Week 1: What is Global Health Policy?

Ten Threats to Global Health in 2019

- To address these and other threats, 2019 sees the start of the World Health Organization’s new 5-
year strategic plan – the 13th General Programme of Work. This plan focuses on a triple billion
target:  ensuring 1 billion more people benefit from access to universal health coverage, 1 billion
more people are protected from health emergencies and 1 billion more people enjoy better health
and well-being. Reaching this goal will require addressing the threats to health from a variety of
angles. 

Issue Description
Air Pollution and - 9 out of 10 people breathe polluted air daily
Climate Change - Considered as the greatest environmental risk to health.
- Pollutants penetrate respiratory & circulatory systems, lungs, brains,
heart
- Kills 7 million people/yr. prematurely from diseases like cancer, stroke,
heart & lung disease.
- 90% of these deaths are in low-middle income countries with high
emissions from transport, agriculture and fuels in homes
- Primary cause of air pollution (burning fossil fuels) is the major reason
for climate change
- Between 2030 and 2050, climate change is expected to cause 250,000
additional deaths per year from malnutrition, malaria, diarrhoea and heat
stress
Noncommunicable - Examples of NCDs = diabetes, cancer, and heart disease
Diseases (NCDs) - Responsible for over 70% of all deaths worldwide (41 million people)
- Over 85% of these premature deaths are in low-middle income countries
- 5 major risks: tobacco use, physical inactivity, harmful use of alcohol,
unhealthy diets and air pollution.
- Exacerbates mental health issues originating at an early age
Global Influenza - WHO is constantly monitoring the circulation of influenza viruses to
Pandemic detect potential pandemic strains: 153 institutions in 114 countries are
involved in global surveillance and response.
- WHO recommends the strains that should be included in the flu vaccine
to protect from the seasonal flu
Fragile and - 1.6 billion people (22% of the global population) live in places where
Vulnerable long-lasting crises (e.g. drought, famine, conflict, population
Settings displacement) and poor health service leave them without access to basic
care.
- Fragile settings are where ½ of the key targets in sustainable
development goals (child and maternal health) are unmet.
Antimicrobial - Antimicrobial resistance threatened to send us back to a time where we
Resistance couldn’t easily treat infections and could compromise surgery and
procedures such as chemo.
- Drug resistance is driven by the overuse of antimicrobials in people and
animals (especially in food production and the environment)
Ebola and Other - 2019 was the “Year of Action on Preparedness for Health Emergencies.
High-Threat - WHO’s R&D Blueprint identified diseases and pathogens that have
Pathogens potential to cause public health emergencies but lack effective treatment
and vaccines.
- Watchlist for priority research and development includes Ebola, Zika,
Nipah, Middle East respiratory syndrome coronavirus (MERS-CoV),
several other haemorrhagic fevers, and Severe Acute Respiratory
 Syndrome (SARS) and disease X.
Weak Primary - Primary health care = 1 st point of contact people have with their health
Health Care care system
- Should provide comprehensive, affordable, and community-based care
- Health systems with strong primary health care are needed to achieve
universal health coverage.
- Lack of resources in low-middle income countries = neglect
Vaccine Hesitancy - Vaccine Hesitancy = the reluctance or refusal to vaccine despite the
availability of vaccine
- Threatens to reverse progress made in tacking vaccine-preventable
diseases
- Vaccination is one of the most cost-effective ways to avoid disease;
prevents 203 million deaths a year and 1.5 million could be avoided if
global coverage of vaccinations improved.
- Reasons people choose not to vaccinate = complacency, inconvenience
in accessing vaccines, and a lack of confidence
- Health workers, especially those in communities, remain the most
trusted advisor and influencer of vaccination decisions
Dengue - A mosquito-borne disease that causes flu-like symptoms and can be
lethal and kill up to 20% of people with severe cases
- High #’s in the rainy seasons of Bangladesh and India
- Disease is spreading to less tropical and more temperate countries such
as Nepal;
- 40% of the world is at risk of Dengue fever; 390 million infections a
year.
- WHO’s Dengue Control Strategy aims to reduce deaths by 50% by
2020.
HIV - 22 million people are on antiretrovirals and taking preventative measures
such as pre-exposure prophylaxis (PrEP  for people who are at risk of
HIV)
- Nearly a million people die every year from HIV/AIDS
- Since the beginning of the epidemic, more than 70 million people
acquired HIV, and 35 million have died.
- Today approx. 37 million people live with the infection
- Young girls and women are increasingly affected by HIV (ages 15-24),
particularly in sub-Saharan Africa (only 10% of the population)

#1 Reason People Die Early, In Each Country - Video

- Leading cause of death in Africa = infectious diseases (diarrhea, pneumonia, malaria,

HIV/AIDS), but early easily treated in places with better infrastructure
- Saudi Arabia’s (and neighbouring Qatar, UAE, Oman) leading cause of death = traffic accidents
- Venezuela = 25,000 people died from homicides (leading cause of death); similar in Columbia
- China = Stroke because the economy has strengthened leading to better foods, less activity and
more air pollution; Syria = War
- Heart Disease in wealthier countries due to the privilege of old age
- Poor countries = diseases that kill young and wealthier countries = diseases that kill in older age

The Danger of a Single Story – Video

- Chimamanda Ngozi grew up in Nigeria

- Convinced that books had to have foreigners and things she couldn’t identify with until she
discovered African books
 - Middle class, conventional family; father was professor and mother administrator. The family had
help
- Roommate felt sorry for her before she even knew her; she had a single story of Africans, one
that wasn’t similar to her life in America
- Western literature forms the image of Africa for the rest of the world; unjustly and ignorantly
- Power (nkali) is the ability to make someone else’s power definite
- Single story creates stereotypes, and the problem with that is that they’re incomplete and don’t
tell the whole story
- Consequence of the single story = robs people of dignity; emphasizes differences; show people as
one thing and that is what they become
- Dispossess people and start their story with “secondly” – start the story with the arrows of the
Native Americans and not with the Arrival of the British

Lecture 1 - Asynchronous
What is Global Health?
- Health issues that transcend national boundaries and governments and call for actions on the
global forces that determine the health for people – Ilona Kickbush (Switzerland)
- An area for study, research, and practice that places a priority on improving health and achieving
health equity for all people worldwide – Koplan and Colleagues (United States)
- Collaborative international research and action for promoting health for all (Beaglehole and
Bonita (New Zealand)
- All high-income countries that have traditionally exported definitions to LMICs of what global
health is  Try to decolonize Global Health and look at it from a different perspective
- Types of diseases leading to lost years of life that are more prevalent in low-income settings:
communicable and infectious diseases, whereas heart disease and cancer are more prevalent in
high-income settings
- WHO has warned against the specific things in an environment that allow diseases to take hold
and policy responses that are needed to fight these threats. They also warn against fragile and
vulnerable settings (protective factors = income, education, status) all make you more vulnerable
to threat.
- Vaccine hesitancy – threat; rushing out the vaccine without providing the necessary evidence to
the public
- Weak primary health care – need an equitable system that’s accessible to all.

Global Health Journal Reading

- Tropical medicine term is dated due to its colonial origins of global health; global solidarity is
at the heart of global health. We’re all in this together, however global health didn’t begin that
way.
a. Global Health 1.0 = tropical diseases such as malaria were killing white colonists, native
labour forces and slaves. Allowed colonial project to continue unabated
b. Global Health 2.0 = international health; paternalistic, colonial racist mindset. People from
HICs are here to help people from LMICs and they should just shut up and be grateful for the
help
- c. Global health 3.0 = about people from HICs leading health programmes in LMICs
- d. Global Health 4.0 = It is the hope of many global health professionals that LMICs will one
day be able to lead their own health programmes and direct their own policies
- Distinction between international and global health: international health focuses on helping
LMICs, global health is about health equity everywhere, including in HIC (no pretence about
global health being defined by global cooperation, national boundaries and specific categories of
actors).
- 2 kinds of problems: problems of discovery and problems of delivery
a. Problems of Discovery: about finding technological innovations to improve global health
equity (e.g., new vaccines for infectious diseases like HIV). The disciplines responsible for
 finding solutions to these problems either predate or would exist without global health, so they
can’t be what defines global health.
b. Problems of Delivery: require social sciences to understand and then to address the
information and motivation problems that may prevent or constrain delivery. They highlight the
failure of governments, non-governmental organizations, the private sector, service providers and
communities to put in place or demand equitable health systems.
- Delivery problems define global health and what makes global health peculiar is that discoveries
and the decisions on whether or how to deliver them are typically at a distance, removed from the
realities of their targets or intended beneficiaries.

What Makes Global Health Unique?

- Global health is about health equity everywhere (including LMICs and HICs)  dominant
streams of how we define the field
- Delivery problems are removed geographically, socially, culturally, and economically from
points of discovery
a. Asymmetries of power, motivation and information between the helper and the helped
- Child mortalities decrease in every income level worldwide and is more pronounced in LMICs
from 1990 – 2017. Relative inequities are steady and growing vs the absolute inequities, which
are shrinking.

Building a Field of Global Health

- Recognize the information paradox between the “helpers” and the “helped”  helpers have more
info and resources that are needed by the helped but the helped know which resources would be
better served to make an impact in their lives
- Communicate between jurisdictions and disciplines  between different fields that have input
into how to improve the determinants of health
- Decolonize global health  global health was rooted in colonialism and we must work daily to
rid it of those embodied aspects.
- “People understand their own lives better than we could ever do, that they and only they can truly
improve their own circumstances and that those of use who work in global health are only, at
best, enablers”.

Dominant and Counter Narratives

- Question your internalized view of the world
- It’s important to this about the dominant stories and counter-narratives to reduce bias
- What is power upholding? Power allows dominant narratives to continue

What is Old and What is New?

International health (Global Health 2.0):
- People went beyond bilateral relations (by cooperating between jurisdictions both within
countries and between around the common interest of eradicating smallpox)
a. Efforts to eradicate smallpox
- Focused on health equity (Alma Ata was a high point focusing on primary health care and health
equity. To this day, no WHO or UN statements or missions that have met the ambition of Alma
Ata and we may have lost ground)
a. Alma Ata declaration
- Was multidisciplinary
a. “International Health” departments
- Embraced and involved non-state philanthropies
a. Rockefeller Foundation
- Rooted in social determinants of health

Working Class in England Reading

 - Cowell gives the weight of 46 youths of 17 years of age from one Sunday school, of whom 26
were employed at the mills and averaged 104.5 pounds. 20 were not employed at the mills and
weighed 117.7 pounds.
- Similar to the prevalence of childhood stunting by household income
- Wealthy and poor have different prevalence of underweight; socially determining the health of
the young people.
- Uses an observational study design (retrospective cohort study); children from Sunday school
should be similar. Look at who’s in the mills and who aren’t and then look at them systematically
to see the weight difference.
- Women work pregnant until due date because they’re afraid of losing wages. They work at night,
have the baby in the morning. Sometimes that deliver their children in the factory.
- Currently, in the US, there’s no policy guaranteeing paid family leave, which is similar to Engel’s
view from the UK (which was the wealthiest nation at the time)
- Philanthropists who were extremely wealthy and created libraries and gave little food to the poor,
were also the ones working people to death (including children) and fighting against the factory
acts.
- Similar to Jeff Bezos, Mark Zuckerberg, Michael Bloomberg
Engels:
- Upper-class industrialist visiting foreign country
- Use of quantitative and qualitative evidence (mixed methods)
- Focused on social determinants of health and health equity
- Advocacy for evidence-based policy
- Concerned with health effects of capitalist development in Europe (focused on the UK because
they are booming industrially and were an example of what was to come for the rest of Europe)
- Mortality among the working-class children especially those of factory operatives is proof of the
unwholesome conditions of their first years
- At 9, a child is sent to the mill to work 6 ½ hours (formerly 8, earlier still, 12 to 14, even 16
hours) daily until their 13th year; then 12 hours until their 18th year
- Factory Inquiry of 1833 mentioned a crowd of crippled people who owed their appearance to
the long working hours; distortions consisted of curved spinal columns and legs. Knees are bent
inward and backwards, and ankles are deformed and thick, and the spinal column is bent forwards
to one side
- Factory atmosphere is damp, warm and has poor ventilation that is deficient of oxygen, filled
with dust and the smell of machine oil is everywhere.
- Factory workers are lightly dressed because of the warm environment and the change of temp
going out into the cold without proper clothing produces colds
- Growth of young operatives is stunted by their work, army recruiting officer testified that
operatives were thin and frequently rejected
- Premature old age resulted in 40-year-old men looking 10-15 years older, while prosperous
classes preserved their appearance if they didn’t drink too heavily.
- Influence of factory work on women’s physique was due to long work hours and was much more
serious and they were also more liable to miscarriage.
- Common effects of breathing in dust included blood spitting, noisy breathing, pains in the chest,
coughing, sleeplessness  asthma or even worse consumption
- Most common accident was the crushing of a single joint of a finger, half or whole hand, an arm,
etc  resulted in a large number of maimed people in Manchester
- Most dangerous part of the machinery was the strapping, which would throw an individual with
great force, breaking bones and resulting in immediate death
- Diseases were caused by the hateful greed of manufacturers

Week 2 – Global Health Policy Actors

Lecture 2 – Asynchronous
Reading: Governance Challenges in Global Health
 - In terms of Global health governance and actors with the global health system, it must be
emphasized that there is a massive network of governments, NGOs, banks, etc.
a. different in size and budget, but they’re all connected in a web with some being more powerful
than others

Global Governance
- Global governance is distinct from national governance in one critical respect: there is no
government at the global level
- Global systems are complex and don’t hold as much power as people think. This is because
sovereign states hold most power within global health and every other global governance issues.
Nation states are where the crux of power is held
- Populations are organized into sovereign nation states, but there is no hierarchical political
authority that has jurisdiction over nation states
- Traditional instruments for mobilizing collective action at the national level – such as taxation,
routine law enforcement, and democratic decision-making procedures – are mostly absent at the
global level.
- Westphalian System

Global Health Governance Terms

- Health Interdependence: no country or organization can single-handedly address global health
threats
- Global Health System: organized social response to health conditions at the global level
- Global Health Governance: how the global health system is managed

Challenge 1: Sovereignty (ultimate authority)

- Health is national responsibility, but the transfer of health risks across borders means no one state
can control them alone
- National sovereignty vs imperative of international collective action (tension)
- E.g., anti-microbial resistance: if one country isn’t responsible with how they handle this it could
spread across borders (transnational) – national sovereignty deals with it

Challenge 2: Sectoral
- Multiple sectors influence health such as:
a. Trade
b. Investment
c. Security
d. Environment
e. Migration
f. Education

Challenge 3: Accountability – 4 Essential Functions of the Global Health System

- Civil society networks, experts, foundations, multinational corporations, and journalist all wield
power in processes of global governance independently of home-country governments
- Which are legitimate interests? How to hold non-state actors accountable?

- Production of global public goods: vaccine

development

- Management of externalities across countries:

factory polluting a river and customers paying for
a product, they aren’t paying for the cleanup, but
the government will charge the company
 - Mobilization of global solidarity: must have financial mechanisms to pool funds between
countries

- Stewardship: bringing everyone to the table to have a forum where priorities can be set

- Ideal – normative - normative power, in its ideal or purest form, is ideational rather than
material or physical. This means that its use involves normative justification rather than the use of
material incentives or physical force.

- Externality - a positive or negative side effect or consequence of an industrial or commercial

activity that affects other parties without this being reflected in the cost of the goods or services
involved
a. Examples – Vaccine development, AMR, fundraising, policy coordination (FCTC)

Challenges for Essential Functions

- Free rider problems: even rich countries can benefit from the WHO without contributing to it
- Sovereignty challenges: can’t force countries to disclose outbreaks or tighten environmental,
regulations
- Weak accountability mechanism: commitments to and acceptance of humanitarian aid can
reverse or refused
- Lack of leadership: global policy arenas are often intentionally weakened because some
countries don’t want empowered governance because they want to maintain sovereignty

Global Health Governance

- Formal decision-making processes
a. United Nations Security Council declarations (doesn’t means its binding even if
its formal)
- Less formal processes
a. Voluntary codes of conduct for corporations (most common such as
memorandums of understanding; change often)
- Democratic deficits:
a. Some countries are undemocratic or don’t represent the interests of marginalized
populations
b. What about nongovernmental organizations (may have a lot of power via money,
people, etc.) that make no pretense of being democratic?

Global Agora
- A ‘global public space of fluid, dynamic and intermeshed relations of politics, markets, culture
and society’
- Social and public space, rather than physical space (not all decisions are made in the UN; there
are many different venues)
- Characterized by disorder and uncertainty (one year an organization may be power and the next
may be different; difficult to judge who will be in power)
- Institutions underdeveloped and political authority unclear
- Elite rule and lack of public participation (can be within democratic governments; few people act
within global governance systems and few people have a voice)

Global Public Policy

- ‘Governing without government’
- Often deal with issues national government can’t or won’t exert authority over (if the exert
authority they global system has little say to overrule them)
- Economic globalization often moves faster than global governments (because institutions are
weak and slow, whereas governments may make trade deals or businesses may make decisions
overnight and global institutions are playing catchup rather than making regulations)
Globalization and Health
Good Bad
- Easier diffusion of useful technologies - Diminished social safety nets
and ideas - Facilitated marketing of tobacco, alcohol,
- Spread of values such as human rights and illicit drugs
(spread through transnational networks) - Easier worldwide spread of infectious
diseases
- Rapid degradation of the environment
Global Policy Processes
1) Problem definition and agenda setting: vacuum of responsibility and cacophony of issues (no
organization with ultimate authority over something, but many different venues competing for
authority, so they can’t prioritize the problems and set agendas in one institution; issues arising
all the time)
2) Formal decision-making: policy transfer among multitude of governance fora (one institution
makes a decision and then it spreads to other institutions, e.g., WHO’s recommendation on
regulating international trade to protect human health, must be passed on to The World Bank,
World Trade)
3) Policy implementation: few enforcement mechanisms and inequity in ability (wealthy countries
with well-established bureaucracies and civil servants that have a history of implementing things
well, do better than weaker countries with institutions and bureaucracies that can’t pay)
4) Monitoring and evaluation: often hold more power than at nation-level (at the global-level due
to few levers for change, strong monitoring of global trends shows what’s working in some
countries and not others and making these findings known globally is powerful because there’s
no way to enforce decisions)

Global Policy Actors

1) Internationalised public official (housed within a national government; may be a bureaucrat or
lawmaker, but their focus is on international effects/laws)
2) International civil servants (works in an international organization like the UN)
3) Transnational policy professionals (may be a university researcher, not necessarily employed
by an international organization or national government)
- Each of these form transnational networks and policy communities within the global agora
- Actors who compose them are formally designated power holders and rule makers who derive
their authority from their official positions within their nation-state.
- Employed by an international organization to staff its secretariat and institute operations
- Consultants, foundation officers, business leaders, scientific experts, 30 Policy Studies Journal,
36:1 think tank pundits, and NGO executives
- Tremendous growth of global health actors in the last decade

WHO
- Global health is rapidly replacing the older terminology of ‘international health’
- International health was a term of considerable currency in the late 19 th and early 20th century. It
referred to primarily to a focus on the control of epidemics across the boundaries between
nations.
- Intergovernmental refers to the relationships between the governments of sovereign nations, the
policies and practices of public health.
- Global health implies consideration of the health needs of the people of the entire planet above
the concerns of particular nations.
- Global is also associated with the growing importance of actors beyond governmental or
intergovernmental organizations and agencies (e.g., media, international foundations, NGOs,
corporations).
- The WHO is an intergovernmental agency that exercises international functions with the goal of
improving global health.
 - Problem #1: The US played a contradictory role: they supported the UN system with its broad
worldwide goals but was jealous of its sovereignty and maintained the right to intervene
unilaterally in the American in the name of national security.
- Problem #2: WHO’s constitution had to be ratified by nation states. By 1949, only 14 countries
had signed on.
- The politics of the Cold War made a large impact on WHO, so when the Soviet Union and other
communist nations left the UN system (and WHO) in 1949, the US and its allies exerted its
dominance. From 1949-1956, when the Soviets returned to the UN and WHO, WHO was closely
allied with US interests.
- The process of reducing Alma Ata’s idealism to a practical set of technical interventions that
could be implemented and measured more easily began in 1979 at a small conference heavily
influence by US attendees and policies held in Bellagio, Italy and sponsored by the Rockefeller
Foundation with assistance from the World Bank.
a. This meeting focused on an alternative concept to that presented at Alma Ata – “Selective
Primary Health Care” – which was created by pragmatic, low-cost interventions that were limited
and easy to monitor and evaluate.
- In the 1980s, the World Bank’s (created in 1946 to help with the reconstruction of Europe and
later expanded to loans, grants and technical assistance to developing countries) influence grew.
Initially, it funded large investments in physical capital and infrastructure, but in the 1970s it
began to invest in population control, health and education.
a. World Bank approved the 1st loan for family planning in 1970.
- In 1980, the Bank argued that malnutrition and ill health could be countered by direct government
action with their assistance and suggested improving health and nutrition would accelerate
economic growth and social spending
- The Bank favoured free markers and a diminished role for national governments
- With the World Bank’s growing influence, WHO began to dimmish.
a. Sign of trouble: 1982 vote by the World Health Assembly to freeze WHO’s budget,
which was followed by the decision of the USA to pay only 20% of its assessed
contribution to all UN agencies and withhold its normal contribution to WHO’s regular
budget in protest to WHO’s “Essential Drug Program” (opposed by US pharmaceutical
companies).
- By 1986-1987, extrabudgetary funds of $ 437 million had caught up with the regular budget of
$543 million
a. The problem was that although the extrabudgetary funds added to the overall budget, they
increased difficulties of coordination and continuity and dependence on the satisfaction of
particular donors
- The Bank recognized that it had great economic power, but WHO has considerable technical
expertise in health and medicine; so, it’s was in the best interest of both parties to work together.

