An actor is an individual or organization participating in health policymaking. Their number has exponentially increased.
The health policy arena involves all actors participating in health policymaking, the relations between actors, and the formal and informal rules regulating the interactions between actors
Actors participating in policymaking can be divided into six main categories: policy actors, experts, interest organizations and lobbyists, citizen groups, producer organizations, the media, and the judiciary.
Actors interact in a network of relations with each other to coordinate their activities. These networks are called policy networks. The health policy arena can be conceptualized as a system consisting of various policy networks.
There are different types of policy networks: insider networks, policy communities, issue networks, epistemic communities, and policy advocacy coalitions.
Policy actors are professionally involved in health policymaking and play various roles in the policymaking process. Policymakers are closely involved in making policy decisions and carry responsibility for these decisions.
Policymakers need expertise and recruit experts for advice. A distinction can be made between core insiders, specialist insiders, peripheral insiders, and outsiders.
Interest organizations represent the interests of their members in the health policy arena. Their number has explosively risen. Interest groups fulfill an articulation and information function in the policy arena. Some organizations are so closely involved in health policymaking that they actually operate as co-policymaker.
Differences in power resources between interest organizations and lack of transparency undermine the integrity of health policymaking.
Citizen participation in health policymaking is not new and has extended over the last few decades. Participation is for the most part issue-oriented and largely dependent upon volunteers.
Producer organizations provide goods and services necessary to achieve health policy goals. Their role in health policymaking marks the state's growing dependence upon the market sector for achieving its policy goals.
The media are closely involved in frame contests in health policymaking. Social media have become a source of misinformation and confusion.
Court rulings can have important consequences for health policymaking. Public law litigation is an instrument to dispute state legislation.
A salient aspect of the globalization of public health is the role of international governmental organizations and international nongovernmental organizations in addressing global health problems. The World Health Organization and the European Union have been closely involved in controlling COVID-19.
The description of how the Dutch government dealt with the outbreak of Q-fever (Box 5.1) is a story of slow action uptake in a complex political-administrative setting with many actors, conflicting interests, lack of direction, inadequate legal instruments, and absence of a decision-making center with enforcement power. Policymaking unfolded in a divided policy arena in which the public health and farmers’ communities did not concur on an effective approach to managing the outbreak. The agricultural community pressured the government to abstain from what it perceived as disproportional measures without hard evidence. It took more than two years before the government ordered the culling of approximately 60.000 goats.
This chapter investigates the role of actors in health policymaking. The chapter starts with the introduction of the concept of actor and health policy arena. Actors in this arena coordinate their activities in policy networks (policy subsystems). The health policy arena can be thought of as consisting of various policy networks. Next follow a series of sections that explore the role of policymakers, experts, interest organizations, citizen groups, producer organizations, the media, and the judiciary in health policymaking. The final part of the chapter is devoted to the global dimension of health policymaking. Attention will be paid to the role of intergovernmental organizations (IGOs) and non-governmental organizations (NGOs) and the involvement of the World Health Organization and the European Union in the struggle against COVID-19.
Box 5.1 Managing the Q-fever outbreak in the Netherlands in 2007-2010
Q-fever is an infectious disease transmitted from animals to humans.
The outbreak of Q-fever concentrated in two provinces (Gelderland and Noord-Brabant). In 2007, the number of reported cases amounted to 168 and rose to 1000 in 2008 and 2354 in 2009. The percentages of hospitalized patients were 17% in 2008 and 15% in 2009. In 2008, one person died from Q-fever, in 2009 six persons, and in 2010 seven persons. Many years after the outbreak, a sizeable group still suffers from the disease. Lawsuits have been filed for claiming financial compensation.
Roughly speaking, the actors involved in managing the outbreak can be divided into two imaginary columns: a public health column and a farmer column. The public health column included, among others, the Department of Health, the Institute for Public Health and the Environment (RIVM), the Center for Infectious Diseases Control, the Healthcare Inspectorate, and the local public health agencies operating in the most hit areas. Important actors in the Agricultural column were the Department of Agriculture, the Central Veterinary Institute, the Animal Health Service, the Netherlands Foods and Consumer Product Safety Authority, and stakeholder organizations representing the interests of farmers. The coordination between both columns was in the hands of the Outbreak Management Team (OMT), a top-level administrative coordination team and, as of November 2008, an expert council. Some actors, including the head of the province of Noord-Brabant and a few city majors, belonged to neither column.
The outbreak of Q-fever sparked a fierce debate on the causes of the disease and the necessity and proportionality of policy options. However, active public intervention failed to occur for a long period, even after a significant death toll rise. For instance, it took until mid-June 2008 that farmers were obligated to report on the presence of sheep and goats with Q-fever. Vaccination of animals on a voluntary basis only followed in 2008. The government also abstained from measures to restrict or forbid the transport of animals. Names of farms with infectious animals were not made public for privacy reasons. It took till the end of 2009 that policymaking gained momentum. Just before Christmas, approximately 60.000 goats were culled. The government has always denied that a TV broadcast of Zembla in December 2009 about indolent government action had triggered this draconic decision.
The handling of Q-fever is an instructive illustration of administrative busyness at several government levels. Decision-making dragged on for a long time, and the coordination between the Departments of Health and Agriculture advanced with great difficulty. Experts and administrators struggled with the cause of infection and spoke as it were in different languages.
