activities
The World Health Organization provides information about the dangers of tobacco (in several languages)
The Smoke Free Partnership contains more information about smoking prevalence in Europe and about European policies to tackle the public health issues associated with tobacco use
For more information about tobacco industry influence on policy see the 2009 World Health Organization report on tobacco industry interference with tobacco control
doi:10.1371/journal.pmed.1000202
PMCID: PMC2797088  PMID: 20084098
16.  Locating regional health policy: Institutions, politics, and practices 
Global Social Policy  2015;15(3):212-228.
Poverty reduction and health became central in the agendas of Southern regional organisations in the last two decades. Yet, little is known about how these organisations address poverty, inclusion and social inequality, and how Southern regional formations are engaging in power constellations, institutions, processes, interests and ideological positions within different spheres of governance. This article reviews academic literatures spanning global social policy, regional studies and diplomacy studies, and the state of knowledge and understanding of the ‘place’ of regional actors in health governance as a global political practice therein. It identifies theoretical and thematic points of connection between disparate literatures and how these can be bridged through research focusing on the social policies of regional organisations and regional integration processes. This framework hence locates the contributions of each of the research articles of this Special Issue of Global Social Policy on the regional dimension of health policy and diplomacy in relation to Southern Africa and South America. It also highlights the ways in which the articles bring new evidence about how social relations of welfare are being (re)made over larger scales and how regional actors may initiate new norms to improve health rights in international arenas engaging in new forms of ‘regional’ diplomacy.
doi:10.1177/1468018115599819
PMCID: PMC4639829  PMID: 26635495
Health diplomacy; global health governance; regional integration; SADC; UNASUR
17.  Diet and Physical Activity for the Prevention of Noncommunicable Diseases in Low- and Middle-Income Countries: A Systematic Policy Review 
PLoS Medicine  2013;10(6):e1001465.
Carl Lachat and colleagues evaluate policies in low- and middle-income countries addressing salt and fat consumption, fruit and vegetable intake, and physical activity, key risk factors for non-communicable diseases.
Please see later in the article for the Editors' Summary
Background
Diet-related noncommunicable diseases (NCDs) are increasing rapidly in low- and middle-income countries (LMICs) and constitute a leading cause of mortality. Although a call for global action has been resonating for years, the progress in national policy development in LMICs has not been assessed. This review of strategies to prevent NCDs in LMICs provides a benchmark against which policy response can be tracked over time.
Methods and Findings
We reviewed how government policies in LMICs outline actions that address salt consumption, fat consumption, fruit and vegetable intake, or physical activity. A structured content analysis of national nutrition, NCDs, and health policies published between 1 January 2004 and 1 January 2013 by 140 LMIC members of the World Health Organization (WHO) was carried out. We assessed availability of policies in 83% (116/140) of the countries. NCD strategies were found in 47% (54/116) of LMICs reviewed, but only a minority proposed actions to promote healthier diets and physical activity. The coverage of policies that specifically targeted at least one of the risk factors reviewed was lower in Africa, Europe, the Americas, and the Eastern Mediterranean compared to the other two World Health Organization regions, South-East Asia and Western Pacific. Of the countries reviewed, only 12% (14/116) proposed a policy that addressed all four risk factors, and 25% (29/116) addressed only one of the risk factors reviewed. Strategies targeting the private sector were less frequently encountered than strategies targeting the general public or policy makers.
