Table 1 - uploaded by Jennifer Prah Ruger
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With the exception of key 'proven successes' in global health, the current regime of global health governance can be understood as transnational and national actors pursuing their own interests under a rational actor model of international cooperation, which fails to provide sufficient justification for an obligation to assist in meeting the health...
Citations
... The reasons for this are as follows: Firstly, there are underlying assumptions that communities have a "sense of place", which means that they are homogeneous. Secondly, it makes for sustainable social capital with natural organizational forms that can easily relate to governments and markets, which are accountable and can plan, manage, deliver, and coordinate better than governments or markets [43]. ...
The rise in aging world populations poses enormous concerns, among which is the critical topic of how to promote active aging by improving the health and well-being of the elderly. Accordingly, installing elevators in old residential buildings has become a main issue in age-friendly community regeneration to make it easier for the elderly to go outside. There is limited evidence on stakeholder involvement in age-friendly community regeneration. Some studies have overlooked the fact that fostering age-friendly communities in developing countries requires innovative governance for inclusive physical and social features despite the low awareness of citizen engagement. With reference to community governance as a structure and process, a theoretical framework is proposed to understand the practice of elevator installation in age-friendly community regeneration in Guangzhou, China. This study adopted the questionnaire survey method and collected 455 valid samples (150 valid samples with installed elevators; 305 valid samples did not install elevators). The findings led to the following conclusions: (1) shared common interests lead to effective community governance and smooth elevator installation; (2) some communities failed to install elevators due to opposition from people whose interests were hindered; and (3) it is important to set up self-governing organizations and find key people in community governance for interest-based negotiation. This paper’s contribution is that it makes up for the deficiency in the previous research that has neglected the elderly’s participation in public affairs via age-friendly community regeneration. Finally, this study suggests further research on the dynamic processes of different types of age-friendly community regeneration affairs.
... (GHG) has been theorised as operating under the rational actor model (RAM) where 'each actor has its own set of goals and objectives, and these actors take actions based on analysis of the costs and benefits of various available options'. 13 Under RAM, each actor acts on their own set of explicit and implicit goals. Explicit goals come in the form of mission statements, bylaws and other founding documents. ...
Objectives
Despite increases in global health actors and funding levels, health inequities persist. We empirically tested whether global health governance (GHG) operates under the rational actor model (RAM) and characterised GHG power dynamics.
Design
We collected approximately 75 000 tweets of 20 key global health actors, between 2016 and 2020, using Twitter API. We generated priorities from tweets collected using topic modelling. Priorities from tweets were compared with stated priorities from content analyses of policy documents and with revealed priorities from network analyses of development assistance for health funding data. Comparing priorities derived from Twitter, policy documents and funding data, we can test whether GHG operates under RAM and characterise power dynamics in GHG.
Participants
20 global health actors were identified based on a consensus of three peer-reviewed articles mapping global health networks. All tweets of each actor were collected in 3-month intervals from November 2016 to May 2020. Policy documents and developmental assistance for health (DAH) financial data for each actor were collected for the same period.
Results
We find all 20 actors and the global health system collectively fulfil the three conditions of RAM based on stated and revealed priorities. We also find compulsory and institutional power asymmetries in GHG. Funding organisations have compulsory power over channels of DAH and implementing institutions they directly fund. Funding organisations also have transitive influence over implementing institutions receiving DAH funding.
Conclusions
We find that there is a correlation between the priorities of large funders and the priorities of health actors. This correlation in conjunction with GHG operating under the RAM and the asymmetric power held by funders raises issues. GHG under the RAM grants large funders majority of the power to determine global health priorities and ultimately influencing outcomes while implementing organisations, especially those that work closest with populations, have little to limited influence in priority-setting.
... Governing for the common good These successful countries use shared health governance to help prevent prema ture mortality and avoidable morbidity. 8 Efficient healthcare and public health sys tems require shared responsibility, shared resources, and shared sovereignty. Private actors and public institutions engage col lectively to ensure the health and flourish ing of all. ...
... Souvent critiquée, la coordination de l'aide en santé globale est complexifiée par un nombre croissant d'acteurs et d'accords de gouvernance. En fait, la coordination et l'harmonisation de l'aide sont des enjeux fortement étudiés dans la littérature contemporaine afin d'améliorer les pratiques dans le monde du développement (Barry & Boidin, 2012;Hatcher, 2003;Ng & Ruger, 2011;OCDE, 2012;Ruger, 2012;Szlezák et al., 2010). Les gouvernements coordonnent leur réponse aux défis de santé globale à travers une variété de mécanismes tous aussi différents les uns des autres (Frenk & Moon, 2013). ...