WHO
- Mission: All people should enjoy the highest standard of health, regardless of race, religion,
political belief, economic or social condition
- Governed by the World Health Assembly composed of 194 member states (one-member state and
one vote; democratically organized)
- Regional offices for Africa HQ (AFRO: Brazzaville, Republic of Congo), Western Pacific HQ
(WPRO: Manila, Philippines), Eastern Mediterranean HQ (EMRO: Cairo, Egypt), South East
Asia HQ (SEARO: New Delhi, India), Europe HQ (EURO: Copenhagen, Denmark), and the
Americas HQ (PAHO, Washington D.C., USA)
- While an impressive 43.8% of WHO’s professional staff are medical specialists, only 0.1% are
economists and only 1.4% and 1.6% are lawyers and social scientists, respectively
- Formally began in 1948, when the 1 st World Health Assembly in Geneva, Switzerland ratified its
constitution.
- 1945: an international conference approved the creation of the UN and voted for the creation of a
new special health agency
 - In June 1948 in Geneva, the WHO was created, and the Office International, League of Nations
and UNRRA merged into WHO, but the Pan American Sanitary Bureau retained autonomous
status as part of a regionalization scheme

WHO Funding
- WHA froze WHO budget in 1982 (very small, smaller than the CDC)
- US decided to pay only 20% of assessed contributions to all UN agencies in 1985 (in protest
against the Essential Drug Program; Americans claimed this infringed on intellectual property
rights held by Americans, so the cut funding to UN agencies)
- Shift in funding from “regular budget” to “extrabudgetary funding” in the 1980s
- WHA only has control over the regular budget (WHA only has control over the regular budget;
voluntary funding come from countries or NGOs and they have the ultimate say over how the
funds are spent – no democratic control over these items)
- By 1990, the Bank’s loans for health surpassed WHO’s total budget
- AC total budget decreased from 46% in 1990 to 21% in 2016-2017; the WHO is 20% democratic

Unequal Influence
- WHO’s core budget is insufficient for the actions it is asked to perform by member states
a. Leads to prioritization of tasks aligning with individual donor priorities than countries’ stated
health needs
- Inequalities of influence persist among states in global health decision-making at both the World
Health Assembly and Executive Board
- Global health governance itself has become highly fragmented.
a. 26 UN entities, 40 bilateral development agencies, 20 multilateral development funds and 90
global health initiatives (this has led to WHO having less influence/authority over global health
matters than before)

Shortcoming of the WHO

- WHO recommendations do not always align with the best available evidence
- Health statistics have been challenged by the Institute for Health Metrics & Evaluation (IHME) –
stats from WHO are inadequate for many challenges facing the world
- Strategy on research for health remains largely unfulfilled
- Co-ordinating role is ill-defined in a landscape of many global health financing and delivery
initiatives like the GAVI Alliance and Global Fund to Fight AIDS, Tuberculosis & Malaria

Issues with Work Culture

- Hierarchical bureaucracy
- Limited financial resources
- Resistance to change
- Avoidance of difficult issues
- Overabundance of meetings
- Tolerance of unequal work effort among staff
- Proactive deference to powerful member states
- Frequent cross-cultural misunderstandings in the workplace (particularly around gender)

WHO’s Dual Functions

- Some have argued to split the WHO in two
- It serves 2 primary functions:
a. world’s pre-eminent public health authority (e.g., health stats, recommendations)
b. Intergovernmental platform for global health negotiations (e.g., coordinating between different
countries that isn’t necessarily dealing with health issues directly
Recommendation (new proposal)
- Political Secretariat: deals with political issues and coordination
- Technical Secretariat: retains regional offices and focus on different health threats
Founding of the WHO
- International Sanitary Office of the American Republics (later PAHO) was founded in 1902 –
Pan American Health Organization
- WHO founded in 1948 at the first World Health Assembly in Geneva, Switzerland
- Incorporated three regional health bureaus, maintaining the independence of PAHO
- Soviet Union leaves UN (and WHO) system from 1949-1956, allowing the US to exert its
influence (power struggle between USA and Soviet Union)

Brock Chisolm
- First director of WHO
- Psychiatrist and soldier born in Oakville
- Loosely identified with the British social medicine tradition (similar to social epidemiology;
medicine should be influenced social factors by caring for the entire person and the policies
which support people living healthy lives rather than just medicine as a technocratic exercise
- First defined health as "a state of complete physical, mental, and social well-being and not merely
the absence of disease or infirmity" 

Global Malaria Eradication

- Approved by WHA (World Health Assembly) in 1955
- Relied heavily on the use of DDT (new tech at the time)
- Great interest because it would also benefit US business interests and “win hearts and minds” in
battle against USSR (Soviet Union)
- Very top-down and siloed approach (funded only malaria eradication and not broader healthy
system around it)
- Recognition of failure to achieve global progress in 1969
- Shift to integrated rural health services

Smallpox Eradication (most successful story from WHO)

- Soviet Union proposes eradication of smallpox as a global goal in 1959
- Supported by the US in 1965
- The WHO certified global eradication of the disease in 1980

Alma-Ata
- Major conference on the organization of health services in Alma-Ata, in the Soviet Union (now
Kazakhstan) in 1978
- Led to the Declaration of Primary Health Care and the goal of “Health for All in the Year 2000”
 Primary Healthcare was a comprehensive package that was quite lofty (even today)
- Intersectoral and multidimensional approach to health and socioeconomic development
- Use of “appropriate technology” – best available and contextually appropriate to achieve health
- Active community participation in health care and health education
- Rise of decolonized African nations, non-aligned movement (neither aligned with USA or
Soviet), socialist movements, a more liberal American government, and re-entry of China in 1973
- Barefoot doctors in China as inspiration
- Proposal to study methods for promoting the development of basic health services in 1968
- New model of “Primary Health Care” – informed everyone’s thinking

Bellagio Conference
Sponsored by the Rockefeller Foundation, with assistance from the World Bank
Promoted “selective primary health care”
a. Pragmatic, low-cost interventions
b. Limited in scope, easy to monitor
GOBI
a. Growth monitoring to fight malnutrition in children
 b. Oral rehydration techniques to defeat diarrheal diseases
c. Breastfeeding to protect children
d. Immunizations
e. Cheap low-cost interventions which can be implemented quickly

1980 World Development Report

- Malnutrition and ill health could be countered by direct government action—with World Bank
assistance
- Linked improving health and nutrition could accelerate economic growth
- Favored free markets and a diminished role for national governments
- Very influential in getting people outside of health interested in healthcare reform

Gro Harlem Brundtland

- Former prime minister of Norway and a physician and public health professional
- Driving force behind the adoption of the FCTC (Framework Convention for Tobacco Control)
- Created Commission on Macroeconomics and Health (linking health to economics)
- Jeffrey Sachs, former ministers of finance, officers from the World Bank, the IMF, WTO, the
UNDP, and public health leaders
- Often made use of PPP model with BMGF as major donors
a. Roll Back Malaria in 1998
b. Global Alliance for Vaccines and Immunization (GAVI) in 1999
c. Stop TB in 2001

Canada’s Role in Global Health

- Emergence as a “middle power” after WWII
- Middle powers achieve such impact by forming alliances, promoting shared norms, working
cooperatively through multilateral channels, and engaging in diplomatic solutions; as a middle
power, we didn’t have the economic or military force to influence other countries, so we exerted
influence via these channels
- Prominent role in creation of UN, peacekeeping, and several UN agencies
- Lester Pearson led World Bank Commission on International Development recommending high-
income countries devote at least 0.7% (largely unmet by any nation worldwide) of GDP to ODA
(Official development assistance) by 1975
a. only UAE, Sweden, Luxembourg, Turkey and Denmark meet this goal
- In 2016, Canada’s net ODA (CAN$3.96 billion) constituted 0.26% of its gross national income,
placing it 15th among 29 OECD countries, and well below the OECD average of 0.40%.

Canadian Global Health Values

- Equity and universality of essential health services
a. Ottawa Charter: Political commitment to health and equity in all sectors, address health gap
within and between societies
- Focus on Determinants of Health
a. Lalonde Report: Human biology, Environment, Lifestyle, and Health care organization
- Gender equity
a. By 2021–22, at least 80% of Canadian aid will target the advancement of gender equality and
the empowerment of women and girls
- Lalonde - First modern government document in the Western
world to acknowledge that our emphasis upon a biomedical
health care system is wrong, and that we need to look beyond
the traditional health care (sick care) system if we wish to
improve the health of the public

Ottawa Charter
- The fundamental conditions and resources for health are:
 1) peace,
2) shelter,
3) education,
4) food,
5) income,
6) a stable eco-system,
7) sustainable resources,
8) social justice, and equity.

Canadian Hypocrisy
- One of the leading countries that drain health human resources from LMICs
- Canada’s global position as a mining giant
- One of only four countries to vote against the UN Declaration on the Rights of Indigenous
Peoples in 2007
- Ranked 55 of 58 countries (very poor) on the Climate Change Network’s list of climate
protection performance
- Canadian commitments to international aid close to an all-time low
- With Canadian companies operating in more than 100 countries, and Canadian mining assets
abroad totalling CAN$170·8 billion in 2015
- Based on 2015 data, as well as budgets announced under the Liberal government, the report
stated

Stephen Harper Years

- ODA reduced by 14%, from 2008 to 2010
- Further cuts in 2012, with 11% cut to IDRC
- Led to the closure of two of its six regional offices and > 1/3 rd of IDRC’s budget remaining
unspent
- ODA bundled with economic policy and trade priorities, rather than human rights, social justice,
and equity
- Controlling science communication (i.e., muzzling), notably for environmental research and
critics of cuts
- Retreat from multilateral initiatives, including withdrawal from the Kyoto Protocol in 2012
- a high of CAN$5.7 billion to $4.9 billion  “cuts by stealth.”

Canadian ODA (Official Development Assistance)

- During the early phase of expanded funding (1997–2008), the most prominent funding channels
were Canadian bilateral assistance mechanisms (47.7%), followed by UN bodies (27·1%).
- From 2009 to 2016, substantially more funding went through international and Canadian non-
governmental organisations and foundations (25.3%), with a concomitant decrease in funding
through Canada’s bilateral assistance mechanisms (36.6%) and UN bodies (15·6%).

Canadian Funding for Global Health Research

- IDRC (International Development Research Centre) is the world’s only government-mandated
organisation devoted to research for development
a. Demonstrated that only 5% of funds were spent on research addressing problems of poor
countries whose citizens bore 93% of the global burden of preventable disease in 1990
- CIHR (Canadian Institute for Health Research) funding for global health increased from CAN$3
million to more than $30 million

Canadian Colonialism
- The 1867 Indian Act imposed a band council system of governance, forbade First Nations from
speaking their languages, denied First Nations the right to vote, and forbade First Nations from
forming political organisations
 - Indian Residential School system (1940s–1996) was a key tool in the cultural genocide of
Indigenous peoples
- Forcibly removed Indigenous children from their families at a young age, relocating them to
state-run and church-run institutions, where they were subjected to assimilation to European
culture as well as profound levels of physical, sexual, and emotional abuse
- Yet to reach full implementation of the 94 recommendations of the Truth and Reconciliation
Commission of Canada
- Seven directly related to health, including funding for Indigenous health centres, and
implementation of the health rights of Indigenous people in international law, constitutional law,
and treaties previously negotiated with the Government of Canada
- Yet to incorporate the UN Declaration on the Rights of Indigenous Peoples into federal law

Lecture 2 – Synchronous
Global Health Actors
Core
- National governments, health ministries, and bilateral development cooperation agencies
Agencies focused on health or with health components
- WHO, UN, UNICEF, the World Bank, GAVI Alliance, UNITAID, the Global Fund, and many
more
Other organizations that affect health
- World Trade Organization, bilateral and multilateral trade blocs, supranational government (EU)

Headquarters in HICs
- International headquarters of the 203 global health actors were located in 16 countries and 73
cities
- 98.5% of headquarters were located in high-income countries.
- U.S. (n = 135), Switzerland (n = 23), and the United Kingdom (n = 13), followed by Belgium (n
= 7), The Netherlands (n = 6), and Canada (n = 4)
- 61.6% of global health actors (n = 125) listed improving health as the sole primary intent of their
organization

Top Actors by Centrality

- WHO
- FHI360
- Global Fund to Fight AIDS, Tuberculosis & Malaria
- Global Health Council
- Médecins Sans Frontières
- Stop TB Partnership
- U.S. Agency for International Development
- U.S. Centers for Disease Control and Prevention
- UNICEF

World Bank
- Formed in 1946 to assist in the reconstruction of Europe
- Later expanded to provide loans, grants, and technical assistance to developing countries
- Expanded to invest in population control, health, and education, with an emphasis on population
control
- 1979, the World Bank created a Population, Health, and Nutrition Department

GAVI (Global Alliance for Vaccines and Immunisation)

- Public-private partnership involving the WHO, UNICEF, donor and implementing governments,
the Gates Foundation and other select non-state actors
- Launched in 2000 as an “insurance policy” among UN-sceptical and US-allied countries
promoting global vaccine coverage
 - Conflict between those wanting health systems reform and country-driven vaccine programs, and
those in favour of vertical immunization programs
- Vertical immunization programs advocate won out in the end

Global Fund
- Led by Canadian International Development Agency (CIDA), the UK Department for
International Development (DfID), and USAID as the 'Ottawa Group' in 2000
- A 'health systems response' to communicable diseases, focusing in particular on HIV/AIDS, TB,
malaria and communicable diseases of childhood
- Conflict between those advancing the massive scaling-up of ART and those opposed
- Those advocates won out in the end

FHI 360
- Originally called Family Health International
- Founded in 1971 managing family planning and reproductive health
- Expanded to HIV/AIDS, malaria, and tuberculosis in the 1980s, and now manages development
programs and conducts research in more than 70 countries
- Mostly grant funded through organizations like DFID, BMGF, and the Global Fund.

Global Health Actors Activity

- Canadian ODA - IMF
- FHI 360 - MSF
- Gates Foundation - UNICEF
- GAVI - US ODA
- Global Fund - WHO
- ICRC - World Bank

2018 Budgets/Disbursements (Approximate)

- Canadian ODA: $4.1 billion
- US ODA: $31.1 billion
- Gates Foundation: $5.0 billion
- WHO: $4.4 billion
- UNICEF: $818.5 million
- Global Fund: $3.2 billion
- FHI 360: $828.5 million
- GAVI: $1.9 billion
- World Bank: $45.7 billion
- IMF: $25.4 billion
- MSF: $1.6 billion
- ICRC: $2.0 billion

Lecture 3 – Asynchronous
Renaissance to Crisis
- Modern era of Global Health starting around 1990s, where spending plateaued and took off in the
mid-1990s to 2000s
Explanations:
1. Response to structural adjustment of 1980s and 1990s
- globally coordinated policy phenomenon where there was reduced policy spending, push
to cut social programs including health spending; retrenchment of welfare state, clawing
back of funding and reduction of spending on health led to greater spending from
development assistance much of which came from private philanthropy and specific
government spending
 2. Focus on key diseases in response to HIV/AIDS crisis in sub-Saharan Africa
and resurgence of TB
- rise of HIV/AIDS as a global pandemic that needed to be addressed, as well as TB (as a
syndemic = the reduced ability for the immune system to tackle tb in areas that were
heavily affected, and this led to a resurgence of TB as a public health issue)

3. WHO and World Bank linked economic development with global health
- Shift in global health framing to improve the economy. If people’s wellbeing is improved
(especially at a young age) with a focus on child and maternal health, the economy will be better
off in the long-term
- Framing of health issues as state security threats: improved spending from government spending;
health issues like TB threatens the population, this leads to destabilization of economic and
political systems and must be address abroad to keep the country safe
- Growth of philantrocapitalism (Philanthrocapitalism is a way of doing philanthropy, which
mirrors the way that business is done in the for-profit world)

- Global Fund suspends funding and WHO has budget cut in 2011
- World Bank pivoting away from health to infrastructure
- BMGF (Bill and Melinda Gates Foundation) increasingly influential without public
accountability – 1990s and 2000s
- No major new private donors emerging
- 2008 crisis leading to austerity in Europe and North America
- Paradoxically, success may have led to stagnation
- HIV/AIDS seen as less of a threat than it was a decade ago
- HICs experiencing economic slowdowns leads to questioning aid to faster growing economies
(even if they are significantly poorer) – there is a perception by people in HICs who were in a
recession that the people in LMICs are growing faster and their economy is doing better than
HICs, but development assistance is needed regardless.
- IMF is not a democratic institution: voting power depends on investment in the institution; USA
invests a lot, so they have a veto power – they used institutional power to block aid to Iran and
Venezuela

The New Normal

- Inability of WHO to exert influence over its funders and competitors
- Rise of new aid donors like China – China spending more on development, but not at the scale
that their economy would permit
- Shrinking space for alternative institutions and donors – plateau of financing and less space for
new institutions to emerge
- Reassertion of hierarchies – people in power are holding onto power and less shift of new
institutions taking power away from old ones
- Shift to market-oriented principles by global health actors
a. Innovation, performance-based funding, management strategies and business plans – A new
thinking that global health institutions should conduct themselves like corporations; accelerated
by philanthropic organizations that see the benefits in daily job
- Multisectoralism degenerating into tokenistic inclusion of CSOs to absorb criticism of structures
and processes – helps to absorbs criticism of structures and processes; inclusion in name only,
when they aren’t actually changing the way thing are run
- “Performance-based funding and the need for efficiency create policy orientated on results set by
donors.” – donors are shifting priorities depending on the money their giving

Malaria
- Mix of actors such as government funders, private philanthropic sectors
- Many channel their money through the Global Fund
HIV/AIDS
- The USA is the dominant player in HIV/AIDS funding
a. Contribute 64% of global spending (all government spending), does include Bill and Melinda
Gates Foundation
- Other government and organizational spending worldwide is quite small in this area
Prevention
- USA funds 55%; less than the overall proportion of spending on HI/AIDS
a. not as focused on prevention, whereas other actors like BMGF and the UK are more focused in
this area
Treatment
- The USA is the overwhelming hegemon, the dominant player for financing HIV/AIDS treatment
a. they spend 90% of the world’s money on HIV/AIDS treatment because they finance access to
treatment (PETFAR) which provided antiretroviral drugs. In this case treatment is prevention
because people won’t be able to spread to others.