Conclusions
This review indicates the disconnection between the burden of NCDs and national policy responses in LMICs. Policy makers urgently need to develop comprehensive and multi-stakeholder policies to improve dietary quality and physical activity.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Noncommunicable diseases (NCDs)—chronic medical conditions including cardiovascular diseases (heart disease and stroke), diabetes, cancer, and chronic respiratory diseases (chronic obstructive pulmonary disease and asthma)—are responsible for two-thirds of the world's deaths. Nearly 80% of NCD deaths, close to 30 million per year, occur in low- and middle-income countries (LMICs), where they are also rising most rapidly. Diet and lifestyle (including smoking, lack of exercise, and harmful alcohol consumption) influence a person's risk of developing an NCD and of dying from it. Because they can be modified, these risk factors have been at the center of strategies to combat NCDs. In 2004, the World Health Organization (WHO) adopted the Global Strategy on Diet, Physical Activity and Health. For diet, it recommended that individuals achieve energy balance and a healthy weight; limit energy intake from total fats and shift fat consumption away from saturated fats to unsaturated fats and towards the elimination of trans-fatty acids; increase consumption of fruits, vegetables, legumes, whole grains, and nuts; limit the intake of free sugars; and limit salt consumption from all sources and ensure that salt is iodized. For physical activity, it recommended at least 30 minutes of regular, moderate-intensity physical activity on most days throughout a person's life.
Why Was This Study Done?
By signing onto the Global Strategy in 2004, WHO member countries agreed to implement it with high priority. A first step of implementation is usually the development of local policies. Consequently, one of the four objectives of the WHO Global Strategy is “to encourage the development, strengthening and implementation of global, regional, national and community policies and action plans to improve diets and increase physical activity.” Along the same lines, in 2011 the United Nations held a high-level meeting in which the need to accelerate the policy response to the NCD epidemic was emphasized. This study was done to assess the existing national policies on NCD prevention in LMICs. Specifically, the researchers examined how well those policies matched the WHO recommendations for intake of salt, fat, and fruits and vegetables, as well as the recommendations for physical activity.
What Did the Researchers Do and Find?
The researchers searched the Internet (including websites of relevant ministries and departments) for all publicly available national policies related to diet, nutrition, NCDs, and health from all 140 WHO member countries classified as LMICs by the World Bank in 2011. For countries for which the search did not turn up policies, the researchers sent e-mail requests to the relevant national authorities, to the regional WHO offices, and to personal contacts. All documents dated from 1 January 2004 to 1 January 2013 that included national objectives and guidelines for action regarding diet, physical exercise, NCD prevention, or a combination of the three, were analyzed in detail.
Most of the policies obtained were not easy to find and access. For 24 countries, particularly in the Eastern Mediterranean, the researchers eventually gave up, unable to establish whether relevant national policies existed. Of the remaining 116 countries, 29 countries had no relevant policies, and another 30 had policies that failed to mention specifically any of the diet-related risk factors included in the analysis. Fifty-four of the 116 countries had NCD policies that addressed at least one of the risk factors. Thirty-six national policy documents contained strategies to increase fruit and vegetable intake, 20 addressed dietary fat consumption, 23 aimed to limit salt intake, and 35 had specific actions to promote physical activity. Only 14 countries, including Jamaica, the Philippines, Iran, and Mongolia, had policies that addressed all four risk factors. The policies of 27 countries mentioned only one of the four risk factors.
Policies primarily targeted consumers and government agencies and failed to address the roles of the business community or civil society. Consistent with this, most were missing plans, mechanisms, and incentives to drive collaborations between the different stakeholders.
What Do These Findings Mean?
More than eight years after the WHO Global Strategy was agreed upon, only a minority of the LMICs included in this analysis have comprehensive policies in place. Developing policies and making them widely accessible is a likely early step toward specific implementation and actions to prevent NCDs. These results therefore suggest that not enough emphasis is placed on NCD prevention in these countries through actions that have been proven to reduce known risk factors. That said, the more important question is what countries are actually doing to combat NCDs, something not directly addressed by this analysis.
In richer countries, NCDs have for decades been the leading cause of sickness and death, and the fact that public health strategies need to emphasize NCD prevention is now widely recognized. LMICs not only have more limited resources, they also continue to carry a large burden from infectious diseases. It is therefore not surprising that shifting resources towards NCD prevention is a difficult process, even if the human cost of these diseases is massive and increasing. That only about 3% of global health aid is aimed at NCD prevention does not help the situation.
