The Global Politics of Access to Medicines

Access to medicines has been a fierce battleground in global health, with the most polarising debates focused on medicine prices and the role of patent monopolies. The way ‘access to medicines’ has been framed has evolved considerably since the 1970s, when the focus was primarily on rational use of generic drugs widely available in developing countries. In the 1990s the advent of the WTO TRIPS Agreement clashed directly with a growing global HIV crisis; the politics of ‘access to medicines 1.0’ that emerged centred squarely on antiretrovirals for HIV/AIDS and intellectual property rules. Subsequently, significant ideational and political shifts have resulted in an ‘access politics 2.0,’ characterised by an expansion of concerns to all diseases, tighter linkages between innovation and access concerns, and shifting political dynamics as high-income countries began to experience directly the challenge of high drug prices. These shifts imply a more complex and potentially more consequential politics of access to medicines in the future.

The Politics of Gender and Global Health

Politics, simply understood as who gets what, when, and how, is self-evidently central to health policy and health equity outcomes. The material, ideational, and institutional interests and power of stakeholders will determine whose health is given salience and who influences those decisions. Gender, understood as the roles, behaviours, activities, and attributes that are expected, allowed, and valued in a woman or man in any given context in turn impacts the influence and interests of those stakeholders. This chapter explores the impact of gender on health outcomes as well as the global health complex’s responding to or leveraging gender to ensure more equitable outcomes. The chapter begins by setting out the significant differences in the gendered distribution of health outcomes. It then presents a conceptual framework that explains the ways through which gender impacts those outcomes, namely how gender serves as and interacts with other determinants of health, how gender influences the differences in health-harming and health-affirming behaviours between men and women, and how gender impacts health programmes and delivery. The chapter provides a historical account of the manner in which global health organisations have treated (largely ignored) gender. It concludes with a discussion of the politics of health that explains why global health remains gender blind despite centuries of empirical evidence to suggest that it could be amongst the most influential determinants of health and promotes ideas of what will be required to ensure that global health is more gender responsive.

The Politics of Global Health Inequalities

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.

The Global Politics of Neglected Tropical Diseases

Neglected tropical diseases (NTDs) are a diverse group of diseases that are prevalent among the poorest populations of the world. They pose a formidable obstacle to the socioeconomic development of the already impoverished communities where they are prevalent. Over the past several decades the World Health Organization (WHO)—as the directing and coordinating authority on international health work—has led global efforts to tackle the mortality and morbidity burdens of NTDs. In partnership with other actors, WHO’s global NTD Plan and Roadmap have oscillated between the politics and financial constraints of the organisation as an intergovernmental organisation of sovereign states and the lack of incentives to catalyse private and corporate actors towards effective action. The global politics of NTDs is now firmly anchored on public-private partnerships. These partnerships nonetheless raise questions about the moral obligation towards underwriting the cost of eradicating these diseases in the developing world. The chapter argues that enlightened self-interest and humanitarianism should compel the industrialised world towards a pragmatic action to address the mortality and morbidity burdens of NTDs among the poorest populations of the world.

Civil Society and Global Health Politics

Civil society may be defined as both a space in society and a collection of certain types of actor. As a space, it exists alongside the state and markets; as a set of actors, it interacts with a range of governmental bodies and businesses. Over the past three or four decades, neoliberal globalisation has dramatically changed the distribution of power across society, while also institutionalising a set of policies that have diminished the role of the state, undermined democracy, and established the dominance of market logic. These developments have influenced both international health policy and the structures of global governance. Furthermore, they have also shaped the nature of civil society’s participation in global health policy and governance. Crucially, civil society does not merely intervene in global health politics from outside, but is itself sculpted by the ideologies and political conditions that surround it. This chapter explores the political nature of civil society and its relationship to global health politics, including the political nature of new non-state actors such as the Bill and Melinda Gates Foundation and the emergence of global health partnerships, which have ostensibly increased civil society involvement in global health governance. It argues that civil society participation in global health governance tends to represent powerful and hegemonic interests rather than those most in need. It also discusses how current political, economic and technological developments will influence civil society’s participation in global health politics, and shape the challenges faced by society more generally.