... The high importance placed on the perspectives and actions of health care providers, which is so strongly evident in this study as well as our previous research on unmet health care needs , lends weight to the potential effectiveness of patient-informed education for health care providers in weakening the connection between stigma and disparities in health access, health outcomes, and future health care seeking for marginalized groups (Bodkin, Delahunty-Pike, & O'Shea, 2015;Chaudoir, Earnshaw, & Andel, 2013). Gorry et al. (2010) argue prostitution stigma and other related stigmas will only be reduced when health providers understand and acknowledge the psychological burden of negative judgment on their patients, i.e., when they understand that stigma is a fundamental determinant of health (Link & Phelan, 1995;Link & Phelan, 2014) and major barrier to health equity (Pauly et al., 2009;Ruger, 2011;Sen & Östlin, 2007). Metzl and Hansen (2014) further contend that in order to combat stigma, providers must develop Bstructural competency,^a concept which includes recognition of the Bassumptions embedded in language and attitude that serve as rhetorical social conduits for some groups of persons, and as barriers to others^(p. ...
Prostitution stigma has been shown to negatively affect the work, personal lives, and health of sex workers. Research also shows that sex workers have much higher unmet health care needs than the general population. Less is known about how stigma obstructs their health-seeking behaviors. For our thematic analysis, we explored Canadian sex workers’ accounts (N = 218) of accessing health care services for work-related health concerns. Results show that participants had mixed feelings about revealing their work status in health care encounters. Those who decided not to disclose were fearful of negative treatment or expressed confidentiality concerns or lack of relevancy. Those who divulged their occupational status to a health provider mainly described benefits, including nonjudgment, relationship building, and comprehensive care, while a minority experienced costs that included judgment, stigma, and inappropriate health care. Overall, health professionals in Canada appear to be doing a good job relating to sex workers who come forward for care. There is still a need for some providers to learn how to better converse with, diagnose, and care for people in sex work jobs that take into account the heavy costs associated with prostitution stigma.
... For example, Raphael and Bryant (2015) considers the power differentials across a capitalist economy's business, labour, and civil society sectors, highlighting how a differ ential balance of power across these sectors has distinctive impacts on the social determi nants of health within social democratic welfare states (Nordic countries), liberal welfare states (Anglo-Saxon countries), and conservative welfare states (European continental countries). Analysis from a shared health governance perspective illuminates a rational actor model of global health governance in which actors and institutions in the global health system fail to adhere to principles of global health justice, which seek to equalise power among global citizens through equal respect for all individuals' health (Ruger 2012). ...
Careful investigations of the political determinants of health that include the role of power in health inequalities—systematic differences in health achievements among different population groups—are increasing but remain inadequate. Historically, much of the research examining health inequalities has been influenced by biomedical perspectives and focused, as such, on ‘downstream’ factors. More recently, there has been greater recognition of more ‘distal’ and ‘upstream’ drivers of health inequalities, including the impacts of power as expressed by actors, as well as embedded in societal structures, institutions, and processes. The goal of this chapter is to examine how power has been conceptualised and analysed to date in relation to health inequalities. After reviewing the state of health inequality scholarship and the emerging interest in studying power in global health, the chapter presents varied conceptualisations of power and how they are used in the literature to understand health inequalities. The chapter highlights the particular disciplinary influences in studying power across the social sciences, including anthropology, political science, and sociology, as well as cross-cutting perspectives such as critical theory and health capability. It concludes by highlighting strengths and limitations of the existing research in this area and discussing power conceptualisations and frameworks that so far have been underused in health inequalities research. This includes potential areas for future inquiry and approaches that may expand the study of as well as action on addressing health inequality.
... Why would they work together towards collective goals rather than continue to pursue self-interest? Even if actors did cooperate, why wouldn't they do so only in instrumental terms, viewing other actors as potential sources of costs or benefits as under a rational actor model (Ruger 2012)? ...
... Surprisingly, there are few examples of looking to IKT to support processes for the same [89]. Shared governance and public dialogue about our social and economic architecture is needed [90], where public moral norms can be re-constructed and internalised (e.g. recreating constructs of health equity as a public good). ...
... Governance processes could enhance current IKT frameworks to open considerations of how to weave evidence into decision-making while acknowledging conflicting norms and values within the political sphere under which it operates. Using shared health governance theory to drive this examination can contribute to more transparent and equity-centred approaches to understanding how these norms and values shape health problems [90]. Expanding IKT models to include governance would require re-examining legitimacy, transparency, power and inclusion in the process of connecting knowledge with action. ...
Background
The persistence of health inequities is a wicked problem for which there is strong evidence of causal roots in the maldistribution of power, resources and money within and between countries. Though the evidence is clear, the solutions are far from straightforward. Integrated knowledge translation (IKT) ought to be well suited for designing evidence-informed solutions, yet current frameworks are limited in their capacity to navigate complexity. Global health governance (GHG) also ought to be well suited to advance action, but a lack of accountability, inclusion and integration of evidence gives rise to politically driven action. Recognising a persistent struggle for meaningful action, we invite contemplation about how blending IKT with GHG could leverage the strengths of both processes to advance health equity.