The authors argue that one step toward improving the situation is better sharing of best practices and what works and what doesn't in policy development. They suggest that an open-access repository like one that exists for Europe could improve the situation. They offer to organize, host, and curate such a resource under the auspices of WHO, starting with the policies retrieved for this study, and they invite submission of additional policies and updates.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001465.
This study is further discussed in a PLOS Medicine Perspective by Stuckler and Basu
The WHO website on diet and physical activity contains links to various documents, including a diet and physical activity implementation toolbox that contains links to the 2004 Global Strategy document and a Framework to Monitor and Evaluate Implementation
There is a 2011 WHO primer on NCDs entitled Prioritizing a Preventable Epidemic
A recent PLOS Medicine editorial and call for papers addressing the global disparities in the burden from NCDs
A PLOS Blogs post entitled Politics and Global HealthAre We Missing the Obvious? and associated comments discuss the state of the fight against NCDs in early 2013
The NCD Alliance was founded by the Union for International Cancer Control, the International Diabetes Federation, the World Heart Federation, and the International Union Against Tuberculosis and Lung Disease; its mission is to combat the NCD epidemic by putting health at the center of all policies
The WHO European Database on Nutrition, Obesity and Physical Activity (NOPA) contains national and subnational surveillance data, policy documents, actions to implement policy, and examples of good practice in programs and interventions for the WHO European member states
doi:10.1371/journal.pmed.1001465
PMCID: PMC3679005  PMID: 23776415
18.  Health diplomacy: a new approach to the Muslim world? 
Three years ago, the Lancet’s frontispiece stated “Health is now the most important foreign policy issue of our time” and last year, the Director-General of WHO, Margaret Chan, in her opening address, to the Executive Board at its 132nd Session said “health diplomacy works”. The nascent field of health diplomacy provides a political framework which aims to deliver the dual goals of improved health in target populations and enhanced governmental relations between collaborating countries. Any government that offered tangible health improvement as a component of aid to a nation with whom they wished to develop stronger diplomatic links would have an advantage in developing a deeper relationship with its citizens.
Here we suggest several different mechanisms through which such links could be developed or enhanced, including: provision of relevant health solutions, applied research, cultural alignment and the development of collaborative networks. The Islamic tradition promotes the practice of medicine as a service to humanity. Physical and spiritual wellbeing are intimately related in popular Muslim consciousness. Thoughtful Health Diplomacy therefore has the potential to bridge the perceived divides between Western and predominantly Muslim nations.
doi:10.1186/1744-8603-10-50
PMCID: PMC4071330  PMID: 24927759
19.  The emergence of a global right to health norm – the unresolved case of universal access to quality emergency obstetric care 
Background
The global response to HIV suggests the potential of an emergent global right to health norm, embracing shared global responsibility for health, to assist policy communities in framing the obligations of the domestic state and the international community. Our research explores the extent to which this global right to health norm has influenced the global policy process around maternal health rights, with a focus on universal access to emergency obstetric care.
Methods
In examining the extent to which arguments stemming from a global right to health norm have been successful in advancing international policy on universal access to emergency obstetric care, we looked at the period from 1985 to 2013 period. We adopted a qualitative case study approach applying a process-tracing methodology using multiple data sources, including an extensive literature review and limited key informant interviews to analyse the international policy agenda setting process surrounding maternal health rights, focusing on emergency obstetric care. We applied John Kingdon's public policy agenda setting streams model to analyse our data.
Results
Kingdon’s model suggests that to succeed as a mobilising norm, the right to health could work if it can help bring the problem, policy and political streams together, as it did with access to AIDS treatment. Our analysis suggests that despite a normative grounding in the right to health, prioritisation of the specific maternal health entitlements remains fragmented.