The lack of formal intervention power partially explains the slow uptake of effective policy measures. Legal considerations and privacy reasons delayed the duty to report. The involvement of many actors, each with their preferences and interests, also contributed to policy delay. While each of them said to endorse the priority of protecting public health, there was nevertheless much disagreement on the strategy to be followed. As so often, economic interests conflicted with the interest of public health. Representatives of the farmers said to accept drastic measures but only based on hard scientific evidence. As long as such evidence was not available in their view, they held hard measures for disproportional. The involvement of two ministers and the absence of a minister with enforcement power also hindered effective policymaking. The absence of an adequate response was not only due to conflicting interests but also the result of a deficient governance structure.
Source: Evaluation Commission Q-fever, 2010.
Health policymaking is the work of actors. An actor is an individual or organization participating in the policymaking process. Each actor represents specific values or norms, stands up for particular interests, or brings in expertise or other resources needed to protect and promote public health. The number of actors in health policymaking has dramatically increased over the last two centuries. In the nineteenth century, only a handful of civil servants at the national level dealt with public health issues daily. A separate Ministry of Health did not exist. The regulation of public health and the medical profession was still in its infancy. Most activities took place at the local level by mutual aid organizations and municipalities.
All this has radically changed ever since. Presently, a vast variety of actors participate in health policymaking. A brief impression: minister of Health, Health Department, other government departments, politicians, international public organizations, public authorities at the regional and local level, public health agencies, public organizations with regulatory and/or supervisory tasks, interest organizations, implementing agencies, advisory bodies, knowledge institutes, healthcare providers, health insurers, other financial agencies, citizens and non-governmental organizations operating at the global level.
Health policymaking can be situated in an imaginary health policy arena which is defined as the set of actors participating in health policymaking, the relations between these actors, and the formal and informal rules regulating the interactions between actors. The focus of this chapter is on actors and the connections between them. The regulatory dimension of the health policy arena is explored in the next chapter.
Actors can be divided into seven main categories: policymakers, experts, interest organizations, citizen groups, producer organizations, media, and judiciary. These categories may partially overlap each other.
Policymakers are closely involved in the making of policy decisions. Examples are ministers, top-level civil servants, and politicians.
Experts contribute to health policymaking based on their general or specific knowledge (expertise).
Interest organizations represent the opinions and interests of their members in policymaking and seek to influence policymaking in accordance with their views and interests.
Citizen groups (activist groups) seek to influence health policymaking. Contrary to interest organizations, they are mainly issue-oriented and mostly dependent upon volunteers.
Producer organizations contribute to policymaking by providing goods and services needed for the achievement of the goals of health policymaking.
The media report on health issues and provide an outlet for policymakers and other actors to inform the public.
Courts fulfill the role of arbiter in conflicts and the role of decision-maker in unchartered areas.
The classification of actors highlights the multi-actor and multi-level setting in which health policymaking occurs.
Actors develop and maintain a network of relations with each other to coordinate their activities because of common interests. These networks are called policy networks (Provan & Kenis, 2007). The health policy arena can be conceptualized as a system consisting of various policy networks, for instance, a network for curative medicine, a network for long-term care, a network for pharmaceutical care, a network for prevention, or a network for occupational health. Policy networks are also referred to as policy subsystems (Freeman & Stevens, 1987). The strength of the linkages between these networks ranges from strong to weak. Policy networks may also (partially) overlap each other by shared membership.
The structure of policy networks varies. While some networks are ‘open’ (inclusive structure), access to other networks is restricted (exclusive structure). While some networks have a tight structure with intensive member contacts, the structure of other networks is loose. While some networks have a mixture of public and private policy actors as members, others consist exclusively of public or private actors. While the state has a leading role in some networks, its role in others is subordinate. While some networks have a more or less formal structure, others operate without formal rules of the game. While some networks possess multiple and vast resources to influence health policymaking, others struggle with a lack of resources. While members in some networks actively seek close cooperation to attain a collective goal (integrated network), members in other networks act more like each other’s competitors (competitive network).
There are several classifications of policy networks. The insider network can be described as the locus of policymaking. It encompasses all actors closely involved in decision-making. Its boundaries are fluid. The handling of the conflict on tariffs of specialists in Dutch hospitals (Box 4.2) illustrates that an insider network does not necessarily coincide with the formal locus of decision-making. The presumption of a single hierarchically structured network ignores the complex structure of the health policy arena.
Rhodes (1997) makes a distinction between policy communities and issue networks. The characteristics of a policy community are: a limited number of participants with some participants consciously excluded; frequent and high-quality interactions between all members of the community; consistency in values, membership, and policy outcomes; and consensus in values and broad policy preferences. Issue networks, on the other hand, consist of many participants; interactions fluctuate and are based on consultation; consensus is limited; conflicts are always looming, and power can be unequally distributed. It is plausible to expect that policy communities exert more power in policymaking than issue networks, in particular if their members maintain direct contact with members of the inner circle of policymaking or participate directly in the inner circle.
Haas (1992) has introduced the concept of epistemic community which he defines as ‘a network of professionals with recognized expertise and competence in a particular domain and an authoritative claim to policy-relevant knowledge within that domain or policy area. Although an epistemic community consists of professionals from a variety of disciplines, they have a share of normative and principled beliefs (…….), shared causal beliefs (…..), shared notions of validity (….) and a common policy enterprise’ (p. 3). An example is the epistemic community of public health experts that advised the government on COVID-19 issues.