The Politics of Global Tobacco Control

This chapter examines the politics that has shifted tobacco control policy over the past three decades, from a long-neglected public health issue to a flagship global health issue supported by collective action by state and non-state actors. These efforts were spurred by the expansion of leading transnational tobacco companies (TTCs) into emerging markets, beginning in the 1960s, amid growing regulation and declining sales in traditional markets. By the 1990s tobacco use was steadily rising in the wake of the global expansion of the tobacco industry. The negotiation of the World Health Organization Framework Convention on Tobacco Control (FCTC) became the focus of intense political contestation between a powerful industry seeking to protect its commercial interests and an alarmed public health community. Since adoption of the FCTC in 2004, this political battle has shifted to its effective implementation in signatory states. This has included the eventual negotiation of the FCTC Protocol to Eliminate the Illicit Trade in Tobacco Products and continued efforts by the tobacco industry to sustain sales through a variety of political strategies.

Global Health Politics

Global health politics has emerged over the last two decades as a distinct interdisciplinary field of study which, although its boundaries are not set, is beginning to demonstrate signs of maturity. It is concerned with the actions, practices, and policies that govern the sphere of global health. Its emergence then is intimately linked with the reconceptualisation of health as global. The field addresses not only the processes of decision-making, but also the structures of power that shape what is possible and the requirement for collective action to address global problems. Politics is unavoidable, necessary and integral to effectively addressing global health challenges. The study of global health politics therefore is not about how to minimise interference in rational decision-making, but rather about explaining and improving the quality of political institutions and processes that will in turn improve global health actions and ultimately outcomes. Fundamental to this is an understanding of the nature of politics and the workings of power. But the field also requires knowledge and techniques from a variety of disciplines, which intersect to produce a more complete understanding than any one discipline can provide. The result is inherently both multi- and interdisciplinary, characterised by methodological pluralism and varied theoretical perspectives.

Non-Communicable Diseases and Global Health Politics

Non-communicable diseases (NCDs), including cardiovascular disease, cancer, chronic respiratory diseases, and diabetes, are responsible for around 70 percent of global deaths each year. This chapter describes how NCDs have become prevalent and critically evaluates global efforts to address NCDs and their risk factors, with a particular focus on the World Health Organization (WHO) and United Nations (UN) system. It explores the factors that have prevented those addressing NCDs from achieving access to resources and a priority commensurate with their impact on people’s lives. The chapter evaluates the global response to NCDs both prior to and since the UN High-Level Meeting on Prevention and Control of Non-communicable Diseases, held in 2011, and considers opportunities for strengthening that response in future.

The Politics of Global Vaccination Policies

Organised efforts to prevent the spread of infectious diseases through mass vaccination began slowly. By World War I, although successes in saving soldiers’ lives offered encouragement, vaccination practices differed from country to country. In 1945, amid the rapid post-war spread of tuberculosis, preventive vaccination was deemed a necessary ‘technological fix’. During the Cold War period, technical cooperation coexisted with ideological rivalry. Although the Soviet Union and the United States supported vaccination for different reasons, they successfully cooperated on the WHO smallpox eradication programme beginning in 1965. Out of this grew the EPI, and disputes between supporters of ‘vertical’ and ‘horizontal’ approaches emerged. In recent decades new vaccine production has become a major driver of market growth for the pharmaceutical industry. New forms of collaboration between public and private sectors (such as public-private partnerships) have been crafted, whilst the global introduction of new vaccines is supported by the GAVI Alliance. However, at a time of shrinking health care budgets the wisdom of disease eradication targets is contested, and parents everywhere are becoming more critical.

Global Health Governance

The international governance of health predates the establishment of the World Health Organization in 1948. This chapter, however, argues that over the past two decades two major transformations have reshaped the politics of global health governance. The first is the emergence of the narrative of global health, which has created a perceived requirement to place increased emphasis on global governance mechanisms. This in turn implies that power should reside less at the national level and more at the global. Second, the institutional ‘architecture’ has been transformed by the emergence of new actors who are having an impact on health policy and outcomes. Combined, these two transformations have had a number of political effects, including a higher profile for global health issues and especially crises; a diffusion of power and authority; the creation of a ‘market’ for funding, with consequences in turn for how the ‘power of the purse’ operates; an increased expectation of the ability of global institutions to act to prevent or mitigate crises; and competing norms over what health is for.