Anti-Microbial Resistance (AMR)

- Dominated by the UK
a. provides 50% of global funding because they’ve identified it as a priority area for influencing
global priorities
b. Key person: Dame Sally Davies

Reproductive and Maternal Human Health Resources

- Canada is an important player, providing 14% in global spending – significant because we’re a
smaller country

Vaccines
- BMGF (Bill and Melinda Gates Foundation) are quite influential, but there are also a good mix of
governmental and philanthropic sector spending, most flowing through GAVI and UN agencies.

Mental Health
- Overwhelmingly dominated by private philanthropy; government sources are underrepresented
- Majority of funding goes through NGOs and foundations as well as UN agencies

Ebola
- 65% of global spending comes from USA because it’s framed as a security issue, security
military spending, state security apparatus spending, threat to state security
a. a lot of government spending

Tobacco
- BMGF overwhelmingly finance, as well as other private philanthropic foundations like the
Bloomberg Foundation
a. little funding from governments because it hasn’t been framed as a security issue

Overcoming the 4 Rs (ways the global health systems has responded to the rise in priority setting by
financing)
1. Reaction: money dedicated to a certain issue, then react, build a global health infrastructure or
institution around where the money is coming from
2. Repetition: repeats what’s been done in the past as an evidence-based first step
3. Results: look for a results-oriented program that demonstrates the effects quickly; In terms of
building for the future, you probably can’t provide donors with the results that want to see within
2-5 years
4. Raising Funds: continue raising funds to grow and address issues if donors aren’t willing to do
so on their own
 Ways to Overcome the 4 Rs
- Global health priority-setting must be separate from global health funding – separate funding
infrastructure from the priority setting by leaving priority setting institutions like the WHO (who
are nominally democratic) and less concerned with global health funding
- The right to health for all must be prioritized over results-based frameworks and return on
investment – long-term thinking about right to health for all must be prioritized
- Global health policy has to be designed by democratic institutions within countries, and without
coercion from outside donors – democratic decision making as to what priorities actually are

WHO Global Nutrition Targets

- Progress in DRC, Mozambique, Angola and Burkina Faso
- Poor outcomes in South Sudan, Chad, Ethiopia, Madagascar, Sudan and northern Nigeria
- Improvements after 2000 likely due to
a. general sociodemographic improvements
b. scaling up of interventions that focused on reducing childhood illness, such as
malaria control, vaccination coverage, HIV prevention and treatment, and water,
sanitation and hygiene facilities – increased spending

Global Nutrition Targets

- Global Nutrition Targets were set by looking at Brazil, China, Bangladesh, and Mexico which all
achieved fast progress in improving nutrition
- “We estimate that no country in Africa is likely to achieve all of the WHO GNT in all of its
territory if current trends continue”

Illicit Financial Flows Video

- Journalists unveiled a tax evasion system used by the Swiss subsidiary of HSBC
- From 2006-2007, roughly 100,000 clients secretly channeled over $100 billion through HSBC
accounts
- Over $13 billion, came from 7,500 clients in Africa (Egypt, South Africa and Morocco), but
significant amounts also came from poorer nations like Eritrea, DRC and Liberia
- UN estimates the cost of these illicit flows in Africa at $50 billion each year, which is more that
the total aid received by African countries
- Represents 24% of GDP in some countries and if the illicit flows were curtailed, it would allow
countries to attain their development goals quicker
- OECD and G20 are discussing the automatic exchange of tax info to efficiently fight tax evasion

Illicit Financial Flows to and From Africa – Video

Convo with Raymond Baker – President of Global Financial Integrity

- Illicit money is one that breaks laws anywhere along the way, either in its origin or movement or
use
- 3 sources of illicitly money: 1) corruption, 2) criminality, and 3) commercial tax evasion
- Cross-border flow of money in Africa is the smallest component, then criminal and the largest
component is commercial
- Global Shadow Financial System (very efficient) facilitates the movement of money it consists of
tax havens where you can secretly bring in money, disguised preparations where the owner of the
business is unknown, anonymous trust accounts, money laundering techniques, missing voice in
the trade (mispricing of imports and exports of trade for the purpose of shifting money out of the
country); all designed to money in a hidden manner
- African Union (AU) embraced the report on Illicit Financial Flows – Financing for Development
Conference put the topic of Illicit Financial Flows (IFF) at the top of their agenda.
- IFF was referred to by the World Bank, the UN, the IMF, the OECD
 - How does the Infrastructure for IFF facilitate terrorism? They all use the same mechanisms to
shift money worldwide; terrorists physically smuggle gold, diamonds.
- The Shadow Financial Systems facilitates the movement of illicit money that provides most of
the terrorist financing money – N. Africa, Isis, Ben Laden; use this method to generate and shift
money where needed to buy weapons or for recruiting
- How do African and Foreign Partners address this issue? Greater financial transparency globally
(richer and poorer countries), which means less opportunities for illicit money to move through
the Shadow Financial System; political will is the main method and engendering a desire not to
take the money.

Global Financial Flows

- Official Development Assistance (ODA) - Remittances
- Loans - Contributions from Religious and
Charitable Organizations
- Repayments - Recorded and Unrecorded Trade Flows
- Debt Cancellation - Foreign Direct Investment
- Portfolio Investment -

Recorded Transfers
- Recorded transfer (not including illicit flows) – on the books
- Positive from HICs to developing countries until 1999, then net negative outflows since then;
considering everything flowing legally, there is money flowing from developing countries to
HICs every year since 1999
- Approx. $500 billion/year for ½ years afterwards

Capital Flight (isn’t including illicit financial flows)

- Unrecorded in official data
- Balance of payments leakages
- Deliberate trade misinvoicing
- Double invoicing
- Look at what’s on the books and compare what one country says vs another country and realize
there’s billions missing from official records and we can determine how much capital flight is
happening.
a. Approx. $13 trillion/year since 2000 – 5-6% of global GDP included in capital flights  lots of
money going unrecorded
- In the mid-2000s, we see up to $2 trillion flowing from developing countries to HICs
a. up to 10% of GDP from developing countries to developed countries
b. Net Transfers – money going in many different directions

International Health Regulations

- First International Health Regulations (IHR) ratified in 1969 building on a century of
international sanitary conferences
a. occasionally have different countries meet to discuss health issues like yellow fever and
malaria should be dealt with on an international basis
b. 1965 there was a loose agreement as to what countries responsibilities were when dealing with
public health emergencies of international concern
- Revised 2005 IHR expanded scope of notifiable diseases was expanded in response to failures in
addressing emerging infectious diseases like HIV/AIDS and SARS
- Objective: to prevent, protect against, control and provide a public health response to the
international spread of disease in ways that are commensurate with and restricted to public health
risks, and which avoid unnecessary interference with international traffic and trade
- Importance of national sovereignty and globalized trade
- Expansion from cholera, plague, and yellow fever to all public health risks, including non-
communicable
 - Cannot infringe on human rights, except when:
a. responding to pressing public or social need
b. pursuing a legitimate aim
c. Proportionate to the legitimate aim
d. No more restrictive than is required
- Requires countries to develop, strengthen, and maintain core surveillance and response capacities
a. No financial support to support these changes in LMICs
- Obligatory reporting of all events that may constitute a “public health emergency of international
concern” – threat-based reporting system
a. Constitutes a public health risk to other States through the international spread of
disease
Potentially requires a coordinated international response
- Additional privacy and informed consent rights
- WHO is no longer limited to using only official data and has authority to request more data from
countries, but no authority to investigate
- Director General can issue non-binding temporary recommendations on how to deal with PHEIC
- National measures can be more stringent if they are:
a. Based on scientific principles and available evidence
b. Are not more restrictive than reasonable alternatives
- No enforcement mechanism for failing to comply with permissible public health measures – only
through public shaming
- Compliance: IHR doesn’t include an enforcement mechanism if States fail to comply with its
provisions
a. Best incentives for compliance are “peer pressure” and public knowledge
b. Consequence of non-compliance include a tarnished international image, increased
morbidity/mortality of affected populations, unilateral travel and trade restrictions,
economic and social disruption and public outage.

What is Power?
- Global North vs Global South
- Rich vs Poor
- Males vs Females
- Economic Interests vs Health
- Not just powerful vs weak, but different forms of power

Dahl (straightforward and commonly cited)

- “A has power of B to the extent that he can get B to do something that B not otherwise do”
- The power to coerce, often through material resources (e.g., army, economic power)
- Commonly cited in “realist” school of international relations
- Doesn’t explain overt/covert influence and delayed unintentional effects – A intends to exert
power over B through easily traceable mechanisms

Bourdieu
- Power is not just overt domination
- Power can be likened to capital
a. Economic: BMGF, World Bank
b. Cultural: Academic titles, expertise
c. Social: Professional networks – knowing someone in a
powerful position or having a foot in the door
d. Symbolic: Positive reputation or image – gives might
beyond economic power to influence others

Barnett & Duval

 - Look at the way power works through either interaction with specific actors or through the social
interactions of a constitution, then they interact that with relational specificity of power and
whether its working directly on someone or whether its working through a diffuse mechanism on
many people
- Compulsory: material, symbolic, and normative power – direct, specific actors putting in place
their power directly onto another actor
- Institutional: rules that constrain the actions of others – originating from a specific actor and
diffusely onto many
- Structural: positions that define relations between actors – social relations
- Productive: categorization, framing, and knowledge-production – diffuse with social relation;
framing an issue in a way that gives a lot of power to some and little power to others; ways of
creating knowledge that privilege certain people

Typology of Power

Physical – direct, coercive use of power

Structural – enforced through physical power
Discursive – media discourse; shapes public discourse

Characteristics of Power
- Many different actors wield different kinds of power
- Categories are not mutually exclusive
a. Expert and moral power often go hand in hand
- Power is fungible (if money is coming in for one thing you can use it for another thing)
a. Moral power (e.g. pastor asking for donations) can be leveraged into economic
power
- Even “weak” actors can wield power
a. Resource-poor NGOs and countries can shape discursive and moral power

Power and COVID-19

Lack of:
• Epistemic power: global health lacks a common
epistemology, sense of causal beliefs, and
methodology
• Normative power: no global social contract
• Compulsory/Institutional power: even powerful
countries can’t force others to share information and
resources
Lack of:
• Productive power: shift from existential threat frame to cost-benefit frame
• Structural power
• Between countries: disruption of global supply chains and disparities in economic
resilience
• Within countries: Inequities along economic, racial, and occupational lines
Positive uses of power:
 • Use compulsory/institutional power to strengthen the WHO, improve infectious disease
surveillance, and assist poor countries build stronger health systems
• Use epistemic power stemming from research on the virus and public health outcomes to reduce
health disparities and bolster global health cooperation

Acemoglu & Robinson

- Emphasized the inclusiveness of institutions to determine whether nations succeed or fail
- “Extractive” institutions block opportunities and creativity
- Democratic, pluralistic systems with legal structures result in successful countries
- Feedback cycles of wealth and inclusiveness promote development (Gates)
- Extractive institutions with corruption and monopolies suppresses development (Slim)

Video
- Countries like the DRC, Zimbabwe and North Korea, which are poor have economic institutions
that create different incentives and opportunities that inclusive economic institutions like the
patent system
- Bill Gates (entrepreneur) made money via computer software industry, whereas Carlos Slim
made money though a telecommunications monopoly.
a. Slim’s income reduces national income in Mexico by 2% per year, whereas Bill Gates creates
incentives and opportunities via ideas and innovations which made him rich and was good for
society.
b. In Mexico, monopolies blocked other people’s opportunities and incentives (extractive
economic institutions) – one party state PRI prioritized Carlos Slim with monopolies
Problems with Robinson’s Argument
1. He blamed poor countries for their underdevelopment
2. Assertion that power and the patent system was broadly distributed is incorrect unless you
were a white man because slavery was protected by the US government

Historical Materialism
- Primarily Marxist approach to analyzing the effects of capitalism on the material conditions of
life
- Would argue that:
a. The logic and interests of Capital (i.e., investors) are upheld by global health policy
b. Developments in global health policy since the 1980s (e.g., rise of philantrocapitalism,
Structural Adjustment Programs (SAPs), international trade) lends strong evidence to its
ideas
c. CSO participation and Multisectoralism is another way of upholding the prevailing
political order by absorbing resistance that does change the underlying logic of capital
- Video: emphasizes that capitalism is to blame for underdevelopment and poverty. We’re made to
believe that making donations and buying capitalist products that also invest is potentially solving
the issues they created, but it’s actually helping the issues continue.

World Systems Theory

- Championed by Immanuel Wallerstein – we shouldn’t be looking at country by country
differences, but instead analyzing the world as one whole system.
- Unit of analysis should be world systems, not competing national systems
- There have only been two systems up to now (world empires & world economies)
- Cycles of hegemony and disorder over time
- Capitalists exploiting workers across the world, rather than just rich countries exploiting poor
countries
 - Non-capitalist exploitative system or egalitarian and democratic system are in competition to
become the next world system but neither has established a 3 rd world system

Core vs. Periphery

- Core: High skill, capital intensive industry and invest in periphery (e.g., North America, Oceania,
Europe)
- Periphery: Low skill (highly educated or specialized labour), labour intensive production and
natural resource extraction (e.g., Africa, Asia)

Dependency and Underdevelopment

- Thomas Sankara (assassinated by French agents) said that Burkina Faso was being undeveloped
by France by debt, and production of primary and secondary goods. He noted the way to combat
this was to produce secondary and tertiary goods within Africa and break the exploitation of the
periphery country by the core country.

Biopolitics
- Focuses on the political control of individual bodies, based on the work of Michel Foucault – less
concerned with coercive mechanism and more with specialized knowledge
- Would argue that:
a. Advancement of specialized knowledge promoted by global health policy changes the
behaviour of bodies
b. Points to the surveillance of women’s bodies (e.g., childbirth) and “diseased” bodies
c. Must recognize whose bodies are being controlled by global health policy and specialized
knowledge (i.e., science) and who is being controlled
Video
- Expert knowledge: upholding power and explaining away significant disparities despite the
weight of the evidence which is contrary

Feminism
- Diverse approaches that base their analysis on the role of sex (biological) and gender (social)
- Would argue that:
a. Women’s bodies are often reduced to childbearing and rearing
b. Unpaid care roles, substandard healthcare, and poverty-related diseases all
disproportionately affect women
c. Sex and gender effects must be considered in all policies and contexts
Video
- Considering the gender dynamics of risk factors and policy can help us understand things on a
deep level compared to if we were gender blind

Lecture 4 – Asynchronous
- Good to know where the epidemic started for genetic phenotyping reasons (e.g. Nepal); not
blaming one country, but rather the UN for negligence
- What is stopping HIC from fully funding LMIC for sanitation and health care projects if they are
aware that it will reduce the spread of infectious disease and the risks they pose to their own
national security?  We aren’t in danger of having a Cholera epidemic in high income countries
because of proper sanitation, so they aren’t willing to put their money behind something that is
very unlikely to happen.

1963 CBC Segment of the Artibonite

- Many of the current concerns in Haiti have long standing roots since the 1960s such as infectious
disease, maternal and child health, reliance on foreign aid, charitable sectors providing aid,
voodoo and cultural beliefs making care inaccessible, Papa Doc
Story 1: Anna Muller
- Has been working for the German Corporation for International Cooperation (GIZ) in Haiti since
1989
- Trained water, sanitation and hygiene (WASH) technician
- Goes around the community for a tour and see that the sanitation and water facilities are poor, she
makes notes for her report and there’s been no improvement during her time in the country
- She notes that are many community partnerships with smaller NGOs, but there are warnings in
Creole stating dispose of diapers and to use clean water
- She visits a local hospital and sees the consequences of the lack of clean water
- Households with one-member sick w/ Cholera – poor households were twice as likely to contract
Cholera because of lack of access to clean water and sanitation
- Sanitation precaution, no budget
- Final Report: over the decades, she realizes littler progress was made. In urban areas, the drinking
water percentages (from pipes) has fallen, and the amount of other improved sources has fallen
67% to 52 % and much has to do with the 2010 earthquake.
a. Sanitation: things are getting better slight faster in rural areas, whereas open defecation rates
are still high but falling
b. In urban areas, there’s been a population boom and the number of improved sanitations has
improved slowly
c. Richer households can afford better water delivered more regularly
d. Fetching water is a gendered issue  mostly women or children; spending an hour fetching
water in addition to other tasks, so piped water would benefit these people disproportionately

Story 2: Joseph Alvyns

- Lives in Port-au-Prince with his mother and 2 sisters
- Goes to primary school and plays baseball in his spare time
- Lives in a ‘middle-class’ household with a latrine and a water source that isn’t too far away
- Japanese government funds the construction of a gutter system using bilateral aid, which will help
with better drainage, but it takes some time due to slow construction. After heavy rain, everything
floods completely (including poorly built latrines which spreads disease)
- Learns about ORS (Oral Rehydration Serum) – miracle cure for Cholera; 4 cups of clean water
and ½ a spoon of salt, 6 spoons of sugar and mix. This is good to drink as soon as you’re sick;
reduced the mortality rate from 50% untreated to under 5% (just with this 1 treatment) and with
other it drops to under 1%

Story 3: Renaud Piarroux

- Professor of Parasitology and Mycology at the University of Aix-Marseille in Marseille, France
- Called to investigate the source of cholera epidemic by the governments of Haiti and France
- Invitation: highly unusual because of suspicion that UN peacekeepers were responsible; rumour
spread around the Pan American Health Organization, WHO, the CDC, but they chose not to
investigate. So, the Haitian government formally requested that the French embassy for assistance
led by Piarroux
- Piarroux looked at the data and saw thousands of cases reported weekly and it wasn’t improving
- Piarroux looked at risk ratio (under 1 = lower odds and over 1 = higher odds)
a. Downstream = 4.91 – 5 times the risk of contracting Cholera
b. IDP Camps = 0.10 – very low chance of contracting Cholera
- All evidence points to MINUSTAH (UN military base) outside Mirebalais on the river, which
flowed into the Artibonite river and downstream into other cities
- Above all else, aid organizations should indeed avoid adding epidemic risk factors to those
already existing and respect the fundamental principle of all assistance, which is initially not to
harm – primum non nocere (oath of the physician – first do no harm).
- Smoking gun: Cholera was brought into Haiti by Nepalese troops through untreated waste that
was poured into the river and a lawsuit was filed against the UN
 - When Piarroux looked back, he noticed it improved but it’s almost 9 years later; now thousands
and hundreds per year, which is much less than the hundreds of thousands back in 2010.

Story 4: Mario Joseph

- Human rights lawyer and head of the Bureau des Avocats Internationaux (BAI)
- Lead lawyer representing victims in high-profile Raboteau Massacre trial

Why is MINUSTAH In Haiti?