Sabatier and Jenkins-Smith (1999) conceptualize policymaking as a struggle between two or more policy advocacy coalitions, ‘each composed of people from various governmental and private organizations that both (1) share a set of normative and causal beliefs and (2) engage in a nontrivial degree of coordinated activity over time’ (p.120). The handling of the outbreak of Q-fever in the Netherlands can be analyzed as a struggle between a ‘public health advocacy coalition’ and an ‘agriculture advocacy coalition’ (Box 5.1). The term coalition suggests that the coordination within a coalition may rest upon common beliefs or interests but also upon more opportunistic or strategic considerations.
Passarani (2019) used the policy advocacy coalition concept in her analysis of the political controversy on the proposal of the European Commission to clarify and update the existing food labeling legislation and provide consumers with clear and understandable information on food packaging. She distinguished between a ‘food industry coalition’ and a ‘coalition of public health and consumer organizations’. While the latter group called for a food traffic light system to inform consumers in making choices on food, the group of food industries opposed such a system as simplistic, demonizing food, and costly. The political struggle on gun control policy in the United States is another example of a fight between two rivaling policy advocacy coalitions (Box 5.2).
Box 5.2 The failure of gun control policy in the United States and its consequences for public health
The lack of effective gun control in the United States seriously threatens public health. Between January 1 and October 1, 2022, there were 515 mass shootings (shootings of more than four people) and 21 mass murders (murder of four or more people in a mass shooting). During this same period, 15 547 persons were murdered (intentional and unintentional homicide, defensive gun use), and 18 348 persons committed suicide with a gun (Kapadia, 2022).
Gun control is a heavily politicized issue in the United States. Cook and Goss (2014) make a distinction between two policy advocacy coalitions (they use the term movement): the gun rights coalition and the gun control coalition. Both coalitions consist of numerous organizations operating at the federal, state, and local levels. Yet, there are important differences between these coalitions: the gun rights coalition can mobilize much more power in policymaking than the gun control movement. The gun rights movement dominates the narrative around gun control and has even set the rules of gun control (regulatory capture). While the tobacco, food, and sugar-sweetened beverages industries are subjected to extensive regulation for marketing products causing health-related harms, gun control has remained largely unregulated.
Cook and Goss mention various factors to explain the powerful position of the gun rights coalition. Its members are very committed to their gun rights and able to mobilize tremendous power at all levels of government. The NRA has excellent political venues to political circles to preclude gun regulation and has managed to pass federal legislation largely immunizing gun makers, distributors, and dealers from a broad range of lawsuits. A structural problem for the gun rights movement is that it must pass several ‘veto points’ in the political arena to get regulative measures approved. In contrast, each veto point provides the gun rights coalition an opportunity to obstruct regulation. Other factors explaining the relatively weak power of the gun control coalition are disagreement among themselves over which option would be most effective and the fact that regulative measures restrict individual liberties, a highly valued good in American culture.
Sources: Kapadia, 2022; Cook & Goss, 2014.
Health policymakers are actors who are closely involved in health policymaking because of their formal tasks, expertise, and responsibilities. Health policymaking is no exclusive activity of the Minister of Health and the Health Department. As will be worked out in the next chapter, a great deal of health policymaking is devolved to the level of regional (in federal states to the level of states) and local public authorities or public organizations operating at arm’s length of the state. Policymaking can also be delegated to privileged interest organizations (Chapter 6). A new development is the involvement of global actors in health policymaking.
Health policymaking has developed into a multi-actor, multi-level activity, and multi-sectoral or transboundary activity. Other departments than the Health Department are closely involved in health issues. Examples are the Department of Finance (e.g. health care expenditures), the Department of Social Affairs (e.g. statutory health insurance), the Department of Education (e.g. training of health professionals), the Department of Public Security (e.g. handling patients with psychiatric disorders), the Department of Economic Affairs (e.g. international trade regulation) and the Department of Foreign Affairs (e.g. geo-political aspects of public health). Policymakers in a political system with democratic control must build a political majority for their decisions. Exploring what is politically feasible requires close contact with Members of Parliament.
The multi-actor, multi-level and multi-sectoral dimension of health policymaking highlights that the state should not be viewed as a unitary actor but as a set of actors, each with their expertise, interests, viewpoints, and routines. Although the government formally acts as a unitary actor, its policy decisions often result from a complicated political and bureaucratic struggle within the ‘state machinery’.
Prudent policymakers recruit experts to make their decisions information-based. Experts, according to Cairney (2021) in his analysis of how the UK government dealt with COVID-19 up to and during the first lockdown, were of great importance for the government in coping with the many uncertainties and ambiguities of the unexpected crisis. Government officials missed crucial knowledge on the scale of the problem and the likely impact of policy interventions. There was also much debate on the problem definition: how serious was the problem and how urgent the need for state intervention? Should state intervention be directed at the elimination or containment of the virus, and what were the most appropriate amount and timing of state intervention? Cairney points out that policymakers select advisors based on their beliefs and policy position. Inclusion is more likely if experts support government policy or the government’s definition of policy problems. Another criterion is the value they attach to the experts’ resources regarding group size, ability to represent a broader population, importance to society and economy, and policy-relevant knowledge. Experts must also be willing to follow the informal rules of the game for advising including, among others, keeping discussions and debates in-house and adopting a pragmatic attitude. Building upon Jordan’s (1974) and Mahoney’s (1997) work on the insider-outsider model of interest representation Cairney distinguishes between for categories of experts:
Core insider or senior government scientific advisors. This category comprises employed civil servants in government departments and other public organizations.