Conclusions
Despite United Nations recognition of maternal mortality as a human rights issue, the relevant policy communities have not yet managed to shift the policy agenda to prioritise the global right to health norm of shared responsibility for realising access to emergency obstetric care. The experience of HIV advocates in pushing for global solutions based on right to health principles, including participation, solidarity and accountability; suggest potential avenues for utilising right to health based arguments to push for policy priority for universal access to emergency obstetric care in the post-2015 global agenda.
doi:10.1186/1472-698X-14-4
PMCID: PMC3974068  PMID: 24576008
20.  “Everywhere but not specifically somewhere”: a qualitative study on why the right to health is not explicit in the post-2015 negotiations 
Background
The Millennium Development Goals expire at the end of 2015 and global negotiations are underway to finalise the post-2015 Sustainable Development Goals. Much activism has occurred encouraging a post-2015 health and development goal embedded in the highest attainable standard of health (‘right to health’). Despite this, the right to health was absent in three key post-2015 intergovernmental Sustainable Development Goal proposals in 2014, one of which was reinforced by the United Nations General Assembly in September 2014 as the guiding document for ongoing interstate negotiations. This article examines why it appears the right to health, so far, is not gaining direct expression in post-2015 discussion.
Methods
This qualitative research is part of a broader study using thematic and discourse analysis examining the high-level policy debate on health goals in the discourse of the formulation of the post-2015 Sustainable Development Goals. Key-informant interviews were conducted in two interview rounds in 2013 and 2014, with participants from multilateral and other organisations (government, academia, civil society and philanthropy) responsible for health in the post-2015 development agenda (or the post-2015 development agenda more broadly). This study synthesises data from both interview rounds on Health and Human Rights in post-2015 Sustainable Development Goal negotiations.
Results
Six reasons why the right to health may not have gained effective traction in the unfolding post-2015 Member State negotiations were found. The first three reasons relate to broader issues surrounding human rights’ (including sexual and reproductive health and rights) positioning within international relations discourse, and the second three relate to the challenges of transforming the human right to health into a practically applied post-2015 health goal.
Conclusions
This paper reports the views of participants, many of who sit at the interface of United Nations and Member State negotiations, on the right to health’s location (and projected trajectory) at two temporal junctions in evolving post-2015 negotiations. The interviews provide insight into high-level hesitancy that the right to health be expressly incorporated in the final post-2015 health and development goal, as well as documents participants’ doubt that rights language will explicitly frame the broader Sustainable Development Goals, their targets and indicators.
doi:10.1186/s12914-015-0061-z
PMCID: PMC4546170  PMID: 26293324
Right to health; Human rights; Global health; Qualitative research; Post-2015; Sustainable Development Goals
21.  Translating Biotechnology to Knowledge-Based Innovation, Peace, and Development? Deploy a Science Peace Corps—An Open Letter to World Leaders 
Abstract
Scholarship knows no geographical boundaries. This science diplomacy and biotechnology journalism article introduces an original concept and policy petition to innovate the global translational science, a Science Peace Corps. Service at the new Corps could entail volunteer work for a minimum of 6 weeks, and up to a maximum of 2 years, for translational research in any region of the world to build capacity manifestly for development and peace, instead of the narrow bench-to-bedside model of life science translation. Topics for translational research are envisioned to include all fields of life sciences and medicine, as long as they are linked to potential or concrete endpoints in development, foreign policy, conflict management, post-crisis capacity building, and/or peace scholarship domains. As a new instrument in the global science and technology governance toolbox, a Science Peace Corps could work effectively, for example, towards elucidating the emerging concept of “one health”—encompassing human, environmental, plant, microbial, ecosystem, and planet health—thus serving as an innovative crosscutting pillar of 21st century integrative biology. An interdisciplinary program of this caliber for development would link 21st century life sciences to foreign policy and peace, in ways that can benefit many nations despite their ideological differences. We note that a Science Peace Corps is timely. The Intergovernmental Panel on Climate Change (IPCC) of the United Nations released the Fifth Assessment Report on March 31, 2014. Worrisomely, the report underscores that no person or nation will remain untouched by the climate change, highlighting the shared pressing life sciences challenges for global society. To this end, we recall that President John F. Kennedy advocated for volunteer work that has enduring, transgenerational, and global impacts. This culminated in establishment of the Peace Corps in 1961. Earlier, President Abraham Lincoln aptly observed, “nearly all men can stand adversity, but if you want to test a man's character, give him power.” We therefore petition President Barack Obama, other world leaders, and international development agencies in positions of power around the globe, to consider deploying a Science Peace Corps to cultivate the essential (and presently missing) ties among life sciences, foreign policy, development, and peace agendas. A Science Peace Corps requires support by a credible and independent intergovernmental organization or development agency for funding, and arbitration in the course of volunteer work when the global versus local (glocal) value-based priorities and human rights intersect in synergy or conflict. In all, Science Peace Corps is an invitation to a new pathway for competence in 21st century science that is locally productive and globally competitive. It can open up scientific institutions to broader considerations and broader inputs, and thus cultivate vital translational science in a world sorely in need of solidarity and sustainable responses to the challenges of 21st century science and society.