- The ‘peacekeepers’ were not in Haiti responding to the 2010 earthquake. They had actually been
there since 2004
- “The UN mission succeeded a Multinational Interim Force (MIF) authorized by the Security
Council in February 2004 after President Bertrand Aristide departed Haiti for exile in the
aftermath of an armed conflict which spread to several cities across the country”
- “Departed” is a very controversial way of framing the issue
- President Aristide was deposed in a ‘coup d’etat’ by US forces and he was shipped out to avoid
bloodshed
MINUSTAH Numbers
- Call for funding to deal with the aftermath of the Cholera epidemic - e.g., healthcare, portable
water and sanitation facilities. Would’ve been led under Zenapa (Haitian led government
organization in partnership with other multilateral
organizations
a. Request approx. $400,000 million to fully fund a
series of activities improve the lives of Haitians. This
would’ve been only 1.7 percent of MINUSTAH’s
budget. Since the earthquake $1.5 million was spent
of the uninvited peacekeepers
b. the UN had the money but chose to spend it
elsewhere, rather than on the people who really needed it

Cholera Accountability Project

- Mario Joseph led a lawsuit to force the UN to pay reparations to families who lost loved ones due
to their negligence
a. Sued an American court (because of its credibility), if they had won, it would’ve placed a lot of
pressure on the UN, but the UN argued that they were immune to being sued and the lawsuit
didn’t worked.

Story 5: Florence Duperval Guillaume

- Named Minister of Public Health and Population (MSPP) IN 2011
- Medical doctor who has had clinical practice and worked for international NGOs
- Long list of ministers that didn’t last; constant turnover – paid very little and many issues; usually
last 1-4 years, but she lasted 5 years

MSPP, in Partnership with…

- Partners are listed like sponsors and they keep the lights on at MSPP

Republic of NGOs
- NGO aid map showed only a few dozen NGOs would signed on voluntarily
- MSPP found hundreds of NGOs with some responsible contacts
- Many unlisted NGOs where the government has no control or idea what they’re doing
 - No way to track and coordinate, but the best Dr. Guillaume can hope for is cooperation from the
biggest NGOs

Patients Can’t Afford Care

- Primary reason people don’t seek care is because they don’t have the money (50% )
- Lack of access for those who want it
- Haiti has also been underfunding its healthcare system, in terms of government expenditures
- In 2000, 16% of funding was allocated to healthcare and in 2014 it was 5-6% of government
expenditure, but the government revenue is much smaller than most countries, so the absolute
magnitude is even smaller, making the disparity even greater.

Cuban Medical Assistance

- Received a lot of Cuban medical assistance
- Guillaume can’t publicly acknowledge
assistance for fear of angering American
politicians
- She accepted the assistance, but kept it
separate from American foreign assistance
apparatus

Who’s in Charge Anyways?

- The operating budget isn’t
the same as from external funding
a. comes from government funding ($27 million USD); external funding was
$2.5 billions, which they had no
control over how it was spent
- $2.4 billion was promised to Haiti in
relief aid after the earthquake

Story 6: Ban Ki-Moon

- Former foreign minister of South Korea
th
- Elected as 8 Secretary-General of the UN General Assembly in 2007
- He wasn’t looked upon favourably; this note
says the people bringing forth the suit have no
right to sue the UN in the USA and that the UN
is immune to being sued
- This view worked for some time, but after evidence came out that MINUSTAH was the probable
source it became weaker.
a. The UN blamed Haiti for a lack of sanitation and clean water practices and said it wasn’t the
UN’s fault
- 6 years later, Moon issued a public apology and recognized the UN role in bringing in Cholera.
a. Moon asked for member states
to contribute to the fund to help
improve the situation after all the
harm done to Haiti
- Formal investigation that looked
into what happened internally; it
was very critical
 - The UN showed resistance to acknowledging the harm done because of the precedence it would
set for people to sue and bankrupt the UN

Lecture 5 – Asynchronous Lecture

Acronym Definition
- GDP = Gross Domestic Product
a. Value of all goods and services produced in a country –
most common way to measure an economy

- GNP = Gross National Product

a. GDP + value of goods and services owned in other
countries – subtracts goods and services owned by other countries within your border. If your
country is wealthy and owns a lot of goods and services outside of your country, then the GNP
will be higher than GDP and vice versa.

- PPP = Purchasing Power Parity

a. Currency adjusted for the cost of living – currency isn’t just how much you can exchange it for,
but how powerful it is within a country. American dollar in NYC is less than in Mississippi
because the value of goods is context dependent.

- Pc = Per Capita
a. Per person – any measure divided by the population

- OOP = Out of Pocket

a. Spending not covered by insurance or government transfers – money taking out of your pocket

- OECD = Organization for Economic Co-operation and Development

a. Rich, mostly European and North American countries – counter the influence of Soviet-allied
countries in an organized, economic manner

- IMR = Infant Mortality Rate

a. Number of deaths in children under 1 year of age per 1,000 live births

- MMR = Maternal Mortality Ratio (or measles, mumps, and rubella vaccine)
a. Number of deaths per 100,000 live births from any cause related to or aggravated by pregnancy
– divided by 100,000 rather than 1,000 because it’s rarer than IMR and to get a better
interpretation

- NPO = Non-Profit Organization

a. An organization that reinvests its profits into its operations rather than to its stakeholders – re-
invest money into operation to further the organization instead of paying dividends to
stakeholders

- NGO = Non-governmental Organization

a. An organization that operates independently of governments – can be influenced or funded by
the government; can be for-profit or not-for profit

- LMIC = Low -and-middle-income country

a. A country with GNI per capita less than $12,375 USD

- HIC = High-income country

- a. A country with GNI per capita more than $12,375 USD
 Canada Health Act
- Federal legislation which governs how healthcare is delivered
throughout all provinces
- 5 key planks which came into place in 1984
- Portability: up to the amount insurable in Canada (e.g., won’t
be fully insured in America)

Public Funding, Private Delivery

- Universal public hospital insurance first enacted in Saskatchewan (rural province w/ small pop.)
in 1947
- Expanded to physicians in 1962, all provinces had adopted a similar program by 1971, and pan-
Canadian standards established in 1984 Canada Health Act
- Vast majority of physicians have private practices that contract exclusively with provincial
government
- Hospitals are public or private non-profit
- Private supplemental health insurance (usually employer-based) covers dental, vision,
pharmaceuticals, and allied health services  shows where OHIP falls short

Governance
- Under the Canadian constitution, the provincial and territorial
governments hold most of the power (delivery, programming, etc.),
while the federal government has important key players such as
StatsCan and CIHR, Health Canada

Federal-Provincial Coordination
- Most routine administration handled at the Regional Health
Authority level
- Provincial government has constitutional responsibility for funding, financing, regulation, and
administration
a. Physicians organization exert significant power
- Federal government exerts power through its ability to tax and transfer funds
a. Provincial equalization (taxes transferred from province to province), convening of
Premiers and Ministers of Health, and high-level strategic planning – economic power

Non-Insured Health Benefits Program (NIHBP)

- Administered by the Federal government for Indigenous peoples registered through the Indian
Act or Inuit beneficiaries of the Nunavut Land Claims Agreement or Inuvialuit Final Agreement
- Métis and non-Status people are excluded from receiving benefits
- Covers vision care, dental care, mental health, medical supplies, prescriptions, and medical
transportation
- Uneven benefits coverage, poor delivery, and issues with medical transportation led to a major
review process in 2017

Health Expenditures Over Time

- Healthcare spending as a share of GDP (7 % to 10%) has increased since 1975

International Comparisons
- Canada is middle of the pack in; less than France, but more than AUS and UK
- The USA will always be an outlier because its system is different and ineffective

Funding Sources
- Most spending comes from taxation (70%), then Out -of-Pocket (ODP) at 15%, private insurance
(13%) and other (2%)
 - Problem: Doesn’t Canada have universal health care? Why is 30% of our spending not covered
under taxation if it’s the source of funding for the entire healthcare system?

Financing - Increasing
- Total Health Expenditure (THE) in US PPP has doubled (2,054 to 4,478) in 15 years
- THE as % of GDP has also increased – not just because the economy is increasing and healthcare
spending is increasing at the same level, but it’s increasing faster than GDP
- Public health expenditure as % of GDP
- PHI (private health insurance) as % of THE
- PHI as % of private expenditure on health

Financing – Relatively the Same

- Public health expenditure as % of THE
- Private expenditure on health as % of THE
- Private expenditure on health as % of total government spending

Financing – Decreasing
- ODP payments as the % of THE
- ODP payments as % of private expenditure on health

What Are We Spending On?

- Hospitals
- Drugs
- Physicians
- Hospitals are the number one category of expenditure, but drugs are
the fastest growing

Detailed Spending Breakdown

- Public health – 5.6%: there’s been calls for at least 105 for THE because
it’s a good investment that results in better health for less money
- Administration – 2.7%: the US spends in excess of 10%; we’re efficient
compared to the US; the smaller this number the better without sacrificing functionality

Pharmacare
- Canada’s the only HIC that guarantees universal healthcare, but doesn’t cover pharmaceuticals
- Canada has the 2nd highest percentage (over 10%) of adults skipping doses or not filling
prescriptions because of cost in the OECD
- Pharmaceutical coverage (private or out of pocket) functions as a tax on the unhealthy
- ‘Partisan issue’. We therefore urge all political parties to commit to implementing a universal,
comprehensive, public Pharmacare plan – beginning with federal legislation and budget
commitments in 2020.
Coverage for prescription drugs has been recommended by:
- 1964: The 1964 Royal Commission on Health Services
- 1997: The 1997 National Forum on Health
- 2002: The 2002 Royal Commission on the Future of Health Care in Canada
- 2018: The House of Commons Standing Committee on Health report of 2018
- 2019: Hoskins Report: needs to be universal comprehensive Pharmacare plan

Feasibility of Pharmacare
- If all the spending (public and private) was pooled in Canada,
it would amount to $28.5 billion per year
 - This number can be reduced every year by using a Pharmacare Formulary, based on Quebec’s
drug plan – using a select number of drugs to treat all conditions and narrowing down to that
- Another $.5 billion could be saved by making increased generic drug substitutions instead of
name brand, which is the same, except one is cheaper
- We could save another $5 million by negotiating with manufacturers as a single purchaser of
pharmaceuticals for the entire nation
- Number of people covered would increase by 12.5 %; more spending to cover more people.
Individually, out of pocket payments would be reduced by 90% (except for small things like
Advil, Tylenol)
- $20 billion in spending per year, saving $8 billion less as a system and covering more people

How Are Healthcare Providers Paid?

Salary (set amount of money per year for services)
Benefits:
o Simple
o Consistent pay
o Can be negotiated regularly
Downsides:
o No financial incentive to provide quality care
o No financial incentive to take on more patients – fewer patients and spend more time with
them
o No financial incentive to treat sicker or high-risk patients – set up in a wealthy, healthy area
without complex cases

Fee for Service (set amount of money given for service e.g., MRI, regular checkup)
Benefits:
o Relatively simple
o All care is compensated
o Prices of services can be renegotiated
Downsides
o No financial incentive to provide quality care
- Huge incentive to overtreat and provide unnecessary care – e.g., C-Sections

Pay for Performance (direct financial compensation for quality of care; allows funders to promote
evidence-based care. The physician’s roster is rated based on how complex or high-risk they may be and
then if they provide appropriate care or if the health of their patients under key measures are also
rewarded)
Benefits
o Rewards quality care
o Allows funders to promote evidence-based measures
Downsides
o Very complex to administer – lots of outcomes to measure
o Cream-skimming can be hard to prevent – Drs. may choose patients who are lower-risk and
know they can treat
o No evidence yet it results in better health outcomes

Capitation (get a set amount of money per patient)

Benefits
o Simple
o Consistent Pay
o Incentivizes taking on more patients
Downsides
o No financial incentive to provide quality care
 o No financial incentive to treat sick or high-risk patients – you’ll work harder and spend more time
with these patients compared to physicians that have healthy patients

Blended Capitation (set amount of money for taking on a set number of patients, rest of money is fee-
for-service or pay for performance)
Benefits
o Incentivizes provision of quality care
o Incentivizes taking on more patients
o Can incentivizes treating sicker or high-risk patients
Downsides
o More complex to administer
o Must be regularly re-evaluated

Why is the US Such an Outlier?

- 90.0% Americans have some insurance; 9.1%
don’t
- 2/3rd of Americans have a private plan
(employer) and 1/3rd have a public plan
- TRICARE – private military insurance
- Medicare – older Americans
- Medicaid – lower income Americans
- VA – military public insurance
3 Hypotheses
1. Inputs used for providing hospital care in the USA are more expensive than in other countries
- prices
2. US hospital stays could be more service-intensive than it is elsewhere – may get more
services than you’d get elsewhere and is it worthwhile?
3. US health system could be less efficient in some ways than are those of other countries –
administrative costs are higher (especially in private insurance)
- Some comparisons suggest that Americans are receiving fewer real resources than people in the
median OECD country.
- Although US Healthcare expenditure is much higher than other countries, they spend 8% GDP on
public health spending – only 1/3 of the population
- For all their spending, they still don’t have more doctors. They have almost the same as Canada
and we spend less.
- Mortality amenable to healthcare (prevention): US is highest in OECD – no underlying healthcare
issues that can’t be addressed by the healthcare system, but rather the system just isn’t doing so
- If you’re employed and get insurance through your employer, you’re obligated to pay through the
employer. Adding this (Health Insurance Poll Tax) to the other taxes people already pay, middle-
class people pay the highest tax rates than the rest of the country. The lowest income pays more
than the highest income people in the country. Non-progressive tax space

1619 Project
- Effect of slavery and racism on American life; policies enacted after Civil War
- It’s not coincidence that Medicare and Medicaid were introduced during the Civil Right
Movement and arguments against expanding insurance boils down to denying people of colour
insurance

Midwives
- Very common practice; especially in Europe
- Maternal mortality is a fraction in these countries than in the US
- “Granny Midwives” – Black-American midwives; took care of Black and poor white women
because of segregation you couldn’t get into a hospital
 - Male doctors blamed midwives for maternal deaths; this took away their importance
- Maternal mortality was highest in the OECD in the 1990s and has increased over that last 15
years
- US is more than double the rest of the world – racial disparities (black mother die more than
white mothers)
- Midwifery was a racialized profession; very successful in the early 20 th century for healthier
outcomes than hospital births, but part of the distain and not allowing them to practice in a cost-
effective way is due to the racial history
- In the 1970s, middle-class white women wanted more of a say in their birthing plans, so
midwifery made a resurgence, except now the midwives were mostly white.

Let’s Talk About Profit

- Oversized drops are wasteful; sold by volume
- US drug companies made $3.4 million in glaucoma and dry eyes drops
- Dr. Alan Robin – patients spend twice as much money as they need to on drops
- Almost every drop of the market is larger than the eye can hold
- US healthcare system wastes $765 billion per year, quarter of overall spending
- Cancer drugs – thousands per infusion; most cancer drugs are infused based on body size, so
patients need different amount, but most come in single-use and the rest is thrown out ($1000
waste per infusion)
- Waste costs money, so someone else have to pay the money back to the drug company and they
consider that profit
- Vials used to be sharable, but now they bill the patient for the waste. Drug companies claimed
they changed to single-use to for supply-chain reasons (a size more widely used)
- Fixable: shareable vials; eye drops – make the drops smaller (micro-drop)

Market Failures in Healthcare

- Demand for healthcare is a derived demand (for health) – People don’t want to buy healthcare,
but they want to be healthy, so they have to buy healthcare. They’re buying it because the doctor
says paying for a service will make them healthier.
- Externalities (negative: moral hazard – additional medical services taken on by someone who
wouldn’t have taken on if they weren’t insured; positive: herd immunity - if you’re immune
through vaccination, you’re protecting yourself and everyone else)
- Informational asymmetries between providers and patients – a doctor knows more about which
procedures work and patients know more about how they feel
- Uncertainty with respect to both the need for and the effectiveness of healthcare – even for people
with the best info, there is uncertainty about what works best and for which person; uncertainty
means you may pay a lot for a treatment that doesn’t work for you

The Case of the Epi-Pen

- Mylan bough the Epi-Pen and raised the price from $57 to $600 (+450% inflation)

What About Innovation?

- Pharmaceutical companies often lie about money needed for innovation/ R&D. Instead, that
money is used for adverting/marketing or buying products that have already been developed or
from public sources.
- Innovation usually happens in university labs
- Banting was restrained by the Hippocratic oath and couldn’t profit from his Insulin discovery, so
he got a research assistant to sign on.

Cuban Public Health Law

- Health care is a right, available to all equally and free of charge – similar in Canada (accessibility
and universality)
- Health care is the responsibility of the state – similar in public administration
 - Preventive and curative services are integrated - comprehensiveness
- The public participates in the health system’s development and functioning – Canada’s doesn’t
have something similar
- Health care activities are integrated with economic and social development – Not in Canada’s act
- Global health cooperation is a fundamental obligation of the health system and its professionals –
Inverse of portability – obligated to provide care to people outside of the country. There are many
Cuban healthcare professionals providing care abroad.

Infant Mortality Rate (IMR)

- Cuba has the lowest IMR among countries with similar living conditions, even lower than the
USA

Why Focus on IMR?

- Relatively easily measured indicator – binary outcome
- Comparable between countries
- Sensitive to changes in population health
- Prioritizes health of some of the most vulnerable populations
- Very little difference between IMR and complex indicators

Polyclinics
- “Each clinic supporting some 20 to 40 family physician and nurse teams. “Basic Work Groups”
composed of a leader from the polyclinic, a nursing supervisor, an internist, a pediatrician, an
obstetrician- gynecologist, a psychologist, and in many cases a social worker have
responsibility for a specified number of family doctor and nurse offices.
- Focus on preventative, primary, and public health services. Polyclinics are quite successful and
have been exported worldwide.