Specialist insiders. These advisors are recruited to specific government advisory bodies ‘on tap’. During COVID-19 this category mainly consisted of public health ex-perts, virologists, clinicians, data scientists, statisticians, and other bio-medical experts.
Peripheral insiders. These experts work for other organizations (e.g. universities, think tanks, research institutes) and seek inclusion in policymaking. Lack of familiarity with the informal rules of advising hinders their impact on policymaking.
Outsiders or experts trying to influence policy externally. These experts primarily act as critical commentators along the sideline and seek to generate interest from external audiences.
Cairney’s classification model offers a useful analytical point of departure for the study of the ‘politics of expertise’.
Nowadays, hundreds of interest organizations seek to influence policymaking at the national and international level (Coen & Richardson, 2009). An interest organization is a non-state organization representing the interests of its members in the health policy arena through the aggregation and articulation of these interests. While some organizations represent health sector-specific interests (e.g. the interests of general practitioners, health insurers, and patients with cardiac problems), others represent the interests of their members across policy sectors (e.g. employer organizations, worker organizations, consumer organizations) or the interests of the corporate sector. Some interest organizations concentrate their activities upon specific public health issues (e.g. safety at work) or medicine-related issues like abortion or medical assistance in dying at the patient's request. There are also interest organizations whose mission is to protect and promote public interests, if necessary, by filing a lawsuit against private companies or agencies that violate these interests in their view (Box 5.3).
Peak or umbrella organizations represent the interests of their associated interest organizations. Examples are the Royal Dutch Medical Association representing the interests of the associated professional organizations, the Dutch Patient Federation representing the interests of the associated patient organizations or, at the international level, the Confederation of European Community Cigarette Manufacturers and the European Federation of Pharmaceutical Industries and Associations. These organizations’ strategic goal is to reinforce their members' influence in policymaking. Speaking with one voice, though, is complicated if the interests of the associated organizations do not run parallel. For instance, the tobacco industry has a much more homogeneous structure than the highly diversified food sector.
Box 5.3 The struggle of the Pharmaceutical Accountability Foundation against excessive pricing in pharmaceutical care
The Pharmaceutical Accountability Foundation (PAF) was created in 2018. Its mission is ‘to further affordable access to medicines and medical technologies’. The organization achieved great success through the fine on Leadiant Biosciences imposed by the Dutch Competition Authority. The Authority sentenced the company for its anti-competitive practices. The company that had raised an orphan drug's price by 500% was also fined in Spain, Italy, and Israel. In 2021, PAF sent a letter of liability to Abbvie, the producer of Humira, which is a medicine against, among others, rheumatism, and Crohn’s disease. The foundation called Abbvie to account for the excessive pricing it had charged for this medicine in 2014-2018 while it was still protected by patent.
According to PAF, pharmaceutical companies abuse their market power and act purely profit-driven. In its view, pharmaceutical companies have a care duty. Their unfair market behavior has created access barriers to health care, resulting in a severe loss of Quality Adjusted Life Years.
Source: Annual Report 2022.
Considerable differences exist in the organizations’ resources of interest to influence health policymaking. While giants such as the tobacco industry, the pharmaceutical industry, the food industry, or the automobile industry can mobilize huge budgets for interest representation, other organizations must work with a small budget to have their voices heard. The financial resources of most public health interest organizations pale into significance when compared to the resources of organizations representing corporate interests. Other important resources are prestige, credibility, a large constituency, and, last but not least, excellent venues to (interest-friendly) ministers, top-level civil servants, and members of Parliament. It also happens that interest organizations employ insiders from the government or, conversely, that their employees switch to influential government posts (revolving door mechanism).
Public health organizations sometimes benefit from the policy initiatives of public authorities. These initiatives offer them an opportunity to get access to the health policy arena through joining advisory committees or participating in consultative meetings. EU programs such as ‘Europe against Cancer’ or ‘Europe against AIDS’ also included large budgets for public health research (Greer, 2009). Sometimes, public authorities explicitly stimulate the creation of counter-interest organizations to promote their objectives. An example is the financing of the European Bureau for Action on Smoking Prevention (BASP) by the European Commission in 1989. BASP had to provide information and argumentation the Commission could use in its initiative to ban tobacco advertising within the European Union. However, BASP was only granted a short life. Due to an influential lobby of Germany, the United Kingdom, and the Netherlands – all countries with a large tobacco industry - as well as internal pressure from the Directorate-General of Agriculture and the Directorate-General of Social Affairs in the European Union, the Commission had to stop the financing of BASP. Two newly established organizations, the European Network for Smoking Prevention (ENSP) and the European Network on Young People and Tobacco (ENYPAT) were explicitly forbidden to engage in lobbying (Boessen & Maarse, 2008).
The number of interest organizations has exploded. Doctors, nurses, hospitals, insurers, patients, the pharmaceutical industry, the food industry, and numerous other organizations with a stake in health issues have organized themselves to articulate their interests. The stakes are high in terms of euros and employment. Particularly in the second half of the twentieth century, the health sector has transformed into a market with tremendous financial interests (Starr, 1982). Commercial interests explain why the corporate sector has organized itself or hires specialized firms to lobby the state. Because state initiatives to restrain the intake of unhealthy food, stop smoking or limit alcohol consumption, to mention a few examples, have potentially big repercussions for the profitability of the manufacturers of these products, they spend millions of dollars to block, mitigate, or delay legislation that would harm their commercial interests. Health policy is no longer the exclusive playground of the medical profession. Globalization has also profoundly altered the structure of interest representation. Nowadays, thousands of accredited interest organizations lobby European institutions (Coen & Richardson, 2009).