“Let me say in conclusion, this University is not maintained by its alumni, or by the state, merely to help its graduates have an economic advantage in the life struggle. There is certainly a greater purpose, and I'm sure you recognize it. Therefore, I do not apologize for asking for your support in this campaign.”
President John F. Kennedy
On the occasion of the Peace Corps Campaign,
On the steps of the University of Michigan Union
doi:10.1089/omi.2014.0079
PMCID: PMC4086476  PMID: 24955641
22.  Physician Emigration from Sub-Saharan Africa to the United States: Analysis of the 2011 AMA Physician Masterfile 
PLoS Medicine  2013;10(9):e1001513.
Siankam Tankwanchi and colleagues used the AMA Physician Masterfile and the WHO Global Health Workforce Statistics on physicians in sub-Saharan Africa to determine trends in physician emigration to the United States.
Please see later in the article for the Editors' Summary
Background
The large-scale emigration of physicians from sub-Saharan Africa (SSA) to high-income nations is a serious development concern. Our objective was to determine current emigration trends of SSA physicians found in the physician workforce of the United States.
Methods and Findings
We analyzed physician data from the World Health Organization (WHO) Global Health Workforce Statistics along with graduation and residency data from the 2011 American Medical Association Physician Masterfile (AMA-PM) on physicians trained or born in SSA countries who currently practice in the US. We estimated emigration proportions, year of US entry, years of practice before emigration, and length of time in the US. According to the 2011 AMA-PM, 10,819 physicians were born or trained in 28 SSA countries. Sixty-eight percent (n = 7,370) were SSA-trained, 20% (n = 2,126) were US-trained, and 12% (n = 1,323) were trained outside both SSA and the US. We estimated active physicians (age ≤70 years) to represent 96% (n = 10,377) of the total. Migration trends among SSA-trained physicians increased from 2002 to 2011 for all but one principal source country; the exception was South Africa whose physician migration to the US decreased by 8% (−156). The increase in last-decade migration was >50% in Nigeria (+1,113) and Ghana (+243), >100% in Ethiopia (+274), and >200% (+244) in Sudan. Liberia was the most affected by migration to the US with 77% (n = 175) of its estimated physicians in the 2011 AMA-PM. On average, SSA-trained physicians have been in the US for 18 years. They practiced for 6.5 years before US entry, and nearly half emigrated during the implementation years (1984–1999) of the structural adjustment programs.