Ontario Health Teams

- Similar to Cuba’s Polyclinics
- Caring for patients more holistically
- Learning from LMICs in HIC settings

Typical LMIC Health Systems

- Universal Single Payer – covers everyone and there is a single financer of healthcare services
a. Brazil, Cuba, Sri Lanka
- Universal Social Insurance – covers everyone and its funded by contributions through
employers and employees and is supplemented from government expenditures
a. China, Rwanda
- Universal Public/Private Tiered Systems – superior private care delivered in private clinics, but
public care for those who can’t afford private care, so everyone is covered
a. Algeria, Chile, Colombia, Iran, Mexico
- Non-universal Public/Private Mix – similar to above, but many people still pay out of pocket
a. Bangladesh, DRC, Egypt, Ethiopia, India, Indonesia, Nigeria, Pakistan, Philippines

Example 1: Chile (HIC)

- Fragmented system with mix of public and private providers
and payers
- Better care for the wealthy, basic care for everyone else
- Very representative of many countries in Latin America who
have the same system
Example 2: Haiti (LMIC)
- Extreme fragmentation dominated by charity care and
overwhelmed and underfunded government services
- Health centers are 38% are public, 42% private, and
20% mixed (government and private sources)
- Private health insurance virtually non-existent (only
4% coverage); technically public clinics people can go
to, but quality of care is low and wait times are long
- Docs without Borders – free healthcare; high-quality
of care for low cost, but usually temporary and take
away from the mixed insurance

Who Pays?
- Social Health Insurance - more prevalent in HICs and upper-middle income and not present in
low and lower-middle income countries
- Private Prepaid Plans - more prevalent in HICs and upper-middle income and drops off in low
and lower-middle income countries
- Out of Pocket – lowest in HICs and more prevalent in low and lower-middle income countries
- Territorial Government – more common in lower-middle income; upper-middle, high and low
are similar
- Other Private Sources – charity care in low, lower-middle and upper-middle income countries

Lecture 5 – Synchronous

Affordable Care Act (ACA) Reforms

- Patient Protection and Affordable Care Act (ACA; or Obamacare)
- Expansion of Medicaid to those with incomes below 138% of federal poverty line (from 100%)
- Subsidies to purchase private health insurance for those with income below 400% of federal
poverty line
- Establishment of health insurance exchanges, with competing private plans covering essential
health services at different pricing tiers
- Some controls on administrative costs, (now toothless) coverage mandate, and reforms to
Medicare payments

Lecture 6 – Asynchronous

Global Health and Foreign Policy

Why does foreign policy care about global health?
- Global health is a direct objective
a. Altruistically maximizes health around the world
- Global health is a tool of foreign policy
a. Realist approach (means to an end) to international relations
b. Health threats to national security & geopolitical interests
- Global health balances science and state interests
a. Bidirectional influence between science and foreign policy

Foreign Aid and Health

- Development assistance for health
a. Increased rapidly ($5.6 billion to $21.8 billion per year)
b. Increasingly focused on vertical HIV/AIDS programs – vertical programs: one health issue at
a time, not trying to integrate
c. Alignment with domestic policy priorities
 - Securitization (is the financial practice of pooling various types of contractual debt and selling
their related cash flows to third party investors)
a. New appreciation for infectious disease threats
b. Extension of aid as “soft power” – provide health aid and hope the country has gratitude for the
aid and in the future their vote in a multilateral institution or vote in the UN

Net ODA Received (Current USD)

- ODA has increased rapidly since 2000

Trade and Health

- Trade can spread communicable disease, harmful products, or healthy commodities
a. Global trade mediated through the General Agreement on Tariffs and Trade (GATT) and
World Trade Organization (WTO)
b. Many bilateral and multilateral trade agreements
- Regulation of health-related trade
a. Regulations to protect public health supersede other trade provisions in limited circumstances
(a country must prove that restricting aid from a certain country is necessary, they can do so as
long as they can attain regulations)
b. Agreement on Trade-Related Intellectual Property Rights (TRIPS) allows for limited
protections for LICs
c. Accelerating migration of health professionals to HICs
- Trade policy and health
a. Restrictions of food imports for public health reasons – e.g., mad cow disease
b. Agricultural subsidies in HICs harm LIC farmers – harms local producers in LMICs

Diplomacy and Health

- International agreements
a. First international conventions regulated control measures for cholera, plague, and yellow fever
b. Eventually leads to the International Health Regulations
- Focus on Public Health Emergency of International Concern (PHEIC) does little to address
endemic (always present in a certain area) diseases – a LMIC with persistent Dengue fever that’s
a burden on society, the International Health Regulations won’t do much because it’s not an
emerging disease threat
- Ratification of the first global health treaty, the Framework Convention on Tobacco Control
(FCTC)
a. Did weakened final language reduce its effectiveness?
- Alignment of foreign and global health policy
a. Germany, UK, Brazil, and Indonesia have unified national global health strategies, but Canada
does not
- Health as an instrument of policy
a. Symbolic diplomacy (USNS Mercy and Comfort) – converted battleships with hospital beds
and staffed by medical personnel and sent to disaster zones: ‘soft power’
b. Transactional health diplomacy
- Cuban health teams – in exchange some key resources like oil or money are used to pay for the
favour of letting the Cuban teams work in their country
- Chinese cooperation in Africa
- Foreign aid has always supported security, economic, and geopolitical interests of donor
governments
a. Rebuilding allied economies after WWII – World Bank and IMF were created to assist with
rebuilding
b. Countering Soviet influence in the developing world
c. Shaping Middle Eastern power dynamics

Recipients of US Foreign Aid

 - Prior to 2000, Israel and Egypt received majority of foreign aid because of an agreement that
came out of the Camp David accord
- More recently, aid has shifted to Afghanistan and Iraq where the US was involved in military
occupation. They used soft power to reduce conflict, fatalities and extend US power in the region

Recipient of Canadian Foreign Aid

- More representative of countries from different regions, but most are LMICs  more balanced
than USA

National Security and Health

- National security
a. Threat, use, and control of military force
b. Threat to degrade quality of life
c. Threat to narrow the range of policy choices
- Protect colonial projects – expand the range of policies choices to have a presence in other
countries and couldn’t do so because malaria wouldn’t let them, so they chose to protect national
security to found these institutions and pursue to policy choice of a colonial project.
a. Founding of the US CDC, LSHTM, and many other institutions to protect colonial ambitions
- Re-emergence of infectious diseases as threats
a. SARS, H1N1, H5N1, AMR, COVID-19, bioterrorism
b. Likely contributed to increased government spending
- Criticisms and concerns
a. Who is data collection benefitting?
b. Sharing of biologic samples
c. Military planners’ influence in priority setting
d. Mismatch in spending and need
- Conflict settings
a. Real benefits of medical cease-fires and humanitarian aid
b. Medical services often used to gain trust of population in conflict settings to curry-favour

Where is US Aid Going?

- 33% bilateral development
- 29% military aid
- 18% humanitarian

Fiscal Multiplier
- Spending money of defence creates a negative effect on the economy for every dollar spent; it’s
not improving the economy of the recipient country compared to if you had spent money on
healthcare
- Money spent on healthcare creates a positive effect on the economy for every dollar spent
because healthy workers are more productive, educated...spur the economy

(Conflicting) Perspectives on Foreign Aid

- Foreign aid can be useful because it can break countries out of a so-called “poverty trap” (Sachs)
a. Vicious cycle to virtuous cycle – poor health, education, poor products in economy, then a
foreign aid intervention is needed to break the cycle
b. Can end poverty by 2025 with $195 billion
- Foreign aid ends up in the hands of corrupt governments and disincentivizes investments in the
future (Easterly) – does more harm than good
a. “Soviet style central planning” – on behalf on government that disburse aid
b. Lack of knowledge and experimentation

Angelina Jolie & Jeffrey Sachs

- 1 billion people worldwide live on less than $1 a day
 - Cheap interventions could transform economies

Millennium Villages Project (MVP) – pushed by Jeffrey Sachs

- Had to retroactively create comparison population to evaluate MVP progress
- US$600 million in direct investments, amounting to $120 per person per year over 10 years for
500,000 people, who lived in select villages. They would get a suite of interventions including
health, education and see if there have been changes to any measures over time.
- On 30 of the 40 measures, the MVP villages are better off, on average, than the comparison
villages.
- The one area in which unequivocal and substantial benefits are observed is maternal health,
including contraception use, antenatal care, and use of skilled birth attendants. The effect sizes for
other key outcomes, including child malnutrition and mortality, are small, heterogeneous, and
unstable – mixed an weren’t sure of what was going on.
- “The centrally planned approach that included provision of a streamlined basket of goods to each
village was said to promote solutions derived from aloof economic models insensitive to local
customs and constraints. Furthermore, the absence of upfront plans for evaluating the project
hinted at overconfidence in the righteousness of the approach, which was inconsistent with the
prevailing equipoise about the effectiveness of approaches to improving the health and wealth of
the world’s poorest.”
a. well-respected economists come in and say the know what the village needs without checking
with the village people if the measure worked
- “the end of poverty—arguably the raison d’être of the entire project—was no closer in the MVP
villages than in the comparison villages.”

Extreme Poverty (living on less than $1.90/day)

- Massive decline in people living in extreme poverty in South and East Asia and the Pacific, but
not in Sub-Saharan Africa

William Easterly
- Lack of accountability to the poor people we’re trying to help
- Critical of foreign aid
- Freedom as economic choice – political freedom to economic maximizing  neoliberalism
perspective

Real Issues with Aid - Easterly

- Lack of accountability to poor people
- Wasteful and foolish projects from aid agencies
- No consequences because poor people can’t spend their own money
- Aid agencies don’t know what to do about problems
- Criticism of the World Bank is censored
- Huge US, UK, European stakeholders
- Tyranny of former colonial powers

World Bank Voting Power

- Voting power isn’t one country gets one vote, but according to your shares in the system
- The more money you put into the World Bank, the greater your vote
- USA= top and Canada = bottom

Questionable Solutions - Easterly

- We’re lucky enough be able to hold public and private suppliers accountable by driving them out
of business – can’t drive Amazon or Wal-Mart out of business because they’re too big to fail
- We can mount political protest and vote politicians out of office
- Economic freedom leads to less poverty and better health
a. Property rights
 b. Liberalized markets
c. International trade
d. Entrepreneurs keeping their rewards
e. Structural adjustment

Is Aid Effective for What?

- Aid for health vs Aid for growth
a. Is it driving GDP growth?
- Almost certainly not – amount of money spent of foreign aid can’t drive GDP growth
- Is it producing positive effects in health and education?
a. If that is the objective, mostly yes

Political Economy
- Broad set of perspectives incorporating both political and economic factors
- Can be based in neoliberal or libertarian thought
- More often refers to Keynesian, Marxian, or other critical perspectives – recognition that the
economy is political and the political systems are influenced by economic factors, and you cannot
separate the two

Political Economy of Ebola

Economic
- Unprofitability of cures (one-time vs chronic) – needed
only when there’s an epidemic. If a biotech company
was relying on a cure to be profitable, this isn’t the
disease to invest in.
- Lack of purchasing power among those affected – Sub-
Saharan African countries. People in the countries have
low purchasing power and money made from the
treatment is low.
- Neoliberal adjustment leading to decaying infrastructure – less gov spending and public provision
of goods means more contact with the forest and populations in villages and a decaying hospital,
when medical centres could’ve handled it earlier on
- Economic incentives for encroachment into forests
Political
o Racism of inaction and targeted actions – if a similar epidemic hit an HIC more research
and money would’ve been spent to treat and prevent
o Governments step in (despite lack of profits) to protect national security – migration and
travel threatened national security
o Lack of strong health infrastructure and
political response

Rockefeller Foundation (Oil tycoon John D Rockefeller)

- Founded 25 schools of public health in North America, Europe, Asia, and South America and
sponsored 2,500 public health professionals to pursue graduate study
- Funded massive elimination/eradication programs for hookworm, yellow fever, and malaria
campaigns, yaws, rabies, influenza, schistosomiasis, and malnutrition
- For public health or to support American business interests?

Legacies of Rockefeller
1. Agenda setting from above – tied strings of money disbursed to leverage that money into a
priority setting when spent
 2. Budget incentives – leverage money by asking other organization to match with local investment
(double the purchasing power); gets buy-in from governments and purchase more than their
money alone
3. Technobiological paradigm – pursuit of improving health through technology
4. A priori parameters of success – goals once a decision to invest in a country and once the goals
were met, they moved on
5. Consensus via transnational professionals – professionals were trained in Rockefeller schools, so
they were able to get buy-in from local experts and elites to operate in the countries – networks
and links because of the investments
6. Adaptation to local conditions – did try to get political buy-in to shape projects to local
conditions; learning and adapting to current situations

Bill Gates Net Wealth

- $120 billion net worth – worth has doubled over 8 years. Money he’s giving to foundation isn’t
bankrupting him

Gates Foundation
• Funding of R&D rather than systems – prefer technical solution rather than systemic solution
(e.g., new bed net, vaccine or app)
• Infectious vs chronic diseases
• Corporate governance board – champion corporate interest which harm health outcomes
• Champions corporate interests that harm health outcomes
• investment in McDonalds, Coca Cola, big pharma, and Exxon Mobil (conflicting
interests) and Microsoft Windows (reason it was so influential was because of a
monopoly power, enforcing patent rights and pursuing other companies for intellectual
property infringement)

Rockefeller vs Gates
Similarities:
• Money comes from exploitative industries – monopoly on tech that was installed on computers
and oil
• Business models can solve social problems – a businessman is best suited for solving social
problems because they can run a big company
• Use of charity as a tax shelter – ulterior motives to donating money; can write off donation to pay
less tax and more clout for being a humanitarian
Differences:
• Public vs private provision of public health: Rockefeller went after a government provided
approach; Gates favours private provision of public health – NGOs, businesses
• Hegemony (Rockefeller) vs fragmentation (Gates – many different private and public actors
working on their own desires)

Philantrocapitalism
• Problem oriented – different problems that need to be solved
• Apolitical (?) – don’t pursue a purely left or right party, above politics
• Market oriented – believe in the power and positive effects of markets due to their experience
• Maintains power structures intact – invest to solve problems, but won’t invest in a way that
reversed power structures

Structural Adjustment Programs (pertaining to NGOization of resistance video)

• Loans given to economies in crisis by the IMF and WB
• Conditions to the loans include things like:
• Austerity: lowering government spending and increasing taxes
• Lowering minimum wages
• Privatization of state-owned enterprises
 • Eliminating food subsidies and price controls
• Encouraging foreign investment
These Conditions had a few side effects
- statistically negative impact on child and
maternal health

What is Neoliberalism?
- In 1930s, Friedrich Hayek, an Austrian born economist created neoliberalism.
- Built on liberalism and a defense of individual liberty, protecting private property and the
freedom of markets from external interference, taxes, regulation, levies
- Neoliberalism argued that the market wasn’t just an absence of interference, but produce a way of
thinking all on its own
- Neoliberalism is characterized by free market trade, deregulation of financial markets,
mercantilism and the shift away from state welfare provision.
- Neo = new
- Emphasizing privatization over state control as the best way to deliver public services
- Hayek vs John Maynard Keynes
- Keynes argued that government should get involved in increasing demand to keep productivity
up, and unemployment down
- Regan and Thatcher, Pinochet (Chile) were believers in neoliberalism
- Neoliberalism leads to fast-paced globalization because it breaks down barriers to trade and
financial flows, prizes innovation above continuities
- Corporation above the Nation

NGOization of Resistance
• NGOs came to fill the void and diffuse political anger after military venture or neoliberalism
ventures (SAP)
However…
• They represent a fraction of cuts to public spending
Leads to:
• Dependence
• Blunting of political resistance
• Accountability to funders rather than people served
• There is always a post-military invasion NGO rush
• “Apolitical” mindset makes aid recipients into perpetual victims in need of the white man’s help
• Depoliticises resistance by providing living wage doing fulfilling work

Lecture 7 – Asynchronous – Guest Lecturer Dr. Holst

- What is foreign aid? The most basic foreign aid definition states that it is “resources given from
one country to another.” These resources include money, materials, and manpower that are
donated to developing countries around the world. Foreign aid is offered to help with emergency
preparedness, disaster relief, economic development, and poverty reduction. The Development
Assistance Committee (DAC), made up of 30 major donors, was created to oversee and discuss
issues surrounding foreign aid; specifically focusing on humanitarian aid and economic
development.
- The Development Assistance Committee (DAC), made up of 30 major donors, was created to
oversee and discuss issues surrounding foreign aid: specifically focusing on humanitarian aid and
economic development. The chart below ranks these
30 donors by how much foreign aid assistance
they gave in 2017 and shows the top
ten developing countries that were on the
receiving end of their aid.
Foreign aid contributing countries
1. United States: $34.73 billion
2. Germany: $25.01 billion
3. United Kingdom: $18.10 billion
4. European Union: $16.44 billion
5. Japan: $11.46 billion
6. France: $11.33 billion
7. Italy: $5.86 billion
8. Sweden: $5.56 billion
9. Netherlands: $4.96 billion
10. Canada: $4.30 billion
11. Norway: $4.12 billion
12. Switzerland: $3.14 billion
13. Australia: $3.04 billion
14. Spain: $2.56 billion
15. Denmark: $2.45 billion
16. South Korea: $2.20 billion
17. Belgium: $2.20 billion
18. Austria: $1.25 billion
19. Finland: $1.08 billion
20. Ireland: $840 million
21. Poland: $680 million
22. New Zealand: $450 million
23. Luxembourg: $420 million
24. Portugal: $380 million
25. Greece: $310 million
26. Czech Republic: $300 million
27. Hungary: $150 million
28. Slovak Republic: $120 million
29. Slovenia: $80 million
30. Iceland: $70 million

Foreign Aid Receiving Countries

1. India: $4.21 billion
2. Turkey: $4.10 billion
3. Afghanistan: $2.95 billion
4. Syria: $2.77 billion
5. Ethiopia: $1.94 billion
6. Bangladesh: $1.81 billion
7. Morocco: $1.74 billion
8. Vietnam: $1.61 billion
 9. Iraq: $1.60 billion
10. Indonesia: $1.48 billion

Canadian Official Development Assistance

o Objective: Supporting sustainable development in developing countries  poverty reduction +
contribution to a more secure, equitable and prosperous world.
o Mix of bilateral assistance to priority countries (mainly in Africa, formerly also in Eastern
Europe) and multilateral aid partnering with UNICEF, UNDP; projects carried out in close
partnership with Canadian organizations
o Priority areas:
1. Increasing food security
2. Securing the future of children and youth
3. Stimulating sustainable economic growth
4. Advancing democracy
5. Promoting stability and security
o Organizational structure:
- Since 1968: Canadian International Development Agency (CIDA)  mandate to
"support sustainable development in
developing countries in order to reduce
poverty and contribute to a more secure,
equitable, and prosperous world."
- March 21, 2013: Amalgamation of CIDA
and the Department of External Affairs into
the Department of Foreign Affairs and
International Trade (DFAIT) (Canada's
Economic Action Plan 2013)  Global
Affairs Canada under the roof of Ministry
of Foreign Affairs

German Development Cooperation (GDC)

- Political leadership: Federal Ministry of Economic Cooperation and Development
(BMZ), in Europe also MoH (= BMG)
- Separation between financial and technical cooperation:
- Financial cooperation mainly channeled through KfW* Development Bank (supervised
by MoF)
- Technical cooperation directly implemented by giz**, to a lower extent by a broad array
of NGO‘s (commissioned by BMZ and other ministries)
- Increasing participation in multilateral funds and institutions  reduced direct steering
capacity compared to bilateral approaches
- Health has been a priority sector for GDC  Germany third largest donor in the health
sector
- Strong commitment for global health in recent years (G7, G20, EU) pushed forward by
the Ebola outbreak in 2013/14 and recently by the COVID-19 pandemic three main areas:
o Health systems strengthening
o Universal health coverage
o Pandemic preparedness

Influence of Private Foundations

- Multilateral and Private Sector Initiatives
and Joint Ventures: e. g. the Multilateral
Initiative on Malaria; the PATH’s Malaria
 Vaccine Initiative (MVI); the World Bank and HIV/AIDS; World Bank’s Malaria
Booster Program
- Partnerships: e. g. the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM),
the Global Network for Neglected Tropical Diseases, the Roll Back Malaria
Immunization Partnership, the Stop TB Partnership, and the TB Alliance, the GAVI
Alliance (on) and Global Alliance for TB Drug Development, and UNITAID
- Private Foundations: e. g. the Bill & Melinda Gates Foundation, Wellcome Trust,
Acordia Global Health Foundation, Aeras Global TB Vaccine Foundation, William J.
Clinton Foundation.
- Civil society: In line with developments elsewhere within the UN system, civil society
role in global health has continued to increase, particularly in shaping and influencing
ideas within the system.