The explosive growth of interest representation has resulted in a crowded health policy arena. It has made policymaking more complex, the more so because the interests of interest organizations often widely diverge. The protection of established interests restricts the margins of policy change. A great deal of interest representation has developed as a conservative force in policymaking. Pierson (1996) gives an instructive example of this effect in his analysis of the ‘new politics of the welfare state’ (Box 4.5).
Box 5.4 The new politics of the welfare state
In his comparative study of the fate of state retrenchment programs to keep public expenditures affordable in four countries (the United Kingdom, Germany, Sweden, and the United States), Pierson describes the politics of retrenchment as a distinct process that fundamentally differs from the process of welfare expansion. The distinctive structure of the politics of retrenchment stems from different political goals (extension versus contraction) and the emergence of a new political context. ‘Large public social programs are now a central part of the political landscape (…….). With these massive programs have come dense interest-group networks and strong attachment to particular policies, which present considerable obstacles to reform’ (p. 146). An illustration of this thesis is the fact that the Thatcher government in the United Kingdom (in charge from 1979 through 1990) had to back off repeatedly from options to privatizing the National Health Service after these options had provoked public outrage. By the end of the decade, the government’s repeated promise had become ‘the NHS is safe with us’ (p. 163). Even a government with much-centralized power had proven unable to break through the clay layer of institutionalized interests.
Source: Pierson, 1996.
The primary function of interest organizations is to influence the health policy agenda and direct problem formulation and policy formation so that the outcome matches their interests. On many occasions, interest organizations of the medical profession have sought to put their stamp on health policymaking. To have his plan for introducing the National Health Service in the United Kingdom accepted, the government had to concede to the British Medical Association that doctors with private practice would not be integrated into the NHS but connected to the Service by contracts (Klein, 1983). Opposition of the medical profession in Switzerland hindered the reform of national health insurance for almost a century. The doctors cleverly used ‘veto points’ in the Swiss governance system (Immergut, 1992). The history of the relationship between doctors and the state in France is a long sequence of conflicts regarding professional autonomy and revenues. In concord with the mutualities, doctor organizations did not hesitate to discredit the centralization of medicine as the ‘Sovietisation of French health care’ which would threaten ‘la médicine liberale’ (Wilsford, 1991). The structure of the US health system is the outcome of countless political battles between the federal and state governments and the powerful associations of doctors and health insurers (Starr, 1982; Marmor & Barer, 2012; Blumenthal & Morone, 2010).
Interest organizations are also engaged in informational lobbying by informing policymakers about new developments, the level of support among their members for policy initiatives, technical issues, and acute practical problems their members are facing. The need for information makes public authorities dependent on the input of interest organizations, particularly if in-house expertise is absent. Their privileged position sometimes enables these organizations to penetrate the inner circle of health policymaking. It even happens that interest organizations act as the principal writer of the regulations they will be subjected to. This phenomenon is known as regulatory capture (Mindell et al, 2012).
The functions of interest organizations indicate no ‘one-way traffic’ between government and interest organizations. Interest organizations are a valuable source of information for the government and can play a legitimizing role. The legitimacy of health policymaking benefits from the signature of leading interest organizations under a common agreement with the government. However, an intimate relationship between the government and interest organizations also entails risks for both. Interest organizations risk being squeezed between their constituency's demands and the government's. On its part, the government must accept concessions in striking a deal with interest organizations. The practice of negotiated agreements between government and interest organizations also raises questions from the viewpoint of democratic control. What is room for the Parliament to reject or amend a hard-won compromise with leading interest organizations?
Effective lobbying requires a keen strategy concerning the what, when, and how of lobbying (Van Schendelen, 2002). It has developed as a professional activity. A strategic issue is which policymakers at which political level and at which moment must be contacted as the primary target of demand articulation. The tobacco lobby followed a two-pronged strategy in its struggle against tobacco control legislation by targeting its lobby both at policymakers in Brussels and government officials in the member states. The Dutch tobacco lobby maintained intensive contact with the Department of Economic Affairs which it saw as the main protector of its commercial interests (Box 2.1) (Willemsen, 2018).
The international pharmaceutical industry deliberately chose the ‘Brussels route’ for its initiative to start an experiment with direct-to-consumer advertising of their medicines in the European Union. The industry considered this strategy superior to the strategy of lobbying individual member states because they were expected to adopt a critical stance to its initiative. The industry employed its close contacts with the Directorate-General Enterprise of the European Union instead of the Directorate-General for Health and Food Safety (DG Santé) to get the experiment on the political agenda of the European Union. DG Enterprise and its commissioner were seen as the industry’s natural ally because of the Commission’s ambition to make the Union highly competitive and leading in industrial innovation in a globalizing world. Other reasons for targeting DG Enterprise were the relatively weak power base of DG Santé and the fact that the experiment with direct-to-consumer advertisement (later for strategic reasons reframed as direct-to consumer information) required adaptations in market regulation. Despite several attempts by the Commission, the experiment has never come off the ground because of resistance from the European Parliament and the Member States. There was much fear that it would increase pharmaceutical expenditures (Boessen, 2008; Passarani, 2019).
Interest organizations may also forge third-party alliances to build up more leverage. An example is the initiative of the tobacco industry to set up the Committee for Freedom of Expression and its appeal to the media and advertising groups to raise their voices against the proposed ban on tobacco advertising (Boessen, 2008).
