NCD - Political Economy

Political Economy of Non‐Communicable Diseases: From Unconventional to Essential. (excerpts)

Michael R. Reich, Harvard T.H. Chan School of Public Health

De: Claudio Schuftan
Enviada em: terça-feira, 30 de abril de 2019 04:10

Political Economy of Non‐Communicable Diseases: From Unconventional to Essential. (excerpts)

Michael R. Reich, Harvard T.H. Chan School of Public Health

This commentary argues that political economy should become viewed as a conventional, indeed, an essential outlook for NCDs, and more broadly

for global health. Political economy factors are integral to the problems of NCDs and

therefore must also be integral to the policy responses.

I have often argued in my career for more attention to political economy in public

health—for more attention to the political dimensions of health policy, especially for low and middle‐income countries.2

The study of politics remains on the margins in the global health community, despite decades of scholarship on this topic, while economics and economic analysis are squarely situated at the center.

Some consideration of definitions is necessary to ensure clarity. In general, most definitions of political economy focus on how the distributions of political

and economic resources affect something we care about: inequality, economic growth, some specific policy, who controls a country, or health.3,4 The analysis of the political economy typically involves consideration of power, along with interests, ideas, ideologies, and institutions.5

Let me suggest a definition of political economy, based on the definition of “politics” that comes from Harold Lasswell, who used it as the title of his 1936 book: Politics: Who Gets What, When, and How.7

Lasswell reminds us that any process affecting the allocation of resources in society

inevitably involves politics. The same principle holds for NCD policies—since NCD policies seek to change who gets what in the health system and in society. This commentary thus concerns “how the allocations of political resources and economic resources affect who gets what, when, and how in relation to NCDs.”

USING POLITICAL ECONOMY TO ANALYZE NCDs

Three themes: a) commercial enterprises and their role as drivers of NCDs.

b) patient organizations and their role in creating solutions to NCDs. and

c) government agencies and their role in changing the institutions and actions for NCDs.

This approach proposes that any effort to discuss the political economy of NCDs should examine these three actors and how they shape both the problems and the solutions for NCDs.

This approach disaggregates society into specific actors and their different political

economy roles. This disaggregation is necessary, because there are so many actors that can obstruct and facilitate change for NCDs. With this approach, political economy analysis helps us learn from the past to design strategies that facilitate the changes we seek in health systems.

This approach highlights the main point of why scientific evidence about NCDs is not enough to improve health. Political economy analysis and strategies are also needed to make progress.

Theme #1: Political economy of changing the determinants of NCDs

In global health today, the promotion of targeted taxes on harmful products—“sin taxes”—ranks high on the global health policy agenda for addressing the determinants of NCDs. The taxes focus on particular products—especially tobacco, sugary beverages, and alcohol.

These commercial products have health impacts on NCDs: cancer, cardiovascular diseases,

respiratory diseases, and diabetes.

The new taxes promise a seemingly magical policy solution: increased flows of new

revenues for the government budget and reduced disease burden and related health

expenditure for the targeted NCDs.

Recently global policy attention has increased on sin taxes and NCDs—but that

attention has focused on the technical economic aspects of policy solutions, and overlooked the political economy challenges of introducing sin taxes.

Introducing sin taxes requires political economy analysis, because there are huge

commercial interests that benefit from the production, sale, and consumption of those products. Introducing sin taxes inevitably triggers a political struggle with commercial organizations. These industries have much greater economic and political resources than perpetually under‐resourced public health advocates. Understanding when and how public health can win—despite powerful commercial forces—requires political economy analysis.

The primary opposition to taxation is transnational companies and their economically interested allies.

What does this look like in practice? One example of this kind of analysis is research

on the successful passage of a soda tax in Mexico. In examining this topic,

colleagues show how advocates achieved legislative success with this politically difficult proposal, using political economy analysis, as one important factor, to decide on strategies to promote the tax and push the tax through the Mexican Congress.

It is equally important to understand how industry interests overpower public

health. Susan Greenhalgh recently demonstrated how Coca‐Cola created a non‐governmental organization in China to shape scientific researchand public policy over a 15‐year period, as she put it, “making China safe for Coke” “through a complex web of institutional, financial, and personal linkages.”

We thus need better understanding of the political economy of the commercial

determinants of health, including actions that can advance sin taxes—along with other effective interventions—to promote public health.

Theme #2: Political economy of using a systems approach to address NCDs.

Changing a health system’s orientation often requires political struggle. Technical

evidence is usually useful, and frequently necessary, but evidence alone rarely produces sufficient system change. One key force for change comes from the people directly harmed by the existing system.

One lesson from the world’s experiences with HIV and AIDS is the critical role of

affected people in organizing social movements to change public policies. We can draw many lessons about the political economy of NCDs from their past experiences. Social movements of people living with HIV/AIDS have played catalytic roles in changing government rules, regulatory policies, health care delivery, accountability structures, public perceptions, and corporate decisions—through direct action, public protest, political lobbying, and strategic negotiation.

I am not suggesting that the social mobilization of people who are directly affected

by a disease alone can achieve these policy changes. But I do believe that civil society’s political pressure (related to their creative use of symbolic politics, to increase political power) is often a catalytic factor to change institutions. The question is how do less powerful groups in society go about changing the policies and the narratives related to NCDs?

Perhaps the world needs mobilizations of those living with NCDs, in order to change

the political economy of NCDs and change resistant government and corporate policies.