Private Foundations in Development

- Private foundations have become increasingly
influential in global health in the 2000s
- Private actors in partnerships and alliances
dispose of funds that exceed the contributions
of member states to UN organizations
- The spectrum of actors challenges public
policy interests in health due to
 Conflicts of interest in health policy setting
 Lack of transparency

Key Challenges of Philanthropic Actors in Health

- Lack of transparency, participation in priority setting and decision making. And control
 doubtful legitimacy
- Enormous financial resources flooding national states and economies, driving (health)
policy decision making and eventually diverting national policy
- Marketisation of international cooperation: Philanthropy interested to “sell” their well-
doing
- Private institution expected to provide a rights-based global public good
- The widely uncoordinated venture philanthropy of
recent years has produced a kind of market
multilateralism  a sector which is to produce a
global public good such as health is driven by a
short-term output-oriented and results based private-
sector perspective
- Global health policy increasingly challenged to ensure policy coherence for sustainable
development

Overarching Global Trends in Health

- Privatization in health: the growth of the share of private sector involvement in public
health systems.
- Commercialization in health: increased provision of healthcare services through market
relationships, where accessibility depends on willingness and ability to pay.
- Financialization in health: a situation where financial motives, markets, actors and
institutions play an increasingly important role in the provision of health services.
Development Effectiveness Principles

SDG Approach
- New cooperation mechanism that
supports integrated and multidimensional
joint programmes
- Address the root causes of poverty and
pledge to leave no one behind, including
vulnerable groups
- Based on coordination, ownership and
multidimensionality
- Pursuing operational performance,
sustainability and multistakeholder
engagement
- Intended to be universal  applying to all countries rather than just the developing
world.
SDG Target 17.11: Double Exports from Developing Countries
- The target of doubling the share of LDCs’ exports in global exports by 2020 is likely to
be missed.
- Travel and transport sectors drive services exports in developing economies
- 100 to 120 million direct tourism jobs are at risk due to COVID-19. (UNWTO, 2020a).
- Loss of USD80 billion in export revenues from tourism expected for 2020 (UNWTO,
2020a).
- Vietnam doubled their share of world goods exports and tripled their share of world
services exports from 2010 to 2019.

Development Aid – Another View

- In 2012, the “global South” received a total of slightly more than EUR 1.15 trillion, in the
form of foreign aid, investments and income from abroad; in the same year, over EUR
2.9 trillion flowed out of it.
- Net Resource Transfers for all low- and middle-income countries have been mostly large
and negative since the early 1980s  sustained and significant outflows from the Global
South summing up a total of EUR 12.9 trillion since 1980
- Main components of outflows:
o Interest payments
o Repatriated foreign investment return
o Illicit financial flows - capital flight mainly due to illicit practices international
trade
- Sub-Saharan Africa is being drained of resources by the rest of the world, losing far more each
year than it is receiving:
- Yearly influx: EUR 142 billion flow into the continent in the form of loans, foreign investment
and development aid
- Outflow: EUR 178 billion  Net loss: EUR 36 billion per year
 - Total net resource outflows from developing to developed countries accounts to about EUR 2.7
trillion per year ≙ approximately 24 times more than the global aid budget  for every EUR of
aid received, low-income countries lose EUR 24 in net outflows

Impact of Free-Trade Associations and Health

- European Union (EU):
o Health is still under national responsibility but increasingly influenced by EU decisions and
laws.
o Free movement of goods, services and people  EU-wide comprehensive social protection,
including portability of pension, health coverage and unemployment benefits
- North American Free Trade Agreement (NAFTA):
o Health policy essentially a matter of member states having the “inherent right to regulate”
the health sector
o Free movement of goods and services only  no incentive to establish NAFTA-wider social
rights and services
- Southern Common Market (MERCOSUR):
o Regulation for health security and public-health concerns
o Social (health) protection for migrant workers from within the community and associated
members but social protection not yet systematically universalized
- East African Community (EAC):
o Intention to adjust social protection to intensive cross-border movement of goods,
services and people  so far focus on research and planning
o Progress hampered by strong belief that health systems have to be harmonized
- ASEAN Economic Community (AEC):
o Health worker mobility priority concern
o Medical tourism, exchange in clinical medicine
- Different effects on the social determinants of health:
o Food security threatened by massive inflow of low-quality food (processed foods and
sugar-sweetened beverages) from richer to poorer countries (e. g. Mexico)
o Potentially improved access to medicines
o Higher Body Mass Index (BMI) and higher cardiovascular disease incidence
o Better job opportunities for the workforce and cross-border support by trade unions vs.
dumping of salaries and worsening of labour conditions due to an increased competition
- Growing economic literature shows free-trade associations to be particularly beneficial for
people’s health low-income countries

Lecture 7 – Asynchronous
Schrecker, Ted (2018): The State and Global Health. In:
- Rather than taking for granted the state’s functions and functionaries as they relate to healthcare
and other prerequisites for healthy living (the social determinants of health), its is more
productive to ask: why do states care about health? Whose health? And under what conditions
are they more or less likely to do so?
Reasons:
1. Forces/Recruitment for army
2. Economic interest
3. Health security (infection risks for elites)
4. Political power: politics
- Defending political power of elites
- Social reform/class struggle/improving living conditions working class
5. Idealism/Philanthropy: Human rights, social rights

Schrecker, Ted (2018): The State and Global Health. In:

-It’s difficult to improve on Halperin’s formulation: Globalisation is a matter of deliberate organization
and collective effort on the part of elites concerned to maintain a specific distribution of resources that
subordinate labour and preserves elite privileges. The discourse of globalization emphasizes the necessity
of governments to adapt to newness and differences, a necessity that forecloses choice. But government
policies are designed, not to adapt to new circumstances, but to promote them.
a. Replace globalization by global health and free trade!

The European Union

- Heterogeneity (geography, demography, economy, labour market, stratification, welfare states,
political systems, historical experiences)
- Different challenges, agendas, visions

EU (Public) Health Policy

- Health in All EU-Policies - aim of collaborating across sectors to achieve common goals. It is a
strategy to include health considerations in policy making across different sectors that influence
health, such as transportation, agriculture, land use, housing, public safety, and education. It
reaffirms public health's essential role in addressing policy and structural factors affecting health
- Public Health Article / Treaty Art. 168 (Principle of Subsidiarity)
- a. Principle of Subsidiarity = EU should only take over if the member states can’t do something
themselves (e.g. pandemic)
- Health Strategy
- Health Programme (2014-2020_
1. Promote health, prevent diseases, foster supportive environments for healthy lifestyles
2. Protection from serious cross-border threats
3. Supporting public health capacity-building and contributing to innovation, efficient and
sustainable health systems
4. Access to better and safer healthcare for Union citizens
- Consequences of crisis 2008/9
- Consequences of Covid-19 pandemic
EU Health Policy
- “Union action shall respect the responsibilities of the Member States for the definition of their
health policy and for the organisation and delivery of health services and medical care (Art. 168
TFEU)

What Stimulated an Interest in EU (public) health activities?

- The EU (Chaps 1-2)

Political Motives for European Cooperation and Integration

Peace (Public) health policies until 1992 not mentioned
in Treaties
Common goals and norms Small exceptions:
- Occupational health (economic
competition)
- Nuclear policy
- Some programmes (drugs, cancer, etc.)
Economic prosperity Around 1992 and later:
- Mad cow disease etc.
- Old new infectious diseases
- Single Market Project
More Power in Foreign Policies Solving Cross-Border Problems
Good Neighborhood in Europe (Public) Health policies “sneaked in”
 - Europe 2020: We need a strategy to help us come out stronger from the crisis and turn the EU
into a smart, sustainable and inclusive economy delivering high level of employment,
productivity and social cohesion.

Seven Flagship Initiatives

1. Innovation Union – framework for research
and innovation; ensure that new ideas turn into
products and services
2. A Digital Agenda for Europe – high speed
internet; benefits for households and firms
3. Youth on the Move – education system;
labour market entry
4. Resource Efficient Europe – decouple growth from use of resources; emissions;
energy
5. An Industrial Policy for the Globalization Era – SMEs and industrial base
6. An Agenda for New Skills and Jobs – modernize labour markets and increase labour
participation
7. European Platform Against Poverty – social and
territorial cohesion; enabling people to live in dignity and
take an active part in society

EU Health Program and Further Programs

- 4 Freedoms (a spillover of consumer protection): Goods,
Services, Capital, People/Workforce
- EU (health) policies
have already important
impact on member states health systems and policies, but EU
health policy has not become fully institutionalized yet.
- “One of the most important facts about politics is that it is
often easiest to exercise influence at the times when fewest
people are disposed to exercise influence. That is because an
effective intervention at the first stages of thinking can create
and kill policy ideas that would take on lives of their own. At
later stages, somebody else – and possibly somebody less
legitimate or qualified – has already taken decisions. (Greer,
2009:160)
- But: EU health policies are often driven by other policy sectors
(e.g. single market)
- Risk: institutionalization of EU health policy dominated by other policy sectors.

Situation and Developments

1. Multilateral agreements: World Trade Organization (1994/1995)
a. General agreement on Tariffs and Trade (GATT 1947/1994)
b. General agreement on Trade in Services (GATS, 1995)
c. Trade Related Aspects of Intellectual Property (TRIPS, 1994)
d. Sanitary and Phytosanitary Measures Agreement (SPS, 1994)
2. Currently deadlock
a. USA blocks the appointment of a new judge
b. WTO institutions cannot decide on sanctions, tariffs
c. EU wants to take decision about implementation of sanctions/tariffs by themselves
d. New EU structure should also be responsible in case of conflicts with bilateral agreements
3. EU
 a. More interest in bilateral agreements: Negotiated by Commission, confirmed by Parliament and
Council; if EU Member States responsibilities are concerned, ratification by national parliaments
necessary (e.g., investment issues)
b. Transatlantic Trade and Investment Partnership (TTIP) (EU/USA)
c. Comprehensive Economic and Trade Agreement (CETA) (EU/Canada; awaits ratification)

Pathways by Which Trade Can Impact Public Health

- Unhealthy commodities
- Industry involvement
- Services on general interest and health services
- Access to medicines
- Antimicrobial resistance and food safety
- Labelling schemes
- Procurement schemes

Critiques / Risks
- Aim of agreements
a. eliminating tariffs
b. reducing “non-tariff barriers” (e.g., discrimination measures, “where legislation, standards and
regulation differ between two parties”

- But:
a. governments use a number of technical measures for health and health services regulation, such
as labelling, licensing, granting permissions and recognition of qualifications

- Fear:
a. “race to the bottom”; restrictions of “government policy space”

- Good Regulatory Practices

a. shaping future regulations (not going behind reached level)
b. liberalisation, can lead to “race to the bottom”
“deregulatory motivation for including this mechanism and involvement of industry in
negotiations and such processes should raise alarm bells”
c. “can influence principles of law-making”
d. “not subject to investor-state or state-to-state dispute settlement provisions
e. “voluntary” – but this isn’t reflected in satisfactory manner in the language of the legally
binding parts of the text

- Investment Protection Measures

a. can undermine democratic policy development
b. includes regulatory chill, whereby other governments are discouraged from taking similar
action, and discriminate against local investors
c. Lobby: strong global industries, such as alcohol, tobacco, food and soft-drinks industries
d. many examples of corporate interests using ISDS to slow or prevent the passage of health
regulation
e. principle of exhaustion of domestic remedies…is often not included
f. EU proposed Investor Court System as an alternative

- Negative Listing
a. all services will be subject to market liberalization unless an explicit exception is made

- Ratchet Clause
a. “regulations could only be amended in a way that leads to more liberalization and not less
 - Science-based approach (favoured in the USA) vs. precautionary principle (favoured in the EU)

- Assessment of trade agreements

a. Sustainability Impact Assessment (economic, social, human rights, environmental impacts)

b. no Health Impact Assessment (HIA)

Key Points
- Trade policies can be harmful
- Trade policies can be regulated
- Trade policies are dominated by politics and allocation of power
- Within the EU:
a. there is an institutionalized structural imbalance
b. there is a political struggle
c. the single market project offers opportunities
d. at the same time, there are differences between countries/regions. We need policies to balance
“regional” development
e. a single market makes it necessary to address health issues (spill over)
- International / global health policies and politics
a. can we expect that the EU behaves “less egotistic” than others?
b. can we expect “spill over”, similar to dynamics within the EU?
c. can international organizations / intuitions develop regulatory power?

3 Dynamics of EU Health Policy

1. Integration begets integration
2. Integration exists and proceeds regardless of whether its wanted, but what it means and how
much it matters can vary and is responsive to the preferences of Member States and health
stakeholders.
3. Crises and shocks get attention: crises provoke action and public health initiatives arise after
outbreaks.
- The European Union has 28 Member States (27 after the expected departure of the UK) and
around 512 million people (about 446 million without the UK), making it one of the world’s
largest political units compared to the US (327 million), China (1 386 million), India (1 399
million) and Japan (126 million).

- EU4Health is EU’s response to COVID-19, which has had a major impact on medical and
healthcare staff, patients and health systems in Europe. By investing €5.1 billion, therefore
becoming the largest health programme ever in monetary terms, EU4Health will provide
funding to EU countries, health organisations and NGOs. Funding will be open for
applications in 2021.

- EU4Health will:
 boost EU’s preparedness for major cross border health threats by creating
o reserves of medical supplies for crises
o a reserve of healthcare staff and experts that can be mobilised to respond to crises across
the EU
o increased surveillance of health threats
 strengthen health systems so that they can face epidemics as well as long-term challenges by
stimulating
o disease prevention and health promotion in an ageing population
o digital transformation of health systems
o access to health care  for vulnerable groups
  make medicines and medical devices available and affordable, advocate the prudent and efficient
use of antimicrobials as well as promote medical and pharmaceutical innovation and greener
manufacturing.
- European solidarity in sharing medical supplies, EU Countries support one another, European
solidarity in bringing EU citizens home, international solidarity, solidarity with neighbouring
partners

Lecture 9 – Asynchronous

- Policy: A series of more or less related activities and their

intended and unintended consequences for those concerned;
Including decisions not to do something.

Explanations – Scarcity of Studies

- Public health is dominated by professionals trained in medicine and epidemiology rather than
social science
- Funding agencies are reluctant to fund political research and career prospects can be limited
- International organizations like the WHO strive to achieve consensus

Rudolf Virchow
- Medicine is a social science, and politics is nothing else but medicine on a large scale. Medicine,
as a social science, as the science of human beings, has the obligation to point out problems and
to attempt their theoretical solution: the politician, the practical anthropologist, must find the
means for their actual solution... If medicine is to fulfill her great task, then she must enter the
political and social life... The physicians are the natural attorneys of the poor, and the social
problems should largely be solved by them.
- Causes of Typhus epidemic in Upper Silesia were due to:
o Poor living conditions, inadequate diet, and poor hygiene
o Lack of democracy, feudalism, unfair tax policies
o Recommended “full and unlimited democracy” and “education, freedom and prosperity"
- Result: fired from position
- As a co-founder and member of the liberal party Deutsche Fortschrittspartei he was a leading
political antagonist of Bismarck. He was opposed to Bismarck's excessive military budget, which
angered Bismarck sufficiently that he challenged Virchow to a duel in 1865. [21] One version of the
events has Virchow declining because he considered dueling an uncivilized way to solve a
conflict. A second version has passed into legend, but was well documented in the contemporary
scientific literature. It has Virchow, having been the one challenged and therefore entitled to
choose the weapons, selecting two pork sausages, a normal sausage and another one, loaded
with Trichinella larvae. His challenger declined the proposition as risky.

Political Research
• Do democracies have any influence on health?
• If so, how do politics impact health?
• How to study the influence of politics on health without becoming a propagandist?
• “Do politics matter? We should realize that if the answer to this important question is no,
then we—those living in democratic societies—are in deep trouble.”

Two Policy Battles

• Pharmacare 2020: universal coverage in Canada
• ACT UP: HIV/AIDS treatment research and access

AIDS Coalition to Unleash Power

• Goals: Gain access to experimental drugs, speed up regulatory process, and end discrimination
• Who: HIV+ people, allies in LGBTQ+ community, and some researchers
 • How: Activism, alliance with researchers and regulators (inside/outside approach)

Pharmacare
• Goals: Launch a national universal single payer Pharmacare program
• Who: Academics, health economists, and patients
• How: Publishing research, reports, petitions, political pressure

Who Influences Policy?

A. Bounded pluralism
B. Corporatism
C. Elitism
D. Pluralism
E. Public choice

- Power is diffused throughout society and no one group holds total power over others
- Policy choice and change is dominated by particular social classes and the state ensures
continuing dominance of those classes
- Issues of high politics are decided within an elitist framework, but most routine domestic politics
are developed along pluralist lines
- Segments society into different sectors and allows limited debate within structures dominated by
a strong centralized state
- Applies economic rationality to collective political problems, incorporating game theory and
various rational choice theories
- Other misunderstood word: third world countries
Pluralism
• Ideal view of representative government
• Political equality and individualism are protected by the right to vote and free speech
• Government can be pressured through lobbying and mass media
• Weakness of individuals overcome by forming groups
• The state is composed of a neutral set of institutions impartially managing different interests
• No set of elites control the state because there are many and they are in conflict
Problems with Pluralism
• The state often intervenes in favour of its own interests or those of powerful elites
• Military, Capital, banks, corporations, etc. often have aligned interests
• How would a pluralist frame the analysis of HIV/AIDS treatment activism in the 1980s?

Elitist Theories
• Positions among political elites only open to members of the dominant economic class
• Interest groups are not equally powerful
• Resources at their disposal and ties to dominant class allow some interest groups to be
heard more than others
• Physicians often form an elite group unlike other unions
• Much political influence occurs in the economic sphere
• Restructuring entire economies of LMICs by powerful industrialized countries happens
without any political process within those countries
Problems
• Can overstate the ability of elites to wield power
• Many policies are decided through routine procedures involving groups of all economic classes
• How would an elitist frame the analysis of the introduction of Pharmacare in Canada?

Difference Between Pluralism and Elitism

- Pluralism suggests that power is spread amongst different groups in society (decentralized), and
that it is the pushing and pulling between these different groups that explains how decisions are
made and how governments are influenced. powerful pressure/interest groups are a classic
 example of pluralism because they show how power is divided amongst these different competing
groups and not concentrated with one organisation.
- Elitism is the exact opposite of pluralism. In elitist theory power is seen as concentrated amongst
a few groups or individuals (centralized), including the government. To use the same example as
before; elitist theory would suggest that only a few major pressure/interest groups, such as the
NRA or AARP, actually have any influence, and that even they struggle to gain power because it
is concentrated in the hands of a few members of government.

Bounded Pluralism
• High politics
• The maintenance of core values – including national self-preservation – and the long-
term objectives of the state
• Low politics
• Not seen as fundamental or key questions relating to a state’s national interest, or those of
important and significant groups within the state
• High politics (macro-politics)
• Often economic questions
• Focus on power in political systems
• Elitist consensus or conflict
• Low politics (micro-politics)
• More technical issues
• Focus on mechanisms and administrative routines
• Pluralist rational decision making or incrementalism
Walt Analytical Model
Mouseland
- Every 4 years there was an election; elected a
government made up of big black cats
- Same as history of Canada for over 90 years
- Made laws good for cats, but weren’t good for mice
- Law: Mouseholes had to be big enough for cats to get
inside
- Law: Mice could only go at certain speed, so the cats
could get food without too much effort
- Laws were good for the cats and hard on the mice
- Mice rebelled by voting black cats out and white cats in
- White cats: Mouseland need more vision
a. promised for square mousehole, twice as big as the round, so cat could get in easier
- Voted back and forth between black and white cats, eventually tried both (coalition)
- Smart Mouse: Why are we electing a government of cats? Let’s elect a government made of
mice! But they threw him in jail  can’t lock up an idea!

What do Canadians Think?

Analysis by Policy Effects

 - Distributive: Provision of services to one group in society without disadvantaging another group
in society
a. Less controversial
b. Open policy process with little resistance from interest groups

Redistributive: Policies that change the distribution of income or wealth

a. Involve strong interest group activity both in support and opposition
b. More controversial

Regulatory: Imposition of limitations on behaviours of individuals or groups

a. Generally, only generate controversy among being regulated

Self-Regulatory: Self-limitation of groups to control their own interests

a. Generally imposed as protection against outside interests affecting a group

Is Wealthier always healthier? The impact of national income level, inequality, and poverty on public
health in Latin America.