Table 5.1 gives an overview of the tactics interest organizations may use in promoting or defending their commercial interests taken from Galea and Castro (2022). The authors point out that public health advocates should gain in-depth knowledge of the playbook of tactics of the corporate sector to develop effective counter-strategies. They should give up the naïve belief that evidence of the effectiveness of public interventions will trump the resistance of the corporate sector.
Table 5.1. Tactics and methods of the corporate sector to protect and promote its commercial activities in public health
Fear mongering by industry takes diverse forms. It includes lawsuits or threats of lawsuits on the grounds of infringing industry’s commercial rights including in intellectual property and economic freedom. It also includes generating fear that constraining the industry would have a disproportionate impact on the economy and on employment.
Industry funds are used to win over support to protect corporate interests from interference. These include direct support to political campaigns and politicians, corporate social responsibility efforts to whitewash or “greenwash” their credentials, and, where allowed, using sponsorship and marketing budgets to gain allies in the media, sport, and cultural scenes.
Corporate power is exerted through front groups that claim to represent the interests of the public or of other industrial sectors. Curbs on public smoking or imposition of licensing hours, for instance, are often initially opposed by the tourism and hospitality industries as being detrimental to their viability, even though these industries are usually found to benefit commercially when the laws are enacted and enforced. Corporate interests also use front groups (such as “smoker’s rights” groups) to undermine the confidence of policymakers by belittling or denying the support of the public for effective public health measures.
Denialism is a reflexive action of the corporate sector to deny the link between its products and health effects, by impugning the findings of health research or the researchers involved.is a reflexive action of the corporate sector to deny the link between its products and health effects, by impugning the findings of health research or the researchers involved. Denialism was a strong feature of the tobacco industry response to the initial findings linking tobacco and cancer and has since become an established part of the playbook for other industries. This systematic deployment of doubt with the support of corporate interests has also, at times, acquired an ideological and political motive.
Industries deflect attention on them and their products using several tactics. They claim health benefits (e.g., “the benefits of red wine”). They fund alternative research directly or through foundations, such as the Foundation for a Smoke Free World to create confusion. They also deflect liability by running campaigns focused on individual responsibility, blaming the consumers rather than the industry itself, for instance, in the ubiquitous “drink responsibly” campaigns. Faced with the prospect of regulation, industry reverts to the trope that voluntary agreements, self-regulation, partial bans, or even public-private partnership are more democratic or market-friendly.
While the resolution of alternate hypotheses is inherent to the scientific method, corporate tactics have used it to delay effective action on curbing consumption of their products. The claims of protective effects of alcohol under certain conditions creates a language divide, constraining public health work to addressing the “harmful use of alcohol”, implying there is a beneficial use and obfuscating the fact that any level of alcohol consumption is carcinogenic.
Source: Galea & Castro, 2022.
Interest organizations see their input into health policymaking as their democratic right. Interest representation is, in their view, a defining characteristic of democracy. Nevertheless, the role of interest organizations is contested. One reason for criticism concerns the unequal distribution of resources these organizations can mobilize for lobbying, as a consequence of which public policy can be biased to the interests of the powerful. Differences in resources may have a profound impact on policymaking. Policy decisions are frequently biased toward the interests of the most powerful interest organizations.
A second reason for critique is the lack of transparency and integrity. There is evidence of undue influence, unfair competition, and regulatory capture to the detriment of the public interest. Some interest organizations are even silent about their sponsors. ‘The more silently, the better’ is the mantra of the Dutch National Employers Association (Andeweg & Irwin, 2009: p. 15). For this reason, various countries and the EU work on a regulatory framework to improve transparency and guard the integrity of public policymaking (OECD, 2013; Coen & Richardson, 2009).
The participation of citizens in health policymaking is not new. From the very moment vaccinations became available, citizens have protested against vaccination on religious grounds or for fear of adverse health effects. Public protests against mass vaccination campaigns and other freedom-restricting policy measures like the introduction of QR-code and the digital passport fit a long historical tradition.
Citizen participation in health policymaking has extended over the last few decades under the influence of the growing stock of knowledge on health risks. Participation is foremost issue-oriented. Citizens, either as individuals or in a group, write letters to Members of Parliament, participate in public inquiry procedures, or conduct research to support their claims. They demand effective state action against the emission of hazardous substances in their neighborhood or resist government activities (e.g. G5 masts or windmills) because of an assumed health risk. In many countries, abortion arouses public emotion. State measures perceived as patronizing can arouse public commotion.
A new development is experimenting with citizen forums in public policymaking. A forum consists of a limited number of individuals forming a cross-section of the population. The purpose of the forum is to discuss complex policy problems and formulate policy recommendations. They are expected to do so with an open mind and the willingness to change one’s opinions because of new information or good arguments. Its members have access to all information they need. Experts should provide them with this information in an impartial way. Citizen forums have also been experimented with in health policymaking. There is some evidence that they can open new directions in dealing with complex health policy issues (see section 8.3 for more information).
Another development is the impact of the internet and social media on citizen participation. The new information technology enables citizens to set up new networks and platforms to share information and influence health policymaking outside the channels of institutionalized interest organizations. As a consequence, interest articulation has become much more fragmented than in the past when incumbent interest organizations sought to aggregate the interests of their members. The immediate access to information – information is only one click away – also affects the relationship between citizens, experts and the state. Citizens are less inclined to accept the ‘truth’ told by experts and the state which says to rely on expert information. Two problematic aspects of this development are the abundance of information and the toxifying impact of the widespread false information on the public debate and the relationship between citizens, experts (science) and the state (see section on media).
