Networks and global health governance: Introductory editorial for Health Policy and Planning supplement on the Emergence and Effectiveness of Global Health Networks

Global health networks are cross-national webs of individuals and organizations linked by a shared concern to address a particular health problem that affects or potentially affects a sizeable proportion of the world’s population. Formal institutions anchor some (e.g. the Global Polio Eradication Initiative). Informal ties characterize others (e.g. surgical conditions).

For several reasons, these networks deserve greater research attention than they have received. First, over the past quarter century they have proliferated and now exist for most problems that stand behind high mortality and morbidity in low- and middle-income countries. Secondly, differences in their effectiveness may be one reason some conditions receive greater attention and resources than others. Thirdly, their proliferation represents a shift in the way global health is governed: from a system dominated by hierarchical forms of organization—especially nation-states and intergovernmental organizations—to one also characterized by horizontal networking and growing participation of non-state actors. Fourth is concern about their legitimacy: by what authority, if any, do they exert power?

This supplement presents findings from a research project examining the emergence and effectiveness of global health networks addressing tobacco use, alcohol harm, maternal mortality, neonatal mortality, tuberculosis and pneumonia. The project, funded by a grant from the Bill and Melinda Gates Foundation, brought together 12 investigators from North American, South American and European institutions to investigate three questions:

1. How do global health networks emerge and evolve?

2. What role, if any, do they play in securing attention, raising resources and influencing policy for the conditions that concern them?

3. What factors shape their ability to do so?

The project has a comparative case study design. The six networks are grouped into three matched pairs: two communicable diseases that affect the respiratory system (tuberculosis and pneumonia); two groups vulnerable at birth (pregnant women and newborns); and two addictive substances (tobacco and alcohol). Within each pair, despite comparable or lower disease burden, the first issue has received greater policy attention than the second. We seek to understand why?

To do so, we develop and employ a framework on factors that may shape the emergence and effectiveness of global health networks (Shiffman, Quissell, Schmitz etal., 2016). It consists of 10 factors in three categories: (1) features of the networks and actors that comprise them, including leadership, governance arrangements, network composition and framing strategies; (2) conditions in the global policy environment, including potential allies and opponents, funding availability and global expectations concerning which issues should be prioritized; (3) and characteristics of the issue, including severity, tractability and affected groups.

The project has three principal findings, reported in the concluding paper (Shiffman, Schmitz, Berlan etal., 2016):

1. Although they are only one of many factors influencing priority, networks do matter, particularly for shaping the way the problem and solutions are understood, and convincing governments, international organizations and other global actors to address the issue. This finding is not an obvious one. The networks might have failed in their efforts. Or attention might have emerged entirely due to other factors, such as the individual rather than networked activity of involved actors, the influence of powerful nation-states or donors, growth in the severity of the problems and new solutions.

2. Networks are most likely to produce effects when (1) their members construct a compelling framing of the issue, one that includes a shared understanding of the problem, a consensus on solutions, and convincing reasons to act, and (2) they build a political coalition that includes individuals and organizations beyond their traditional base in the health sector, a task that demands engagement in the politics of the issue, not just its technical aspects. Maintaining a focused frame and sustaining a broad coalition are often in tension: effective networks find ways to balance the two challenges.

3. The emergence and effectiveness of a network are shaped both by its members’ decisions and by contextual factors, including historical influences (e.g. prior failed attempts to address the problem), features of the policy environment (e.g. global development goals) and characteristics of the issue the network addresses (e.g. its mortality burden).

Each of the nine papers in this supplement provide evidence for these findings. The introductory paper (Shiffman, Quissell, Schmitz etal., 2016) presents the conceptual framework and study design. Quissell and Walt (2016), examining the Global Partnership to Stop TB, find that having a centralized core group and a strategic brand helped the network to coalesce around a primary intervention strategy—directly observed treatment short course. However, this same centralization and stability has hindered its ability to adapt. Berlan (2016) discovers that global efforts to fight childhood pneumonia have lagged in part due to difficulties proponents have had in finding a shared identity that could facilitate network coalescence. Smith and Rodriguez (2016) find that the push of the Millennium Development Goals and network coalition-building and framing strategies stood behind a rise in the global agenda status of maternal survival in the 2000s after decades of neglect. Shiffman (2016) reveals that in the 2000s an effective group of committed champions brought global attention to the previously overlooked issue of newborn survival; however, resources remain insufficient due in part to the network’s recent emergence, its predominantly technical rather than political composition and strategies, and its inability to date to find a framing of the issue that has convinced national political leaders of the issue’s urgency.

Gneiting (2016) compares efforts by tobacco control activists to ensure national adoption of two interventions—smoke-free environments and taxation—covered by the 2003 Framework Convention on Tobacco Control. He finds more effective implementation of the former intervention, due less to the evidence base than political factors, including the strength of opposition to taxation. Schmitz (2016) discovers that a network formed to address alcohol harm was able to bring policy attention to the problem, but struggled to affect policy change due in part to disagreements over the value of a public health framing of the issue and a perceived failure of Prohibition. Gneiting and Schmitz (2016) reveal that greater progress on tobacco control than alcohol harm reduction is a result in part of the comparatively stronger capacity of tobacco control proponents to maintain consensus on policy solutions and to build a global coalition. The concluding paper (Shiffman, Schmitz, Berlan etal., 2016) elaborates on the project’s overall key findings noted earlier, and presents directions for future research on global health networks. It also suggests reasons both to affirm their legitimacy—including their members’ expertise and the attention they bring to neglected issues—and to question that legitimacy—including their largely elite composition and the fragmentation they bring to global health governance.

An overarching theme that emerges from these studies is that we might usefully characterize global health networks as engaged in strategic social construction that is path dependent. The idea of path dependence (Collier and Collier 1991; Mahoney 2000; Pierson 2000) pertains to the strong influence of initial decisions on subsequent developments, a result of increasing costs to change over time. The idea of strategic social construction (Finnemore and Sikkink 1998; Khagram etal. 2002) refers to the capacity of actors, acting instrumentally on principled concerns, to shape social reality. Strategic social construction that is path dependent implies that forces connected both to structure and agency influence global health outcomes. It suggests that network effectiveness is historically conditioned, but not historically determined: strategic networks can transcend historically imposed barriers; inattentive networks can squander historically provided opportunities. Rather than focus alone either on the decisions of actors or on social structure, future research on networks would do well to examine how historical precedent and structural forces interact with individual and organizational agency to produce global health outcomes.