Tax Havens
- Rich people are hiding wealth offshore in the region of $7.6 trillion

Corporate Interests
• “In my prior life as an insurance executive, it
was my job to deceive Americans about their
health care”
• Wendell Potter, former vice president of
corporate communications for Cigna
• Objective: to “enhance shareholder value”
• Liaised with America’s Health Insurance Plans
(AHIP)
• How to counter impending release of Michael
Moore’s Sicko (2007)?
• Hire PR firms to make countries with
socialized health insurance systems look
worse than the US
• Cite questionable statistics from “business
leaders”, industry insiders (Pacific
Research Institute), or medical associations
(Canadian Association of Radiologists)

Pharmaceutical Lobbying
Stages of Policymaking
• Problem identification
• How do (or don’t) issues get on the
policy agenda?
• Policy formulation
• Who formulates policy and how is
policy formulated?
• Policy implementation
• What resources are available to
implement policy?
• Policy evaluation

Are Policymakers Rational?

 • Problems are rarely concrete and well-defined
• There are limits to time, imagination, and information available to policymakers
• Policymakers are driven by competing values and ideologies
• Equity vs efficiency, costs vs benefits
• Past policies constrain current choices
Video
- 1982: AIDS deaths in USA – 853
- Oct 15th, 1982: White House Press Briefing – Journalist Rev. Lester Kinsolving asks Deputy
Press Secretary Larry Speakes the first public question about the AIDS epidemic
- AIDS – Gay Plague (1 in 3 people die)
- White House wasn’t concerned with the epidemic;
President wasn’t responding
- 1983: AIDS deaths in USA – 2304

- Poll indicated majority favour quarantine for AIDS victims

- 51% percent of respondents supported a quarantine of
AIDS patients, 48% approved of identity card for those
with AIDS antibodies and 15% supported tattooing those
with AIDS
ACT UP Video
- 7 years for Reagan to mention AIDS; cost millions of lives
- ACT UP guilt tripped the government by using public sympathy
- Protest for quicker release of drugs and fought for the government’s use of resources
- 1st time a patient group demanded to be heard by bureaucrats in Washington
- Drug approval rates were drastically increased for AIDS and Cancer
- Became educated to speak with lawmakers

Inside/Outside Tactics
- “How did I meet Larry? He called me a murderer and an incompetent idiot on the front page of
the San Francisco Examiner magazine.
- Mr. Kramer’s name-calling wasn’t personal, Dr. Fauci explained.
- “I was the face of the federal government. I was the one out there trying to warn the public, and
he was, too. That was his way of saying, ‘Hello? Wake up!’ That was his style. He was
iconoclastic, he was theatrical — he wanted to make his point.”
- The “outside” movement becomes a home for activists to exchange information, develop
strategy, publicize their agenda, plan protest and engage in the indispensable work of long-term
organizing and movement building.
- The insider position—be that inside of Congress, unions or interest and advocacy groups—
requires risk and courage to be in or near the centers of power but to remain loyal, not to the
machine, but to political project of transformative social change. The insider with “eyes on the
prize” works to funnel resources to the outside, legitimizes the mass movement’s work and
articulates its vision. The effective insider does not try to control or limit protest but welcomes
unruly activism as the best possible bargaining chip.

Ryan White CARE Act

- Ryan White Comprehensive AIDS Resources Emergency (CARE) Act passed in 1990
- Now covers AIDS treatment for over 500,000 people (about half
of all HIV + Americans) with a budget of over $2 billion

HIV/AIDS Medication Polling

Incrementalist Model
• Limits to implementation influence policy objectives
 • Policymakers select the best option from a small number of incremental options
• Only some important consequences are considered
• Policymakers value consensus overachieving ideal policies
• Many small changes are constantly revisited
• Little space for major policy initiatives
• Focus on small less-than-ideal changes, knowing that few
problems can be solved at a time
• Past decisions constrain current policy options
However,
• Very constraining view of the process, and more relevant to
stable political systems

How the Pace of Change Affects the Scope of Reform: Pharmaceutical Insurance in Canada, Australia
and the UK
Normative vs Explanatory
- Rational models are aspirational (normative)
- Incremental models are empirically descriptive
(explanatory)
- Mixed scanning separates:
- Macro decisions (rational)
- Micro decisions (incremental)

Lecture 10 – Asynchronous
Video – Smoking and Health
- Cigarettes smoking contributes to mortality of certain diseases and overall death rate
- Causally related to lung cancer in men, bronchitis & emphysema
a. higher death rate coronary artery diseases; cardiovascular diseases
- Pipe smoking and lip cancer
- Report doesn’t include what’s in the tobacco smoke that causes lung cancer, no causal link with
lung cancer (just based statistical evidence)

Symptoms
- ½ of smokers will dies of a cause related to their tobacco use
- Second-hand smoke kills 1 non-smoker for every 8 smokers that
die of direct use
- #1 cause of death
attributed to tobacco –
Ischemic Heart
Disease (over 6 million) died in 2005, cerebrovascular
disease, lower respiratory infections

Female Smoking Rates

- Relative smoking rate among women – higher rates in
Europe, US, Australia
- When compared to men, it’s less, but the regions
affected by men – Eastern Europe, East Asia, Russia,
South-East Asia, North Africa and Middle East
- Higher-income women in the Western world and in men (LMICs) and away from the high-
income Western world
- In some countries, mortality rates are attributed to 25% of overall deaths

Inequities in Smoking Rates

 - Disparities according to wealth and adults with mental illness consume more tobacco at a higher
rate
- Lowest wealth groups smoke at a higher rate in many countries; India, Indonesia, Burkina Faso
- Over ½ of people initiated smoking tobacco by the age of 13 and that declines by 14, 15, 16 years
of age  tobacco marketers have to hook kids by the age of 14 because after that the chances of
initiating in tobacco use is reduced

Five Transnational Companies (control majority of the world

market)
1. Philip Morris International (PMI)
2. British American Tobacco (BAT)
3. Japan Tobacco International (JTI)
4. Imperial Tobacco
5. China Tobacco (CNTC)
- PMI and BAT are some of the largest private
companies controlling the market across the world
- CNTC is a state monopoly, common across N. Africa,
Middle East, Europe and have perversive incentives
because governments may want to decrease tobacco use, but they rely on profits from tobacco
through state monopoly  decrease money coming into state coffers in the form of monopoly on
tobacco or reduce sales and protect the population’s health?

Tobacco Tactics in LMICs

- Economic activity
- Marketing and advertising
- Political activity
- Deceptive/manipulative activity

Economic Activity
• Purposeful smuggling products into countries that limit/tariffs imports – clever because they
allow, they’re products to be smuggled into countries that limit sales or tax them to0 heavily and
then when the problem gets bad, they negotiate legal market entry with countries that have no
leverage because the black-market products are already coming in.
• When the problem becomes bad, they negotiate legal market entry
• In the 1990s, up to a third of cigarettes produced went “missing” – knew what was happening and
turned a blind eye
• Even today, 60-70% of smuggled cigarettes are produced by major tobacco companies – mass
produced
• Attempting to undermine current tracking efforts – higher tech methods like chips and the
tobacco companies are actively combatting this
• Enter Joint venture agreements with local companies (smaller companies based in 1 country.
Once the smaller company becomes dependant, the larger company buy them and expands
monopoly power – external organization like IMF)
• Once they become dependent, they buy them and create monopolies
• Often facilitated by the IMF
• Used in FSU countries (1990s), Indonesia (1971), Cambodia (1990s), Philippines (1995)

Direct Quotes
• “With regard to the definition of transit it is essentially the illegal import of brands from Hong
Kong, Singapore, Japan, etc. upon which no duty has been paid.” – BAT
• “Transit trade is volatile, and disruptive to the orderly operation of markets. It is in BAT’s
interest that markets are legal, taxed and controlled. However, our primary responsibility is to
meet consumers’ demands as profitably as possible.” – BAT
 • “Transit: the nature of this business brings paradoxical requirements of an arm’s length approach
and close supervision. Where BAT has legitimate interests in the end markets it must be able to
disassociate itself from direct involvement in parallel imports. Nevertheless, indiscriminate
sourcing can and does lead to potentially embarrassing problems.” -BAT
China
• China opens markets after the 1975 Cultural Revolution
• BAT struggled to access the Chinese market through a joint venture agreement with the CNTC
• Blamed bureaucratic complexity and restrictions on foreign investment
• In early 1980s, BAT intensively increased smuggling of its brands as the CNTC limited legal
imports of foreign cigarettes – as state monopoly attempted to limit illegal import, they
circumvented that
By 1996 the CNTC estimated that 99% of the foreign brand cigarettes sold in China were smuggled

IMF Complicity
• In 1999, IMF promises to loan $35 million to the Moldovan government
• Conditioned on the privatization of wine and tobacco
• Most Moldovans were opposed, so parliament rejected privatization and loan
• The IMF suspends its loan to Moldova in response
• In response to a worsening recession in 2000, parliament reverses the law and privatized the
tobacco sector – the IMF opened up a market to a private tobacco that want open before

Marketing and Advertising

• Introduction of "mild", "light", and "low-tar" cigarettes (just as dangerous as regular) as one way
to target women
• Aggressive marketing in countries without restrictions
• Use of tobacco branding on non-tobacco products
• Sports sponsorships, clothing products, concerts, movies, etc.
• Market segmentation that outcompetes local brands
• Philip Morris used TV ads to introduce its Marlboro brand to Japan
before ad bans were put in place in the late 1980s
• BAT advertised on TV and radio in neighboring countries that
broadcast into Thailand to get around a ban on tobacco ads – radio could broadcast over the
border

Political Activity
- Aggressively lobby to limit marketing restrictions and increased taxes – not beneficial to their
bottom line
- Support friendly politicians through donations and advertising
- Prevent or counter tobacco-control efforts through both domestic lawsuits and trade actions
- Reversal of tobacco ad ban in Uzbekistan (1994)
- Blocking Kenyan tobacco control law (1999) and taking new law to Supreme Court (2006)
- Voluntary regulation pledges to prevent laws being passed (Argentina, Lebanon, Uzbekistan,
Costa Rica, and Malaysia)
- Building schools and wells in Sub-Saharan Africa as Corporate Social Responsibility (CSR)
John Oliver Video
- Australia: 2011, plain packaging law; replaced marketing with warning images of eyeballs,
damaged lungs, etc.
- Tobacco companies aggressively cite international trade laws and file lawsuits they may lose and
finance lawsuits that they’re opposition (e.g., smaller governments) may not want to take on for
financial reasons

Deceptive/Manipulative Activity
- Recruiting scientists to undermine health warnings
 - International Committee on Smoking Issues (ICOSI) was founded in 1977 to coordinate
misinformation campaigns and has been renamed many times since then
- Introduction of Youth Smoking Prevention Programs – paradoxically, most programs cause
active harm because they create lower perceived harms of tobacco, stronger approval of smoking
and strong intentions of smoking after engaging in these programs
- Founding of “third party” organizations to represent their interests – Foundation for a Smoke Free
World
- Plain Packaging: brown colour selected because it’s the most unappealing and pictorial and stats
have been found to reduce smoking
- NCACT- Misleading on Contraband: Plain packaging has increased contraband tobacco in other
countries and will likely do the same in Canada.
a. Canadian members of NCACT: Canadian Convenience Store Association (CCSA), Canadian
Taxpayers Federation (front organization), Canadian Tobacco Manufacturers Council
- Industry estimates of contraband are always misleading: In Quebec and Ontario, none of the data
supports data that cigarette contraband has increased in recent years, but rather a greater effort
through police and local communities, which lessened the market.
- Foundation for a Smoke-Free World: founded by a $1 billion gift by PMI over the course of 12
years
a. giving credence to different theories of how smoking can be done safely or home remedies
b. idea that all policy solutions are top-down and don’t work and casting doubt on the ones that
do work
c. idea that people just need to be educated and solved the issue on their own via vapes (which are
sponsored by PMI)

Indonesia Case Study

- One of the hardest hit countries in tobacco epidemic
Youth are Getting Hooked Early
• Some 78 percent of Indonesian smokers started before the age of 19 years.
• Between 1995 and 2004, smoking prevalence for male children 15 to 19 years of age increased by
139 percent
• Among children under 15 years who already smoke, 8 out of 10 have tried to quit but were
unsuccessful
Inequities in Tobacco Use
- Poorest males in 1995 smoked significantly more than those in the wealthiest quintile (5 th)
- 2004, the inequity has decreased significantly, but there is an equal distribution across all
socioeconomic groups

Consumer Sovereignty
- “The economic principle of consumer sovereignty suggests that consumers make the best
decisions about how to spend their own money. This argument is based on two assumptions. The
first is that consumers make informed decisions with full knowledge of the costs and benefits of
their choices. The second assumption is that individuals bear all of the risks of their
consumption decisions; that is, their actions have no cost or impact on others. Tobacco use
violates both of these assumptions.”
Arguments
- Majority of smokers start as kids and kids don’t know about the cost and the long-term effects of
tobacco use on their body
- Implications for the deliberate misinformation campaigns that are put out by these companies
making it difficult to know the costs
- Smokers don’t bear all of the risks because second-hand smoke kills many people
- Report funded by Bloomberg Foundation (communicable diseases and tobacco use)

Consequences Go Beyond Health

• Reduced food spending results in poor nutrition for entire families
 • Poor health and premature death lead to worse economy
• Poor health outcomes lead to increased spending to subsidize healthcare costs

Tobacco Tax in France

- What can be done? What policies make a difference?  TAX
- Raising price of cigarettes with tobacco tax and this increase in price created a steep decline in
the # of cigarettes consumed daily
- # of lung cancer deaths in men also decreased

Tobacco Tax in Indonesia

- Look at real price rather than nominal price
- Nominal (sticker price) increased gradually until 1990s then rapidly increased
- Real price accounting for inflation notes that the real price hasn’t changed much in 35 years
- In LMICs, there’s a growing middle and upper class and higher household incomes, and one of
the things they spend their money on is tobacco
- We want tobacco products to get more expensive in comparison
to household income over time – becoming less affordable – New
Zealand; steady increase in affordability in Bangladesh, Sri Lanka
- Indonesia cigs are more expensive because tobacco companies
price them higher; not due to tax but marketing decisions by
tobacco companies

Tax Avoidance (BAT)

- For every $1, they shifted 61 cents in profits to a UK office where it paid no tax
a. legally and illegally evading taxes in LMIC to KIC where they pay no tax
- In Bangladesh, there are pre-tax profits made by the local BAT office, rather than paying
corporate tax on all of these, they siphoned off through royalties’ fees that it charges itself in a
jurisdiction where they only pay 15% compared to the corporate tax in Bangladesh where they
would pay 45%, which results in $6 million in lost revenues.
- In Kenya, they siphoned pre-tax profits into dividends through an investment company (in
Netherlands) and results in $2.7 million in lost revenues for Kenya
- Use of shell companies which are tied to BAT in the UK, they loan themselves money and
service the loans with pre-tax profits leading to avoidance of corporate tax which leads to a loss
of $33 million in Indonesia revenues.

Framework Convention on Tobacco Control

- Tobacco use is an epidemic that kills nearly 6 million a year
worldwide
- Sheesha is popular among youth
- FCTC and MPower can help reduce tobacco use, monitor tobacco use
and prevention policies; implementation 20-40% reduction in 5 years
and 56% in 15 years
- Binding treaty signed on by many nations  global health treaty
(2003)
- a treaty adopted by the 56th World Health Assembly held in Geneva, Switzerland on 21 May
2003. It became the first World Health Organization treaty adopted under article 19 of the WHO
constitution. The treaty came into force on 27 February 2005. It had been signed by 168 countries
and is legally binding in 181 ratifying countries.
- a supranational agreement that seeks "to protect present and future generations from the
devastating health, social, environmental and economic consequences of tobacco consumption
and exposure to tobacco smoke" by enacting a set of universal standards stating the dangers of
tobacco and limiting its use in all forms worldwide. To this end, the treaty's provisions include
rules that govern the production, sale, distribution, advertisement, and taxation of tobacco. FCTC
 standards are, however, minimum requirements, and signatories are encouraged to be even more
stringent in regulating tobacco than the treaty requires them to be
- a watershed moment for international public health; not only was the treaty the first to be adopted
under WHO's Article 19, but it also marks one of the first multilateral, binding agreements
regarding a chronic, non-communicable disease

FCTC Ratifying Countries

- Overwhelmingly, signed by many nations. However, the USA, Morocco, Argentina, Indonesia
did not sign
- Successful interventions: Pack warnings have increased the most, the monitoring, smoke-free
environment and the least successful intervention is taxation
- HICs: 23% of countries have a retail price of more than 75% in tax  GOOD (HICs are more
protected by this tax)
- Proportion of HICs nations (60%+) cigs have become less affordable

What Has Happened Over Time?

- What has happened since the FCTC was implemented?
a. Socialization Effect – during the negotiating
process (1999-2003); people (the public and
government) paying attention and
anticipating and changes law or behaviours
during this time
b. Normative Effect – Treaty adoption (2003):
once a treaty was adopted officially,
countries said act now
c. Legal Effects – Formal Ratification (2005 –
present): legal with formal ratification at the
country level (negotiated, adopted
(international) and ratified (national) into law)

- What Changed? Did the downward trend change after the implantation of FCTC?

Interrupted Time Series Analysis

• No significant global change in level or slope
• Significant decrease in Europe
• Significant increase in Upper-middle-income countries, low- and middle-income countries,
Oceania, the Americas, Asia, and China

Robustness Checks
• Global findings were robust to:
• Socialization effects: Using 1999 as the intervention point instead of 2003
• Normative effects: Aligning data by year FCTC signed
• Legal effects: Aligning data by year FCTC ratified in each country
• Composition effects: Removal of China and countries that have divided since 1970 from
the sample
• Findings are robust to:
• Time effects: Using a one- and two-year distributed lag model
• Composition effects: removing China from the dataset
• Population effects: removing population weighting
• Model effects: Using alternate models with regional and subregional dummy variables;
using simple predictive models

In-Sample Forecast Event Model

 • The gap between predicted and actual consumption increased from five cigarettes per adult per
year in 2003 to 150 cigarettes per adult per year in 2008 (would’ve expected less consumption
than actually observed)

Efficacy vs. Effectiveness

• Implementation capacity
• LMICs may not be able to implement tobacco control as quickly or effectively as high-
income countries
• Treaty Mechanisms
• Absence of enforcement mechanisms motivating implementation
• Globalization and contraband
• Trade liberalization allowed more efficient tobacco trade and means of evading tobacco
controls

HICs vs LMICs
• European Union accession
• Countries implemented tobacco control due to EU requirements for new member
countries
• Increasing affordability in LMICs
• Incomes are rising faster than tobacco prices in many countries

Synthesis
• “Varied implementation of tobacco control policies and shifting trends in cigarette affordability
across countries may have generated market equilibrium effects incentivising the tobacco
industry to move its lobbying, marketing, and promotion activities away from high income
countries (where they faced increasingly stringent regulations) and towards low- and middle-
income countries and Asian countries (with far less stringent measures).”