Producer organizations provide goods and services necessary for the achievement of health policy goals. Presently, for-profit producer organizations provide many goods and services, including, among others, pharmaceuticals, medical equipment, financial services, technical services, information, and research. Many activities have been outsourced to the market sector. The increased role of producer organizations in health policymaking marks a growing dependence of the state on the for-profit sector. Conversely, medical companies are often dependent upon public investments in innovation (Mazzucato, 2021). Examples are large public investments in developing anti-COVID vaccines, new antibiotics, and orphan medicines.
As described in the first chapter, the state’s increased dependence upon the for-profit sector is closely connected with the extension of state intervention. Some fields in medicine are largely controlled by the bio-medical industry with a clear commercial interest in expansion. The public control of air, water, and soil quality requires ever more technical expertise to be hired. Newly developed trace-and-track technologies played an essential role in the management of COVID-19.
The role of the media in modern health policymaking can hardly be underestimated. The media do not confine their role to informing the public about health affairs but also influence the political agenda by reporting about problems and scandals and informing the public about information acquired from or leaked by anonymous sources. Investigative journalists have laid bare various examples of rent-seeking and misconduct in health care. The media also play an important role in frame contests. Their selection of the news and framing of health problems and policy initiatives influence how people perceive and assess these problems and initiatives.
Besides, the media are an indispensable medium for politicians and stakeholders to have their stories told and generate media attention. News management and political communication (Wolfsfeld, 2011) have become essential in current public policymaking. An ‘army’ of spokespersons and spin doctors is every day in action to influence public communication and avoid political harm to the minister they serve. Conversely, the media are interested in good contacts with policymakers for access to information. The relationship between media and politicians is reciprocal.
The media play a critical role in risk communication during major and enduring public health threats like COVID-19. Their challenge is to inform the public as best as possible. Media information is crucial in situations of great uncertainty and anxiety among the population. Gollust and her colleagues (2020) have argued that media information on COVID-19 has reinforced the dividedness among the American public. The media were actively involved in frame contests by reporting the pandemic in politically filtered ways. Right-leaning news sources were more likely than other media sources to disseminate specific pieces of misinformation and conspiracy theories. President Trump used these news sources to downplay the severity of the pandemic by calling it a hoax and blaming China for its outbreak (’China Virus’). In press conferences, he also recommended therapies missing any scientific ground (e.g. hydroxychloroquine). No surprise that Republican voters were less likely than Democratic voters to consider the virus an imminent threat and take precautions. The authors conclude that Trump’s use of the media contrasted with the basic principles of risk communication.
A new development is the impact of social media on public opinion. For many people, social media have become the prime source of information. Millions of people nowadays have direct access to information that is just one click away. Within seconds, information can spread across the country and the global world. Social media are a medium with multiple faces, particularly during a pandemic when there is a great need for information and many people live in fear and anxiety. Public authorities can avail of social media as a channel to inform the public on health issues and give information on how people can protect themselves against infection. On the other hand, however, social media have become a source of confusion and a medium for the large-scale spread of misinformation, fake news, and pseudo-therapies (Banerjee & Meena, 2021). Social media were one of the main causes of the outbreak of an infodemic described by the World Health Organization as ‘too much information including false or misleading information in digital and physical environments during a disease outbreak’ (www.who.int/health-topics/infodemic). An avalanche of information can cause confusion and risk-taking behavior and undermine public trust in the government. Because digital disinformation can threaten public health (McNeill Brown, 2020), unmasking disinformation and fake news has become a new challenge for public health authorities. Finally, social media can stir up stigmatization and polarization through spreading fake news and conspiracy theories for political gain.
Courts do not directly participate in policymaking and are bound by the law. Nevertheless, court rulings can have a significant policy impact. For instance, the introduction of the Social Support Act in the Netherlands, which made municipalities responsible for providing social support services, was followed by hundreds of lawsuits from clients who disagreed with the type or amount of social support they received from their municipality. Some court rulings forced municipalities to revise their implementation strategy policy. Claims for financial compensation are also on the rise. Victims of Q-fever have filed a lawsuit against the state, arguing that the state had failed to take appropriate policy measures to protect their health.
Another development is public law litigation (Greer, 2008): individuals or organizations dispute the lawfulness of state decisions and ask the court for a judgment. An example is a judicial review of the legality of the March 2020 lockdown regulations in England. A few businessmen alleged that these regulations breached various public law principles and violated human rights. However, the Court of Appeal dismissed the claim entirely (Wagner, 2022). Likewise, the German government asked the European Court of Justice to annul the EU Directive on the ban on tobacco advertisements in the EU because it missed, in its view, an appropriate legal basis (Boessen, 2009). Some countries (e.g. Germany) have a constitutional court that can be asked to judge the lawfulness of legislation or international treaties.
Some court rulings have a considerable impact on health policymaking. An example is the landmark decision of the United States Supreme Court in Roe v. Wade in 1973 on the constitutionality of laws that criminalized or restricted access to abortion. The court ruled that the right to privacy extended to a woman’s decision to have an abortion in the early period of pregnancy. The Supreme Court annulled this decision in 2022, arguing that the American Constitution does not regulate abortion and that the right to abortion cannot be derived from the Constitution. The Court’s ruling implies the abolition of the federal right to abortion; regulation of abortion is left to the states. While some states have issued or planned legislation to protect women’s right to abortion, other states have introduced legislation that only permits abortion under strict conditions (a woman’s health is at risk or rape). The Court’s rulings underscore the importance of its composition. The nomination of new judges has become a political issue with potentially big consequences for (health) policymaking.
