PRB

Jeremy Shiffman is a Visiting Scholar at PRB, and professor of public administration and policy at American University in Washington, D.C. A political scientist by training, he researches the politics of health policy and administration in low-income countries, with a particular interest in health agenda-setting: why some issues receive priority while others are neglected. He has investigated maternal survival, newborn survival, family planning, donor funding for health, and health systems reform, among other issues. His research has been funded by the Gates, MacArthur, and Rockefeller foundations. His work has appeared in The Lancet, Population and Development Review, The American Journal of Public Health, Social Science and Medicine, Health Policy and Planning, The British Journal of Obstetrics and Gynaecology, and The Bulletin of the World Health Organization. Heidi Worley, senior writer/editor at PRB, spoke with Shiffman about his current research on global health networks.

WORLEY: How do you define a “global health network?
SHIFFMAN: Global health networks are cross-national webs of individuals and organizations linked by a common concern about a particular global health problem. They now exist for nearly all high-burden health conditions in low-income countries. These networks connect various types of institutions—United Nations agencies, donors and foundations, national governments, nongovernmental organizations (NGOs), medical associations, research institutions, and think tanks. Some network members produce knowledge; others advocate; still others provide funds, develop policy ideas, or implement programs. Among their activities, global health networks exchange information on promising new interventions, debate how best to address conditions at global conferences, organize campaigns, and press governments and donors to provide resources.

WORLEY: Can you give us some examples?
SHIFFMAN: For some health conditions one can identify a specific institution that facilitates collective action, for example, the Roll Back Malaria Partnership. For other conditions, multiple institutions bring together individuals and organizations in networks: For instance, for HIV/AIDS there are biennial international conferences, civil society coalitions, a formal UN body (UNAIDS), a financing mechanism (the Global Fund to Fight AIDS, Tuberculosis and Malaria), and a large bilateral program (the U.S. President’s Emergency Plan for AIDS Relief). For still other conditions—mental health, for example—institutions are weak, making informal ties crucial for network formation and spurring collective action.

WORLEY: Why is it important to study global health networks?
SHIFFMAN: In the past three decades, the global health landscape has shifted dramatically with the proliferation of global health networks. Thirty years ago, international health looked considerably different—strong networks of individuals and organizations existed for a few conditions: malaria, smallpox, polio, and several other vaccine-preventable childhood diseases. For most conditions, however, if a global effort existed at all, it was largely housed in an international organization, usually the World Health Organization, that worked bilaterally with national governments rather than through a global network. Yet despite their growth, health policy scholars have given global health networks little attention. As a result, we don’t know much about why they have emerged, what effects they produce, and what roles they play in the global governance of health.

WORLEY: Which networks are you examining in your research program?
SHIFFMAN: Our research program considers six global health networks addressing high-burden conditions in low- and middle-income countries to learn more about how networks emerge and what effects they have. Our case studies include networks that address tuberculosis, pneumonia, tobacco use, alcohol control, newborn mortality, and maternal death in childbirth. These studies are part of the Global Health Advocacy and Policy Project, a research initiative funded by the Bill & Melinda Gates Foundation that groups 14 investigators from North America, South America, and Europe.

WORLEY: What outcomes are you studying?
SHIFFMAN: Two questions ground this project.

• Effectiveness: Why are some networks better able than others to assert influence in the direction of their preferences?
• Emergence: Why do networks more easily crystallize around some global health issues than others, and once formed, why do some flourish while others stagnate?

Effectiveness refers to the extent to which networks are able to change the world to meet their members’ perceptions of what reality should look like.¹ We examine effectiveness by considering outputs, policy consequences, and impact. Outputs are the immediate products of network activity, such as guidance on intervention strategy, research, and international meetings. Policy consequences pertain to the global policy process, including international resolutions, funding, national policy adoption, and the scale-up of interventions. Impact refers to the ultimate goal of improvement in population health.

By emergence we mean both the formation and the evolution of networks. Global networks materialize around some issues but not others. And among those that form, only some flourish. Understanding whether and how they emerge is crucial if we wish to understand their role, particularly since early decisions on matters such as governance, membership, and focus may have lasting consequences.²

While our focus is explaining the emergence and effectiveness of networks, we also consider their legitimacy, that is, whether they have a right to exert power, and why they differ in the degree to which they are perceived to have this right.

WORLEY: How will you examine the effectiveness and emergence of global health networks?
SHIFFMAN: Emergence and effectiveness of global health networks are best understood by looking at the interaction among three categories of factors.

Features of networks themselves and the actors in them: leadership, governance, composition, and framing strategies.

Features of their policy environments: allies and opponents, funding, and global norms.

And particular characteristics of the issues they address.³ Especially important are:

• Severity of the problem: Robust networks are more likely to emerge when problems lead, or are perceived to lead, to high mortality and morbidity, economic damage, or social disruption.
• Tractability of the problem: Networks are more likely to form and be effective on problems perceived to be solvable.⁴
• Nature of the affected populations: Populations that inspire sympathy, especially those understood not to be responsible for acquiring the condition—children affected by HIV/AIDS, for instance—are more likely to inspire network mobilization.⁵ Also, positive network results are more likely if affected populations are able to mobilize on their own behalf. People living with HIV/AIDS, for instance, have been a backbone for a global AIDS movement, facilitating its growth, effectiveness, and perceived legitimacy.

This research program on global health networks will conclude at the end of 2014 and will culminate in a series of articles based on the findings. Collectively, these papers will represent the first comparative research effort on the emergence and effectiveness of global health networks.

References

1. Kathryn Sikkink, “The Power of Networks in International Politics,” in Networked Politics: Agency, Power, and Governance, ed. Miles Kahler (Ithaca, NY: Cornell University Press, 2009).
2. Paul Pierson, “Path Dependence, Increasing Returns, and the Study of Politics,” American Political Science Review 94, no. 2 (2000): 251-67.
3. Margaret E. Keck and Kathryn Sikkink, Activists Beyond Borders: Advocacy Networks in International Politics (Ithaca, NY: Cornell University Press, 1998); and Deborah A. Stone, “Causal Stories and the Formation of Policy Agendas,” Political Science Quarterly 104, no. 2 (1989): 281-300.
4. Stone, “Causal Stories and the Formation of Policy Agendas.”
5. Stone, “Causal Stories and the Formation of Policy Agendas”; and Anne Schneider and Helen Ingram, “Social Construction of Target Populations: Implications for Politics and Policy,” American Political Science Review 87, no. 2 (1993): 334-47.