Lecture 11 – Asynchronous

Political Economy and Geopolitics

- Political economy: analysis concerned with the interaction of economic processes and power
relations
- Geopolitics: considerations of relations between territorially based actors which have interests in
defending or expanding their spatial power – certain countries become more powerful than
others

4 Key Events in Geopolitics

1. Defeat of US forces in Vietnam (1975) – dented US hegemony (aka they were becoming a world
superpower)
2. Collapse of the Soviet Bloc (early 1900s) – established the US as the only remaining superpower
with no alternative
3. Wars in the Middle East (ongoing)
4. Emergence of China as a global power (1990s – 2000s)

3 Stages of Political Economy

1. Overaccumulation of capital – investors have enough capital to invest in things to make capital
and the cycle continues
2. Increased credit and financialization to avert crises – sometimes there isn’t enough fluidity, and
this is where credit comes in; allows economies to avoid crises to a degree
3. Geographic shifts in production and finance – geographic specialization wherein certain aspects
of production are localized, and that certain financial headquarters are located in a particular
geographic location
David Harvey
- Argued that the process of generating unevenness should be understood in more general ways, as
“different places competing endlessly with one another to attract investment. In the process they
tend to amplify unevenness, allowing capital to play one local and regional or national class
configuration off against other.
a. geographic specialization leads to unevenness and competition to attract geographic capital
from the financial centres and this leads to a race to the bottom (e.g., Amazon competition for
2nd headquarters – tax breaks, construction)

Political Economy Geopolitics Trends

- Shift power away from working class
towards capital
- Rise of austerity measures and
Washington consensus
- Consolidation of the EU
- -
- Waning of 3rd World nationalist projects
(1st world = nations allegiance to US; 2nd
world = nations allegiance to Soviet; 3rd
world = all other nations)
- Formal democratization in many parts of
the world
- High profile terrorist attacks and rise of
militarization
Increasing use of “humanitarian
interventions”

Bretton Woods Accords

• Created IMF, World Bank, and the General Agreement on Tariffs and Trade (GATT) in 1944
• Washington Consensus emerges in the 1980s
• Deregulation
• Privatization of public services
• Goals of low inflation rates and stable currencies
• Enhancing the operations of multinational corporations
• Replacement of GATT with the World Trade Organization

Larry Summers
- World Bank Chief’s economist and later served in
the Clinton administration as Treasury Secretary
- Thinking leads to negative consequences and the
logic behind it sounds neutral, but for the countries
being affected, it’s ridiculous (e.g., US dumping toxic waste in Cuba)

NAFTA (eliminate tariffs – taxes on most imported and exported goods)

- One of the main objectives of the Washington Consensus Model was promoting free trade
agreements – NAFTA (goal: eliminate tariffs and allow the free flow of goods and trades, but not
people)
In the US and Canada, there are smaller effects on overall employment
In Mexico, however:
• Far greater loss of employment in agriculture than gains in export manufacturing
• Shift to large-scale export agriculture and importation of cheap processed foods – lead
high NCDs
• Weakening of environmental protections leading to high-profile toxic waste
contamination events

Debt Crises and Recessions

- Sovereign debt – debt held by countries
 - High unemployment = countries make currency cheaper by printing extra money which leads to
increased exports, higher tourism and investors get good bargains
- Low employment = more expensive currency by printing less money which increases purchasing
power
- Greece borrowed lots of money, but it didn’t change the fact that they’re economy was weaker
than other European economies
- Half-way integration – Germans don’t mind supporting poor Germans, but they don’t want to
support poor Greeks with their tax dollars, unlike in the USA where poorer states like Alabama
and Mississippi get money from richer states like New York and California via welfare, social
services, but since its all one country the money will be circulated
- One currency with different interests – Greece wants to devalue the money to pay back their debt,
meanwhile Germany wants to keep their currency powerful to maintain low unemployment and
send products abroad and get more money back.

Monetary Policy in Zimbabwe

- Incredibly difficult, especially for poor people with little savings because it becomes worthless
and receive income that doesn’t increase, and rising inflation means you can’t afford anything

Monetary Policy in Cuba

- 2 sets of currency – 1st for the tourism sector and the second for local currency – (e.g., food, rent)
- Tourism currency is far more powerful than local currency, so any occupation paid in that
currency is far better off than doctors and lawyers who are paid in the local currency; leads to
income inequalities

Reinhart & Rogoff

- Set amount of sovereign debt that a country can accumulate and after a threshold is met, after
exceeding the country’s growth is put at risk; if 90% of GDP is exceeded, a country’s growth is at
risk and when it’s higher than 90%, you’ll face economic collapse.
- This theory isn’t supported by recent economics

The Money in AIDS

South African AIDS Epidemic
- People with AIDS increased rapidly in the 1990s, especially 98-99 (peak)

1999 NYT Editorial

- High price of pharmaceuticals and different strategies
of LMICs to afford to treat their populations especially
in Sub-Saharan Africa
- Intellectual property rights made it unaffordable for
people in LMICs to purchase drugs for their
populations
- If countries can get around intellectual property rights,
there won’t be any
money for R&D
- NYT recognizes that pharma companies
have a great impact on American
domestic and foreign policy
- Public funding led to the development of
these drugs

South Africa’s Bitter Pill

for World’s Drug Makers
Response from the International Chamber of Commerce
- Acknowledge that medicines are essential, but the real question is how to finance a country’s
access to the meds regardless of a patent.
- Cutting off revenues will deprive entities of conducting R&D or the funds needed
- Innovative companies with reduce companies in a certain area, can increase prices in another area
to recoup the lost revenues
Political Pressures
- Clinton felt political pressure when planning a trip to S. Africa
a. Human rights watch said administration failure to make the prevention and punishment of
genocide in South Africa reflects the low level of American interest in Africa
b. Clinton administration was slow to condemn killings in Rwanda’s genocide and not allowing
African nations to intervene
c. A rep from the Black Caucasus said no administration has ever really been focused on Africa
d. Monica Lewinsky scandal

US Health-Related Foreign Aid

- During Clinton’s administration, health-related foreign aid had stalled or decreased
- Clinton was trying to do a lot to support African nations, but his administration was supporting
pharma companies refusing to lower their prices to life-saving drugs.

How Drug Giants Let Millions Die of AIDS

- On Clinton’s trip to S. Africa a law was passed for a marketplace
for meds based on affordable prices
How this was done?
- Compulsory licensing: allows businesses in a country in a state of
emergency to manufacture generic products and pay royalties to
the patent owner
- Parallel Importing: allows nations to import meds more cheaply
in one nation compared to another.
- PETFAR program under Bush administration to fund AIDS
medications
- ¾ of deaths are being avoided now because of these meds

IMF
- IMF changed in the 2008/2009 financial crisis; consequences in terms of mortality and morbidity
were felt very strongly in Sub-Saharan Africa – 28,000-50,000 infant deaths attributed to the
financial crisis
How did a financial crisis in the US greatly impact the Sub-Saharan Africa? Why such reliance on
the US? Recommend policies that…
• Prevent falls in national GDP from turning into income shortfalls for households
• Limit the extent to which decrease in GDP leads to a decline in the quantity or the quality of
critical health services —such as prenatal and postnatal check-ups for women, attended birth
deliveries, and growth monitoring for children
• Ensure that girls receive sufficient food and critical services – gender dynamics to consider

A Smarter, Gentler IMF (IMF agrees)

• References to “preparing for the next downturn” – another economic downturn in the future;
secondary consequences of COVID-19
• To make progress toward achieving the UN
Sustainable Development Goals on infrastructure and
public services, these countries will require additional
public spending.
• Investing in infrastructure, healthcare and education is
better for economy than military of energy subsidies
Haiti
- Regressive transfer – if more rich people are buying gas, and the government is subsidizing fuel,
it’s disproportionately affecting the rich
a. Haitians listened and this led to backlash against the government because removing the
subsidies led to a 38% increase on gas, 47% on
diesel and 51% on kerosene
b. hike in gas prices affects taxi drivers;
impoverished people spend a lot of income on
these services and leads to increases in
transportation and disproportionately affect low-
income people
c. A lack of kerosene affects people’s ability to
cook; will use charcoal and firwood which are unhealthy options leading to a decrease in life

- IMF recommendation: raise revenue

collection. 3-5% of GDP in additional revenue
over the next 5 years if they improve the
efficient of their current tax systems.
- IMF advocates: progressive income taxes,
which will reduce inequality and reform
taxation of large multinational corporations
(especially digital ones).

Structural Adjustment Programs (large-scale economic reforms that were usually implemented in
countries on the conditionality of loans) – if the World Bank or IMF loan money, the receiving nation
must agree to conditions and make these structural adjustments to the economy; tied to the Washington
Consensus Goal.
• Economic stabilisation
• Limit fluctuations in exchange rates, inflation, and balance-of-payments
• Liberalisation
• Facilitate the free flow of trade and capital, such as the removal of tariffs
• Deregulation
• Removal of governmental ‘red-tape’ vis-à-vis business practises, such as stipulations in
employment relations law
• Privatisation
• Transferal of enterprise from state to private ownership, thereby fostering competition
and market efficiencies

Chicago Boys
- A group of economists educated at the University of Chicago and brought a neoliberal view to
Chile
- Needed to have a fascist coup against democratic elected state to implement measure; major
backlash over economy not benefitting; privatization led to inequities

Disaster Capitalism – Naomi Klein

- Shock as a political tool
- In a state of shock, you can’t protect your interests – progression
- An economic crisis leads to normal democratic structures and governments being removed from
the equation and large-scale macroeconomic decisions being forced on countries without their
democratic consent. Shock therapy – the idea that its necessary to reinvigorate the economy and
these changes are only possible when the government is in a state of shock

Structural Adjustment Programs Affect Health By…

 • Lowering government health expenditure
• Alters the quality and quantity of services provided to children and mothers
• Produces medical supply shortages, loss of human capital, and replacement of defunded
maternal health services with ineffective traditional birth attendant programs
• Affecting the healthcare workforce
• Force government cuts to wages and personnel in the healthcare sector
• Reduced wages and job security often create incentives for health workers to move
elsewhere, producing ‘brain drain
• Introducing cost-sharing or user fees to enhance the fiscal sustainability of healthcare services
• Greatly reduce access to even the most rudimentary health services for the poor
• Changing the public-private mix
• Raises financial barriers for poor women and children as providers shift to a profit-driven
business model 
• Promoting decentralisation of health systems
• Can produce a more fractious and unequal implementation of services—including those for child
and maternal health—national
• Devaluating currency
• Devalued currencies promote export competitiveness, but increase the real cost of
imports, including pharmaceutical goods and health equipment 
• Promoting trade and capital account liberalisation measures
• Short-run loss of tariff revenue available for healthcare and the long-term repatriation of
profits by multinationals receiving tax holidays
• Privatizing outside the health sector
• Sale of state-owned enterprises may produce a windfall in the short-term, but the
cumulative loss of profits from such businesses reduces government revenues in the mid-
term
• Privatisation may also result in public sector job loss that is not necessarily substituted by
the establishment of new positions in the private sector
• Increasing reliance on unsanitary water accompanying increasing privatisation and deregulation
• Water and sanitation facilities under private ownership may introduce unaffordable fees
for water access, leading the poor to rely on water from degraded sources
• Devoting government revenue to facilitate debt servicing
• Resources devoted to debt servicing may impinge upon health sector budgets, thereby
reducing spending dedicated to improving child and maternal health outcomes
• Trade liberalisation and currency devaluation leading to a rising real price of food
• Reduces maternal and child nutritional intake, and contributes to double burden of both
malnutrition and obesity in the same settings
• Justifying short-run economic contraction
• Increased short-run unemployment may reduce income available to pay for healthcare
even as privatisation and user fees increase the cost of services
•  Affecting broader psychosocial dynamics
• Heighten psychosocial stress, with implications on health outcomes, including child and
maternal health; or, alternately, prompt greater social cohesion as communities work to
overcome adversity
• Provoke social unrest, thereby exacerbating existing social, economic and health
problems

IMF
- Financial market turbulence and severe drought damaged the economy and Argentina turned to
IMF for help
- $50 billion loan to Argentina will help restore market confidence, lower inflation, reduce public
debt, assist the poor and empower women in economy.
- The plan was created and implemented by the government of Argentina with support of the IMF
However…
 - Bailout crumbled in 2019 under Macri presidency

Dr. Jeffrey Sachs, Shock Therapist

• Stabilized Bolivia’s using SAP to address hyperinflation in the 1980s, with consequences of:
• Reduction of mining workforce from 30,000 to 7,000 (large employment sector)
• Dismissal of 30,000 public service workers
• Began series of privatizations of state-owned services (water)
• Water War of 2000 in Cochabamba

IMF Statement on Ecuador

- IMF argued they would be handled more responsibly
a. protests against conditionalities of the loan – civil unrest

COVID-19 and Paradigm Shifts

• Adopt a systems approach to consider COVID-19 in
broader global context
• Four million chronic respiratory disease deaths per year
• Pneumonia leading cause of death among children
• Non-communicable diseases cause 70% of global deaths
• Depression leading cause of disability globally
• Full impacts of climate change loom
• Strengthen global health governance
• Funding for pandemic preparedness is sparse and mechanisms complex
• International Health Regulations not fully implemented and ignored
• Weakened and underfunded WHO
• Fragmentation of global health actors
• Overreliance on vertical programs and reactionary to epidemics
• Going beyond the Pasteurian paradigm
• Single cures for single pathogens
• Overreliance on randomized controlled trials
• Must address social, political, environmental, and individual factors
• Syndemics of communicable and noncommunicable diseases
• Combine health security and development research
• Local context matters
• Austerity policies have left some countries unprepared for the pandemic
• Inappropriate diffusion of policies from high to low income countries
• Must maintain public trust and cooperation through tailored strategies

Lecture 11 – Synchronous
- Fiscal policies: monetary policy – if you want more of less spending, devaluing the currency, how
much debt…
- Shock Therapy for cultural adjustments - structural adjustments are very unpopular and wont
reach a democratic majority. Attach these ideas as requirements to get things done, so you do
everything at once because you normally cant get it down
- Neoconservatism (promoted by military and homogenous states and advocates closed borders) vs
Neoliberalism (economic growth and power to increase capital; self reliant agent; business
interests); both are US BASED
Five Geopolitical Currents (Ideologies)

1. Resurgent Right Wing: Tradition – Neoconservatism (nationalist perspective): unilateral petro-

military imperialism
 2. Washington Consensus: Tradition - Neoliberalism: reform neoliberalism with provision for
“transparency”; USA focused, opening up markets to promote economic growth and
3. Post Washington Consensus: Tradition – Lite Social Democracy: fix “imperfect markets”,
Keynesianism (in a downturn, governments should spend more to counteract the downturn)
4. 3rd World (countries not aligned to US or Soviet; promoting their interests) Nationalism:
Tradition – National Capitalism: increased (but fairer) global integration via reform of interstate
system, based on debt relief and expanded market access; DON’T USE 3 rd World when referring
to developing countries because it’s a historical term
5. Global Justice: Tradition – Socialism, Anarchism: deglobalization of capital (not people);
globalization from below, international solidarity (decomodified state services – shopping for
services like health services)

- What is the IMF? - 190 countries working to foster global monetary cooperation, secure
financial stability, facilitate international trade, promote high employment and sustainable
economic growth, and reduce poverty around the world
a. IMF is a Washington Consensus (historically)
b. Enforced neoliberalism through loans
c. Today, they’re shifted to Post-Wash (lite) social democracy due to the
promotion of social services

- What is the G77? - The Group of 77 at the United Nations is a coalition of 134 developing
countries, designed to promote its members' collective economic interests and create an enhanced
joint negotiating capacity in the United Nations.
a. G77 (134 countries designed to promote members collective economic interests)
b. 3rd world nationalism – banding together as developing countries to promote
their interests

- What is UNICEF? - a United Nations agency responsible for providing humanitarian and
developmental aid to children worldwide (humanitarian agency)
a. Post Wash Consensus because it’s a UN agency that’s impartial and doesn’t take
political stances, but promotes social democratic solutions (i.e., protecting children)
b. Global justice would be more radical and take a political stance, which the UN does
not

- Where is the World Social Forum? - The World Social Forum is an annual meeting of civil
society organizations, first held in Brazil, which offers a self-conscious effort to develop an
alternative future through the championing of counter-hegemonic globalization
a. World Social Forum (annual meeting of civil society (NGO, grass-roots) …which
attempts hegemonic (opposed to the 1 dominant power) globalization)
b. Global justice because they believe in international solidarity and maintain a political
stance

- Where is the US Pentagon? The Pentagon is also often used as a metonym for the Department
of Defense and its leadership.
a. US Pentagon (department of defence and leadership)
b. Resurgent Right Wing because it’s national focus and defensive of its own
interests

Trump’s 7 WHO Demands

1. Investigations into the W.H.O.’s handling of the outbreak and the source of the virus
• Implemented in July
2. Call on China to provide live virus samples and stop censoring Chinese doctors or journalists
• No scientific need
• No mandate for WHO
 3. Say that countries were right to consider travel restrictions during the pandemic
• Already softened guidance
• Refusal to play a role in elections
4. Dispatch a team to Taiwan to study its successful pandemic response
• Taiwan not member state
• Political reasons for selecting one country
5. Pre-qualify coronavirus drugs and vaccines for use around the world once they were authorized
by major regulators
• Would have overruled independent scientific advice
6. Ensure that countries like the United States that contribute heavily to the WHO are proportionally
represented on the organization’s staff
• Would have transformed WHO from democratic (one country one vote) to corporate
representation (similar to World Bank or IMF)
7. Support proposed changes put forward by the Group of 7 (United States, Germany, Japan,
France, Britain, Canada and Italy) - Has been acted on

PRACTICE QUESTIONS
1. You attend a lecture by a renowned philosopher of health, and she states, “There is no such thing
as a fundamentally good or bad health status – only scientifically provable deviations from a
typical functional ability for human beings as a whole.”
Which of these concepts best describes her statement?
A. A naturalist conception of health
B. A normative conception of health
C. A positive conception of health
D. An internal conception of health

2. How many provisions are in the Canada Health Act?

A. One
B. Three
C. Five
D. Ten

3. Which of these services is NOT universally covered by Canada’s public health insurance?
A. Hospital stays
B. Urgent care visits
C. Prescription drugs
D. Family physician care

4. Which of these is NOT a reason the US healthcare system is the most expensive in the world?
A. Inputs for hospital care are more expensive
B. There are more physicians per capita
C. Administrative costs are higher
D. Hospital stays are more service-intensive

5. What is the primary source of funding for Canadian healthcare?

A. Out-of-pocket spending
B. Private insurance
C. Taxation
D. Other spending

6. Cuba’s healthcare system is an example of:

A. Non-universal Public/Private Mix
B. Universal Public/Private Tiered Systems
C. Universal Social Insurance
 D. Universal Single Payer system

7. What is costing the Canadian healthcare system the most money?

A. Hospitals
B. Drugs
C. Physicians
D. Administration

8. This remuneration system pays physicians a set amount of money per patient on their roster
A. Salary
B. Fee for service
C. Capitation
D. Pay for performance

9. How often are Canadians are skipping their medications compared to other OECD countries?
A. Less than average
B. Average
C. More than average
D. The most

10. What percentage of Americans with health insurance are publicly insured?
A. 5%
B. 18%
C. 25%
D. 34%

11. According to CIHI, how much money does Canada spend per person per year on pharmaceuticals?
A. $248
B. $549
C. $1,074
D. $3,951

12. Power is diffused throughout society and no one group holds total power over others
A. Bounded Pluralism
B. Corporation
C. Elitism
D. Pluralism
E. Public Choice

13. Policy choice and change is dominated by particular social classes and the state ensures continuing
dominance of those classes.
A. Bounded Pluralism
B. Corporatism
C. Elitism
D. Pluralism
E. Public Choice

14. Issues of high politics are decided within an elitist framework, but most routine domestic politics are
developed along pluralist lines.
A. Bounded Pluralism
B. Corporatism
C. Elitism
D. Pluralism
E. Public Choice
15. Segments society into different sectors and allows limited debate within structures dominated by a
strong centralized state
A. Bounded Pluralism
B. Corporatism
C. Elitism
D. Pluralism
E. Public Choice

16. Applies economic rationality to collective political problems, incorporating game theory and various
rational choice theories.
A. Bounded Pluralism
B. Corporatism
C. Elitism
D. Pluralism
E. Public Choice