Power is omnipresent in global health. As members of the Health Systems Global SHAPES (Social Science Approaches for Research and Engagement in Health Policy and Systems) power cluster, we try to foster a systematic examination of power in health policy and systems research and action. Earlier this year, for example, the cluster co-authored an article on the “10 best resources on power in health policy and systems in low- and middle-income countries,” drawing on a structured search as well as consultation process during the 2016 Global Symposium on Health Systems Research in Vancouver.
The paper presented and synthesized ten outstanding resources that provided either a conceptual or empirical exploration of the role of power in health systems. We then went on to describe priorities for the field, which included the need for:
- More research – especially action-oriented research – on the connections among flows of power at different levels of the health system
- Better understanding of issues of power at the frontlines of health care provision
- More participatory action research and more research that is co-produced by researchers and implementers with clear social change objectives
- More thinking about methodological and theoretical tools to study power
From the time we began writing our paper in 2015, several new or resurgent trends in global health, geopolitics, and social movements have reshaped the health policy and systems landscape. The priorities for the field that were identified in our paper can be used as a lens to explore some of these emergent global health and governance trends, some of which are on the agenda for the Fifth Global Symposium for Health Systems Research in Liverpool. Strengthening recognition of these trends is a critical step to any effort to characterize and understand the diffuse forms and expressions of power in health systems. Some of these trends include:
- The commercial determinants of health: Health researchers increasingly recognize the influence of commercial actors in shaping health. Taxes on alcohol, sugar and tobacco are now the focus of a reinvigorated debate, and there is growing pushback against commercial involvement in health research. Ilona Kickbusch and colleagues proposed the rubric of the ‘commercial determinants of health’ to illustrate the fundamental role of the private sector in marketing products that are detrimental to health, and in actively working against regulation. A broader conceptualization of the commercial determinants of health may include the ways neo-liberal trade practices are influencing power dynamics within health systems. For example, power analysis could engage with the confluence of rising corporate interests in health and reduced collective bargaining power for most professions around the world, set against (in many places) the still-powerful influence of medical doctors and their interests. Taxes and the impact of trade policies on drug availability will be presented at Liverpool.
- The interface of public and private interests in health systems: Private interest in profit impacts on health service delivery beyond simplified debates about public versus Indeed private profit motives exist to varying degrees in public systems, and some governments try to make the private more public, by incentivizing the delivery of public goods in privatized systems. Issues such as the regulation of private health care providers and insurance companies, and a plenary dedicated to “polemic and pragmatism” on the private sector are on the agenda in Liverpool.
- The impact of closing civil society space on the context for health service delivery and health advocacy: International think tanks and NGOs note an increasing trend of closing civil society space globally. Decreasing space may manifest in de facto and de jure restrictions on speech, action, and funding. A wide range of activities are undercut, including civil society monitoring of health services, citizen efforts to expose and counter corporate capture of regulatory processes, and other efforts on the social determinants of health. Too, NGOs and community groups may lose funding from governmental and other sources. In many contexts, this closing space is accompanied by changes in political discourse regarding populations that disproportionately experience poor health status and access, such as ethnic and religious minorities, women, low caste or indigenous groups, gender non-conforming people, and people engaged in criminalized behavior. Civil society space is less explicitly present in the Symposium program, but germane.
- Decreased commitment to multilateralism: Global health has come to be organized by deliberative, multilateral action – action that is theoretically focused on promoting health and well-being for all. However, nationalist and security-oriented agendas are increasingly challenging international health cooperation. Cuts to funding for WHO, UNFPA and other multilateral organizations, increasing focus on global health as a matter of security for wealthy countries, and the increasing fragility of multilateral political entities such as the European Union weaken efforts to identify and address emerging global health challenges as well as norms of solidarity.
These interlinking trends have very real implications on health around the world. For example, officials negotiating a Declaration for the September 2018 UN General Assembly High Level Meeting on Ending Tuberculosis succumbed to U.S. pressure and dropped references to TRIPS (Trade-Related Aspects of Intellectual Property Rights) flexibilities. The importance of multilateralism is implicit in many Liverpool events; we anticipate discussion and questions about how the current political context affects effective multilateral action.
Each of these trends has specific manifestations in different countries, but are shaped by a confluence of global forces. The research priorities we proposed in the ‘Top 10…’ paper can help to generate knowledge that can disrupt these emergent power dynamics shaping health. To produce actionable knowledge, research on power should take a ‘glocal’ approach by relating such emergent global phenomena to their expressions at the frontlines. Co-leading and designing such research with actors in different geographic and social positions is appropriate; it ensures that the study of power in health systems is apt, and also recognizes how we, ourselves are actors in the dynamics of power.
Given the diversity of countries and disciplines to be represented at Liverpool, we look forward to panels and interactions where we can discuss these issues, and consider methodological and ethical questions regarding such research.