Conclusion
Physician emigration from SSA to the US is increasing for most SSA source countries. Unless far-reaching policies are implemented by the US and SSA countries, the current emigration trends will persist, and the US will remain a leading destination for SSA physicians emigrating from the continent of greatest need.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Population growth and aging and increasingly complex health care interventions, as well as existing policies and market forces, mean that many countries are facing a shortage of health care professionals. High-income countries are addressing this problem in part by encouraging the immigration of foreign health care professionals from low- and middle-income countries. In the US, for example, international medical graduates (IMGs) can secure visas and permanent residency by passing examinations provided by the Educational Commission of Foreign Medical Graduates and by agreeing to provide care in areas that are underserved by US physicians. Inevitably, the emigration of physicians from low- and middle-income countries undermines health service delivery in the emigrating physicians' country of origin because physician supply is already inadequate in those countries. Physician emigration from sub-Saharan Africa, which has only 2% of the global physician workforce but a quarter of the global burden of disease, is particularly worrying. Since 1970, as a result of large-scale emigration and limited medical education, there has been negligible or negative growth in the density of physicians in many countries in sub-Saharan Africa. In Liberia, for example, in 1973, there were 7.76 physicians per 100,000 people but by 2008 there were only 1.37 physicians per 100,000 people; in the US, there are 250 physicians per 100,000 people.
Why Was This Study Done?
Before policy proposals can be formulated to address global inequities in physician distribution, a clear picture of the patterns of physician emigration from resource-limited countries is needed. In this study, the researchers use data from the 2011 American Medical Association Physician Masterfile (AMA-PM) to investigate the “brain drain” of physicians from sub-Saharan Africa to the US. The AMA-PM collects annual demographic, academic, and professional data on all residents (physicians undergoing training in a medical specialty) and licensed physicians who practice in the US.
What Did the Researchers Do and Find?
The researchers used data from the World Health Organization (WHO) Global Health Workforce Statistics and graduation and residency data from the 2011 AMA-PM to estimate physician emigration rates from sub-Saharan African countries, year of US entry, years of service provided before emigration to the US, and length of time in the US. There were 10,819 physicians who were born or trained in 28 sub-Saharan African countries in the 2011 AMA-PM. By using a published analysis of the 2002 AMA-PM, the researchers estimated that US immigration among sub-Saharan African-trained physicians had increased over the past decade for all the countries examined except South Africa, where physician emigration had decreased by 8%. Overall, the number of sub-Saharan African IMGs in the US had increased by 38% since 2002. More than half of this increase was accounted for by Nigerian IMGs. Liberia was the country most affected by migration of its physicians to the US—77% of its estimated 226 physicians were in the 2011 AMA-PM. On average, sub-Saharan African IMGs had been in the US for 18 years and had practiced for 6.5 years before emigration. Finally, nearly half of the sub-Saharan African IMGs had migrated to US between 1984 and 1995, years during which structural adjustment programs, which resulted in deep cuts to public health care services, were implemented in developing countries by international financial institutions as conditions for refinancing.
What Do These Findings Mean?
Although the sub-Saharan African IMGs in the 2011 AMA-PM only represent about 1% of all the physicians and less than 5% of the IMGs in the AMA-PM, these findings reveal a major loss of physicians from sub-Saharan Africa. They also suggest that emigration of physicians from sub-Saharan Africa is a growing problem and is likely to continue unless job satisfaction for physicians is improved in their country of origin. Moreover, because the AMA-PM only lists physicians who qualify for a US residency position, more physicians may have moved from sub-Saharan Africa to the US than reported here and may be working in other jobs incommensurate with their medical degrees (“brain waste”). The researchers suggest that physician emigration from sub-Saharan Africa to the US reflects the complexities in the labor markets for health care professionals in both Africa and the US and can be seen as low- and middle-income nations subsidizing the education of physicians in high-income countries. Policy proposals to address global inequities in physician distribution will therefore need both to encourage the recruitment, training, and retention of health care professionals in resource-limited countries and to persuade high-income countries to train more home-grown physicians to meet the needs of their own populations.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001513.
