Advancing Global Health – The Need for (Better) Social Science

Abstract

In his perspective "Navigating between stealth advocacy and unconscious dogmatism: the challenge of researching the norms, politics and power of global health," Ooms argues that actions taken in the field of global health are dependent not only on available resources, but on the normative premise that guides how these resources are spent. This comment sets out how the application of a predominately biomedical positivist research tradition in global health, has potentially limited understanding of the value judgements underlying decisions in the field. To redress this critical social science, including health policy analysis has much to offer, to the field of global health including on questions of governance.

In his perspective “Navigating between stealth advocacy and unconscious dogmatism: the challenge of researching the norms, politics and power of global health,” ¹ Ooms argues that actions taken in the field of global health are dependent not only on available resources, but on the normative premise that guides how these resources are spent. However, these are currently not explicitly revealed in discussions on ‘best-buys’ in global health. Indeed, the level of resources that are presented as available for global health by donor countries are dependent on how (or in this extent) how much of a priority health or specifically global health is.

Yet, rather than explicitly acknowledging the value judgements implicit in decisions on funding for global health - and having an open debate about the politics guiding funding and interventions – these remain ignored. Discussions focus on which best ‘technical’ or ‘scientific’ interventions should be adopted within a given field, such as maternal and child health or HIV. Here criteria for decision-making are mostly presented as apolitical focused on how to (a) save the greatest number of lives or (b) reach the greatest number of people (with the ultimate objective of saving or improving their lives) within the constraints of a specific budget. This masks wider political agendas that may be underlying decision-making processes as well as a frank discussion on who has power in global health and on how to hold those actors accountable. Ooms argues that actors in global health are either aware of their normative premise but seek to hide the motives advocating by stealth, or are unconscious of the dogma that guides their decision-making.

Researchers and scientists working in the field of global health are currently caught in this paradigm. They – we – try to present different interventions or policies as scientifically sound while seemingly and at all cost avoiding head on discussion of the value judgements that determine decisions and research agendas. The ‘real’ reasons for why a set of interventions are chosen over others often lie outside of the realm of biomedical research but are dependent on actor power and on politics. To understand why certain policies fail while others succeed does not depend simply on identifying the best medication, the most effective intervention or technology, but rather it is the contestation between different underlying values ie, Ooms’ normative premise, and how these play themselves out in the policy process within a given context.

Ooms is right to argue that the engagement of social sciences with the field of global health to date has been limited. Global health has its roots in biomedical sciences, building strongly on empirical observation, replicable experiments and proof of an intervention working ‘effectively,’ rather than questioning the basic premise or underlying agenda that is so badly needed to address the core questions in global health. Gilson and colleagues have in the past examined the potential contribution of social sciences to the field of health policy and systems’ research (and thus to questions of global health). ² Their insight of the different knowledge paradigms underlying biomedical and social science research explain some of the limitations we currently experience in global health research. A positivist worldview underlies much of clinical, biomedical and epidemiological research. This type of research focuses on investigating facts and knowledge in a single reality that can be observed – ie, the empirical focus that global health research has taken. It contrasts with social science which often centres on the relativist knowledge paradigms, where realities are constructed by actors who bring empirical and replicable findings to life in relation to their specific social context. Such research acknowledges the validity of multiple realities as opposed to the idea of ‘one absolute truth’ that has guided biomedical research informed by the normative knowledge paradigm.

The Need for Health Policy Analysis Focused on Process

Here two areas of research offer particularly valuable insights and potential for the field of global health. First, the domain of health policy analysis focused on process, and relating these to outcomes. The work by Gill Walt, Lucy Gilson, and Jeremy Shiffman has much to offer. ^3-5 Rather than assuming a ‘black-box’ of issues from which policies and priorities arise, Shiffman’s framework of agenda-setting (building on the work of John Kingdon) explains why maternal mortality emerged as a priority in global health at a specific time. ⁵ Gilson’s analysis highlights the role of front-line health workers to understand why a policy succeeds and why it fails. ⁶ These studies show how important it is to examine the different processes that govern the development of policy and its implementation in detail. They demonstrate that rather than focusing solely on the content or what might be termed the ‘ingredients’ of a policy, procedural questions, actors involved, their values and ideas, as well as broader contextual issues are what determines whether a policy developed in Geneva, Seattle or Washington, DC can successfully be replicated in different low- and middle-income settings.