Think about breast cancer. Women with breast cancer and their families have been

a major force worldwide in putting the issue on national policy agendas and compelling governments to devote more resources to screening, diagnosis, and treatment.

Think about lung cancer, emphysema and COPD. In social movements to promote

tobacco control, people suffering from smoking‐related illnesses have played important symbolic roles.

Patients and families help change the power dynamics related to NCD policies, help change the social narrative about responsibility for NCDs, and influence who gets what, when, anhow for NCDs.

Social movements of victims have played critical political roles for major reform

efforts in many domains beyond public health.

Social movements of patients may not be necessary for the advancement of each NCD; for diabetes, for each type of cancer, for different cardiovascular disease, for mental illness. But I do believe that social movements can play a catalytic role in changing social values and narratives and in transforming government and corporate policies, in ways that can advance efforts to address NCDs.

These social movements also play a critical role in changing the stigma associated

with NCDs, making it more acceptable to discuss what were once considered “private” or “family” matters such as mental illness, cancer, and other NCDs—as  public issues.

It is not easy, however, to take personal troubles into the public realm, to create a

group of common sufferers and transform a health issue into an effective political

mobilization.

An additional factor that creates challenges for addressing NCDs is the lack of

connections across different diseases. Social mobilization on breast cancer or lung cancer, for example, does not transfer into activism on other NCDs, such as diabetes or mental health.

In sum, we need better understanding of the political economy of social movements

of NCDs in diverse national settings, especially understanding how social movements can put specific illnesses on national policy agendas and can compel changes in policies and resource allocations.

Theme #3: Political economy of reforming governance of NCDs.

We know from social science that institutions tend to resist change. Every

established social system is biased and resists reform. Every system promotes attention to certain issues and avoids attention to others. Thus, changing built‐in systemic bias is not easy. Once a system adopts a particular policy, it is difficult to change that policy because the system develops positive feedback loops and stakeholders develop strong interests in maintaining that particular organization of benefits.

The gap in global governance for NCDs is striking for international agencies. We

have many declarations about giving higher priority to NCDs. But development assistance still provides very limited resources for NCDs in low‐ and middle‐income countries.

How are development agencies, such as the World Health Organization, the US

Agency for International Development, and the World Bank, being held accountable for their calls to increase attention to NCDs? The political economy of holding multilateral organizations accountable for supporting health system transitions to NCDs is a critical topic.

At the national level, the governance of NCDs is weak and confused. Many health

systems—particularly in low‐ and middle‐income countries—are not oriented toward providing NCD‐related services, and remain focused on infectious diseases.

They all lack trained health workers and essential medicines for NCDs, and these situations are distinctly worse in rural areas.2In short, huge gaps exist between what is needed for NCDs and what is provided.

The core challenge is how to transform existing health systems, with a continuing focus on infectious diseases, to meet changed patterns of disease. The NCD tsunami is no longer something to expect; the tsunami has arrived and most nations’ health systems are not ready. In short, the epidemiological transition is happening faster than the governmental transition.

Many low‐ and middle‐income countries confront similar challenges for cancer. Lack

of resources, lack of equipment, lack of personnel, lack of priority, and lack of data all add up to late detection, limited capacity to treat, and large numbers of cancer deaths.

Deciding how to organize the ministry of health for NCDs is not easy. One high

government official recently asked me: Should there be a separate government “center” for each NCD? Or a single NCD center, with individual directors for each NCD? If international aid is not available for NCDs, how much domestic resources should be used for NCDs, and where can those funds come from? Should the government introduce a separate sin‐tax for each NCD? How should the government decide how much to allocate each of the major diseases? According to the burden of disease, or according to the effectiveness of interventions, or according to the pressures of different provider or patient groups?

An additional political economy challenge for national action on NCDs is that

interventions are often needed outside the health sector, for example, on food and

agriculture regulation, or in changing the curriculum of schools. These actions require cross‐ministry collaboration or conversations that can create significant bureaucratic and budgetary obstacles to effective action.

Setting national priorities and organizing government agencies for NCDs are

political economy processes that we need to understand better in order to address the governance challenges for NCDs.

CONCLUDING COMMENTS

In concluding, I would like to focus on this message: Let’s move political economy from unconventional to essential in global health, starting with NCDs. Here are three suggestions.

First, development agencies and foundations need to move from slogans and

lip service to actions and financial support on political economy. Donors need to make funding available for political economy analyses in health reform loans and grants, and make these analyses a required part of health policy development. This will help create a demand for new and improved methods of analysis and for people trained in political economy.

Second, global health researchers need to direct more attention to the political economy of NCDs. There is significant room for expansion based on real‐world practices. Researchers can help explain how effective NCD policies overcome obstacles of corporate and bureaucratic resistance and how social movements successfully pursue reforms. We need better insight into how to change

government structures and policies to provide effective prevention, treatment, and

palliative care for NCDs.

Third, we need an accountability mechanism for assessing political economy

analyses in practice and in research. In effect, we need a mechanism that will improve the quality and effectiveness of political economy. This accountability mechanism could include a clearinghouse of political economy studies and researchers, a review process to assure high quality political economy analyses, and an evaluation process to assess the impacts of different kinds of political economy methods and strategies to assure effective action.

These are doable efforts. In the short term.  

Focused attention will help us advance the place of political economy in global health. This in turn will help us support people working at the frontlines in health systems to effectively address NCDs. Policy makers and policy analysts need to give more attention to the role of political economy factors in understanding the determinants of NCDs in their countries and designing effective policy responses for NCDs, as argued in this article.

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