Discussion
Action on root causes of health inequities implicates disruption of structures and systems that shape how society is organised. This infinitely complex work demands sophisticated examination of drivers and disrupters of inequities and a vast imagination for who (and what) should be engaged. Yet, underlying tendencies toward reductionism seem to drive superficial responses. Where IKT models lack consideration of issues of power and provide little direction for how to support cohesive efforts toward a common goal, recent calls from the field of GHG may provide insight into these issues. Additionally, though GHG is criticised for its lack of attention to using evidence, IKT offers approaches and strategies for collaborative processes of generating and refining knowledge. Contemplating the inclusion of governance in IKT requires re-examining roles, responsibilities, power and voice in processes of connecting knowledge with action. We argue for expanding IKT models to include GHG as a means of considering the complexity of issues and opening new possibilities for evidence-informed action on wicked problems.
Conclusion
Integrated learning between these two fields, adopting principles of GHG alongside the strategies of IKT, is a promising opportunity to strengthen leadership for health equity action.
... In its simplest form, global health governance refers to the framework of international norms, rules and principles that define and shape the way by which societies make and implement collective decisions (i.e. global health policy) to respond to health problems and challenges in the context of specific national and common transnational interests Ruger 2012;WHO 2014;Kickbusch and Szabo 2014). The intersection of traditional and RP influence here is evidenced, for example, in Thailand's lead in the UN's Foreign Policy and Global Health Initiative (FPGHI) as well as that country's national and international efforts to promote both the SDGs and Universal Health Coverage (UHC). ...
The idea of this paper is inspired by the dismal experience and lessons from the initially ineffective global (WHO-led) response to the 2014–2016 West African Ebola virus epidemic. It charts the evolution of global health policy and governance in the post-World War II international order to the current post-2015 UN Sustainable Development Goals era. In order to respond adequately existing and emerging health and development challenges across developing regions, the paper argues that global health governance and related structures and institutions must adapt to changing socio-economic circumstances at all levels of decision-making. Against the background of a changing world order characterised by the decline of US-led Western international liberalism and the rise of the emerging nations in the developing world, it identifies the ‘Rising Powers’ (RPs) among the emerging economies and their soft power diplomacy and international development cooperation strategy as important tools for responding to post-2015 global health challenges. Based on analysis of illustrative examples from the ‘BRICS’, a group of large emerging economies—Brazil, Russia, India, China and South Africa—the paper develops suggestions and recommendations for the RPs with respect to: (1) stimulating innovation in global health governance and (2) strengthening health systems and health security at country and regional levels. Observing that current deliberations on global health focus largely, but rather narrowly, on what resource inputs are needed to achieve the SDG health targets, this paper goes further and highlights the importance of the ‘how’ in terms of a leadership and driving role for the RPs: How can the RPs champion global governance reform and innovation aimed at producing strong, resilient and equitable global systems? How can the RPs use soft power diplomacy to enhance disease surveillance and detection capacities and to promote improved regional and international coordination in response to health threats? How can they provide incentives for investment in R&D and manufacturing of medicines to tackle neglected and poverty-related diseases in developing countries?
... Several of these articles stress the lack of integration of ethics and ethical guidance in public health policies and interventions [40,43,44,48,50,55,57,61]. Education and/or the assistance in ethics while developing/implementing public health interventions is also recommended [12,40,44,53,55]. Ten articles comment on existing and/or propose frameworks for an ethical evaluation of public health interventions in various contexts (including in health promotion, allocation decisions in humanitarian aid, health governance, and the monitoring and evaluation of interventions) [12,23,36,39,46,48,54,57,58,61]. ...
... Likewise when confronted by policies that are not adapted to the local contexts, as cultural factors are particularly important when it comes to food [26,111]. Partnerships and cross-sectoral collaborations may be needed at different levels, across different sectors, public or private [54,165]. Some authors from our sample stress the importance of not working in silos [12,85], one policy aimed at improving access to healthy food, for instance, may not be effective without the concurrent implementation of other social measures to reduce poverty or environmental barriers. ...
... The implementation of a policy may require additional measures that were not initially described or planned in the policy, so it is also possible that several policies must be implemented at the same time to be effective [71,79]. Those in charge of implementing nutrition-related policies may also have to cope with significant political resistance [88], lobbying pressures [80,88], bureaucracy [47], and the risks raised by the presence of potential conflicts of interests when developing partnerships [54,96]. Those involved in implementation need training and/or support, technical assistance, resources and ethical guidance for the adaptation of interventions to (cultural, social, economic, political, etc.) local contexts [55,73]. ...
[This corrects the article DOI: 10.1371/journal.pone.0186897.].