Second, increasingly attention of researchers in global health has focused on the rise of evidence-based policy-making in health, and the extent to which the use of ‘evidence-based policy-making’ itself has been political. ⁷ For example, the initial abstinence only focus of the US President’s Plan for AIDS Relief (PEPFAR) was critiqued for presenting an approach informed by religious values and beliefs as empirical evidence. ⁸ This type of research, analysing the policy process and ‘how’ evidence is used, go to the core of understanding how the normative issues in global health shape action and inaction as well as success and failure.

The importance of process (and the factors shaping it) to understanding outcomes of global health policy have implications for the type of research and focus required to address the most pressing issues in global health to date. While outcome data, and quantitative analysis are essential, these will in many instances need to be informed and addressed by qualitative research, mixed methods to understand context and actors and research focused on complexity. To enable discussion of the normative challenges at the heart of global health will thus require new knowledge, new types of evidence and significantly greater investigation of the policy process and the very nature of what is conceived of as evidence to inform decision and policy-making in global health.

The application of critical social science theory to interrogating some of the core questions of global health is only just beginning (Ooms provides as an example for this treatment of antiretroviral medicines for HIV and AIDS in low- and middle-income countries). Social science methods have already been employed to understand better why some policies and initiatives succeed and others fail. But not enough. Many of the central questions of global health: whose interests’ are served by interventions adopted and funded in global health, who decides on the overall resource envelope for global health challenges, remain unanswered. These types of political economy questions, investigating underlying power relations and normative premise can only be answered through greater, more rigorous application of social sciences to the field. And a focus on health policy analysis and research focusing on the role of evidence and ideas in health policy-making.

Governance of and for Global Health

One aspects of global health research where the potential for greater insight through more and more rigorous research of this type seems particularly important is governance. The health challenges facing the world are many and they are complex. Infectious diseases continue to threaten health and the very fundamentals of our society as evidenced by the recent Ebola outbreak, the rise of non-communicable disease and the health impacts associated with globalisation (notably, migration, and inequalities in health). These call for a coordinated response involving the many different types of actors working in the field of health, from national governments, international organisations to private sector actors and foundations. ⁹ Governance of and for global health has received increasing attention during the past decade. ^10,11 Governance for global health was subject to a Commission, ¹² and has its own academic journal associated with it. Yet, a pervasive framework for understanding relations between the different global health actors and their actions is still missing. And while the Commission and its Commissioners have highlighted the importance of acknowledging the political determinants of health, ¹³ this has so far resulted in only a limited amount of actual research. Developing a pervasive framework of governance for global health, as well as for the analysis of such governance will be essential to addressing global health challenges and developing the field.

However, to bring such ‘social science muscle’ to the field of global health will require substantial resources and investment. Despite the developments of the field of global health, including focused on governance, the majority of funding continuous to be awarded to large, often single focus programmes. These often have as an ultimate goal a health outcome or even eradication of a disease. This pattern of funding limits the types of research that needed to ultimately succeed in these endeavours of improving health and eradicating disease. Much has already been achieved by current approaches in global health, and many lives saved and improved. Yet, so much more could be accomplished if the current approach of large ambitious health programmes focused on ‘technical’ or biomedical solutions was equalled by attention and focus on process and power relations. So while Ooms argues it is not about resources but about informed debate on how these are spent – such debate itself requires resources.

Why Does the Gates Foundation not Have a Programme on the Political Economy of Global Health?

In sum, the greater and more rigorous application of the social sciences, a focus on process and power relations in global health is essential to addressing the normative challenge Ooms’ outlines. Policy analysis offers particular value here, as does research focused on the role of and contestation of evidence. To enable such research will require a significant refocusing of resources currently available in global health research, and a restructuring of how policies and programmes are designed to ensure they are informed by the type of social science research highlighted. While the value of this type of research and knowledge is increasingly acknowledged and articulated this has not been translated into tangible actions and resources. Why does the Gates Foundation not have a programme on the political economy of health? Or on health policy analysis? And the same question could be asked of many other global health funders and actors.

The continued failure to refocus efforts and resources will mean not only limitations in the field of global health. It will ultimately result in the failure to address the big challenges posed by growing health inequalities, the re-emerging threats of communicable disease and the rise in non-communicable disease.

Ethical issues

Not applicable.

Competing interests

Author declares that she has no competing interests.

Author’s contribution

JH is the single author of the paper.

Citation: Hanefeld J. Advancing global health – the need for (better) social science: Comment on: "Navigating between stealth advocacy and unconscious dogmatism: the challenge of researching the norms, politics and power of global health." Int J Health Policy Manag. 2016;5(4):279–281. doi:10.15171/ijhpm.2016.13