The Foundation for Advancement of International Medical Education and Research is a non-profit foundation committed to improving world health through education that was established in 2000 by the Educational Commission for Foreign Medical Graduates
The Global Health Workforce Alliance is a partnership of national governments, civil society, international agencies, finance institutions, researchers, educators, and professional associations dedicated to identifying, implementing and advocating for solutions to the chronic global shortage of health care professionals (available in several languages)
Information on the American Medical Association Physician Masterfile and the providers of physician data lists is available via the American Medical Associations website
The World Health Organization (WHO) annual World Health Statistics reports present the most recent health statistics for the WHO Member States
The Medical Education Partnership Initiative is a US-sponsored initiative that supports medical education and research in sub-Saharan African institutions, aiming to increase the quantity, quality, and retention of graduates with specific skills addressing the health needs of their national populations
CapacityPlus is the USAID-funded global project uniquely focused on the health workforce needed to achieve the Millennium Development Goals
Seed Global Health cultivates the next generation of health professionals by allying medical and nursing volunteers with their peers in resource-limited settings
"America is Stealing the Worlds Doctors", a 2012 New York Times article by Matt McAllester, describes the personal experience of a young doctor who emigrated from Zambia to the US
Path to United States Practice Is Long Slog to Foreign Doctors, a 2013 New York Times article by Catherine Rampell, describes the hurdles that immigrant physicians face in practicing in the US
doi:10.1371/journal.pmed.1001513
PMCID: PMC3775724  PMID: 24068894
23.  Improving health services for African migrants in China: A health diplomacy perspective 
Global public health  2014;9(5):579-589.
Global health has been an increasingly prominent component of foreign policy in the last decade. The term health diplomacy has been used to describe this growing interface between foreign policy and global health, and it encompasses both the concept of using health to further foreign policy objectives, as well as the idea that diplomatic tools can be helpful for attaining public health goals. The Chinese presence in Africa has grown in the last 15 years, generating increased interest in Sino-African relations. While much has been written in recent years about the Chinese presence in Africa, the growing numbers of Africans in China have attracted considerably less attention. Many are small-scale traders and might be expected to face many of the health challenges common among foreign migrants, but their health needs have been largely unrecognised. In this paper, we consider how a health diplomacy approach could be applied to African migrants in China, and the potential advantages and limitations of this strategy. We identify areas of overlap between public health, trade, and foreign policy goals that can be emphasised to generate support for improved services for African migrants in China and to engage partners from a diversity of sectors.
doi:10.1080/17441692.2014.908935
PMCID: PMC4089857  PMID: 24807820
China; Africa; health diplomacy; migrants; migration
24.  One Health: Past Successes and Future Challenges in Three African Contexts 
Background
The recent emergence of zoonotic diseases such as Highly Pathogenic Avian Influenza (HPAI) and Severe Acute Respiratory Syndrome (SARS) have contributed to dominant Global Health narratives around health securitisation and pandemic preparedness, calling for greater co-operation between the health, veterinary and environmental sectors in the ever-evolving One Health movement. A decade later, One Health advocates face increasing pressure to translate the approach from theory into action.
Methodology/Principal Findings
A qualitative case study methodology was used to examine the emerging relationships between international One Health dialogue and its practical implementation in the African health policy context. A series of Key Informant Interviews (n = 32) with policy makers, government officials and academics in Nigeria, Tanzania and Uganda are presented as three separate case studies. Each case examines a significant aspect of One Health operationalisation, framed around the control of both emerging and Neglected Zoonotic Diseases including HPAI, Human African Trypanosomiasis and rabies. The research found that while there is general enthusiasm and a strong affirmative argument for adoption of One Health approaches in Africa, identifying alternative contexts away from a narrow focus on pandemics will help broaden its appeal, particularly for national or regionally significant endemic and neglected diseases not usually addressed under a “global” remit.
Conclusions/Significance
There is no ‘one size fits all’ approach to achieving the intersectoral collaboration, significant resource mobilisation and political co-operation required to realise a One Health approach. Individual country requirements cannot be underestimated, dismissed or prescribed in a top down manner. This article contributes to the growing discussion regarding not whether One Health should be operationalised, but how this may be achieved.
Author Summary
The One Health movement requires more robust evidence around its practical implementation if it is to truly become a way forwards for addressing health issues at the human, animal and ecosystem interface. The research in this paper discusses some of the recent successes and challenges with both Emerging and Neglected zoonoses in the sub-Saharan Africa context. Through speaking to various human and animal health practitioners and policy makers in Uganda, Nigeria and Tanzania, the authors have created three case studies highlighting the various successes of the approach to date, but also clarifying areas where the approach will take longer to implement, often as a result of the wide institutional and policy changes required in many countries. The authors conclude that whilst the “goodwill” is certainly there, the reality of planning, executing and budgeting for joint interventions – particularly at the national or regional level – proves in many cases more difficult than first thought. It is hoped however that through gaining better insight from those charged with the decision-making in these countries, One Health practitioners will be encouraged to build on the momentum through addressing some of the issues that arise with its implementation.
doi:10.1371/journal.pntd.0002884
PMCID: PMC4031173  PMID: 24851901
25.  Culture, class, and service delivery: The politics of welfare reform and an urban bioethics Agenda 
Conclusion
Culture and class remain contested terrains in policy narratives about the right of the urban poor to access health and social services delivery systems under welfare reform. An urban bioethics agenda is needed to address these dilemmas that have arisen in the context of PRWORA and had an impact on access to health and social services in the urban environment.2;18 Such efforts, however, must address the intellectual framing of the urban poor, as well as the public policies that inscribe deterministic and stereotypical ideas about the poor alongside incomplete portraits of barriers to greater social and occupational mobility.
The focus of social science researchers on the delineation of behavioral characteristics among an urban “underclass” in some instances further marginalizes and stigmatizes an already isolated urban poor. Even though Wilson, the Harvard sociologist who popularized the term “underclass” in his earlier research, has now largely disowned it, tales and stories a bound in the social policy and health literature. The media also commonly underscore perceptions that establish rumor as social science and promote stereotypes that the poor are lazy and unwilling to work. Wilson, who has analyzed contextual and neighborhood factors such as the migration of jobs to the suburbs, has also declared stance that is in opposition to those, such as New York University political science professor Lawrence Mead, who embrace a “culture of poverty” thesis and have set the tone for some welfare reform initiatives by arguing that behavior, and not joblessness, is the key, “My guess,” Mead stated after welfare reform was enacted in 1996, ”is that culture came first, and drove away the economy or the good jobs, rather than the other way around,” 21(p3)These statements continue to have dramatic impacts on the stigmas attached to public programs by promoting the idea that those in spatially concentrated radical and ethnic groups in urban areas are not members of the working class. Such perceptions have also contributed to a belief that those who participate in publicly subsidized social welfare and health insurance programs do not work.
Whether one accepts that the denial of health care to citizens and noncitizens in contemporary America derives in large part from the promotion of images of the poor as pathological, states have moved steadily to institute a variety of policies under welfare reform that continue to prescribe narrower eligibility criteria for access to service delivery systems. This is occurring as the US Congress hesitates to restore excluded populations, and there are reports of questionable practices targeted at those who are eligible based on current legislation. On several occasions, for example, the Civil Rights Division of the US Department of Health and Human Services has made inquiries (and issued sanctions) in cases for which state and local governments have discriminated against potential Medicaid and TANF applicants by ignoring regulations that stipulate that applications be delivered to applicants on request in a timely manner.3
While it is the explicit responsibility under welfare reform of the US Congress to pass legislation restoring eligibility to excluded populations, an urban bioethics agenda framed in a historical context has much to offer prevailing policy discourses. If, as political theorist Stone notes, a policy alternative is to be judged “by the company that it keeps,” then urban bioethicists can offer human rights paradigms and additional policy alternatives based an assessments of earlier historical experiences of stigmatization that embodied similar forms of evil.23
doi:10.1093/jurban/78.1.81
PMCID: PMC3456202  PMID: 11368206

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