Similarly, the ruling of the European Court of Justice in 1998 that the principle of free movement of persons and services applied to cross-border health care, unless the application of the principle would harm health care in a member state to a significant degree, had major consequences for member states. This ruling and other rulings on cross-border care have compelled member states to revise their restrictive policy in cross-border care (Palm & Glinos, 2010). After lengthy negotiations, they eventually agreed on a European Directive on regulating cross-border care to fill the regulatory gap. The Directive came into force in 2013.
A salient aspect of the globalization of public health is the rise of organizations operating on a worldwide scale and carrying out a broad range of activities ranging from assistance to nations in fighting the outbreak of infectious diseases and building up a health system that serves the needs of their population to programs directed at saving children’s lives and protecting people’s health. The number of these organizations has steeply increased after the Second World War. Nowadays, it is impossible to imagine international public health without the input of these organizations.
A global distinction can be made between two categories of organizations. The first category consists of international governmental organizations (IGO’s). These organizations have been created by states to pursue a collective good. The World Health Organization, the United Nations Children’s Fund, and the World Bank are well-known examples active in public health. The latter organization is a major international funder of health sector activities in low-income countries. Non-governmental organizations (NGO’s) make up the second category. Examples are Red Cross, Medicines without Borders, Care International, and Human Rights Watch. NGO’s are mainly dependent on private (for-profit) donor organizations for the funding of their activities. A well-known charitable foundation is the Bill and Melinda Gates Foundation which supports various programs directed at enhancing healthcare and reducing extreme poverty. Over the years, the foundation has spent hundreds of million dollars on the eradication of malaria and tuberculosis and programs to improve family planning, essential nutrition, and basic sanitation. The World Health Organization has become increasingly reliant on financial contributions from NGOs as well as private donor organizations, letting Huisman and Tomes (2021) conclude that public-private partnerships nowadays dominate global health policymaking. Conversely, national governments and IGOs give financial support to the activities of NGOs. NGOs and IGOs also collaborate in global health networks.
A great deal of the activities of IGOs and NGOs consists of providing technical assistance. These activities are mostly organized around a particular issue (e.g. malaria and aids). Some NGOs, such as Medicines without Borders, concentrate their activities on international refugee and disaster relief. NGOs can also act as stakeholders in the international public health arena by calling attention to public health problems and participating in global policy networks.
The emergence and rapid growth of the number of NGOs in the field of public health has fundamentally altered the international scene. Nowadays, mixed coalitions of NGOs and IGOs play a leading role in fighting global health problems. Some observers have argued that the role of NGOs has surpassed the role of IGOs. In his study of global governance, Weiss (2013) even considers intergovernmental organizations ‘the weakest link in the chain that collectively underpins global governance’ (p. 15).
It should be noted that contributions of private donor organizations to public health in low- and middle-income countries have a double face. The fight against HIV/ AIDS is a good example. On the one hand, their contributions are indispensable to overcoming the limited capacity of these states to raise sufficient funds to establish an adequate public health system. In some countries, the level of HIV/ AIDS donations compares in magnitude to the country’s total budget for public health. On the other hand, there are concerns that the high level of donor funding attention distorts priority-setting in these countries’ health policies (Shiffman, 2007). Donor organizations are also free to withdraw their donations. Finally, one should not forget that taxpayers subsidize donations because philanthropic organizations receive tax privileges for donations (Costa-Font et al., 2020).
Global public health has grown into a field in which international governmental and non-governmental organizations, including for-profit organizations, cooperate in global networks or transnational public-private partnerships for public health. The members of these networks seek collaboration in more or less formal networks while retaining their independence of action. The networks have an independent extra-governmental status, though they may be incorporated into formal governing frameworks (Ansell et al., 2012). Global networks respond to the challenges of global governance in public health and other transboundary problems like climate change, the proliferation of weapons of mass destruction, terrorism, or financial instabilities. They can be viewed as an organizational vehicle for coordinating activities of the public sector, the private sector, and civil society in a world where coordination through hierarchical direction (‘world government’) is politically and practically unfeasible (see next chapter).
Currently, numerous global networks are active in pursuing public health. An example is the Global Alliance for Vaccines and Immunizations (GAVI). Dedicated to ‘immunization for all’, the organization operates in countries with few resources to save children’s lives and protect people’s health by increasing access to immunization (website GAVI). Other examples are the World Food Program, the Coalition for Epidemic Preparedness Innovations, and the Global Fund to Fight AIDS, Tuberculosis and Malaria. The World Food Program (WFP) is the world’s largest humanitarian organization saving lives in emergencies and using food assistance to build a pathway to peace, stability, and prosperity for people recovering from conflict, disasters, and the impact of climate change. Governments are the principal funder of WFP but corporations and individuals make substantial contributions as well (website WFP). The Coalition for Epidemic Preparedness Innovations (CEPI) was founded in 2017 at the World Economic Forum. Its mission is to develop vaccines against emerging infectious diseases. Important donors are the Bill and Melinda Gates Foundation, the Wellcome Trust and a consortium of nations. The European Union also participates in it (website CEPI). The Global Fund to Fight AIDS, Tuberculosis and Malaria, which started its activities in 2002 is a global partnership that aims to ‘attract, leverage and invest additional resources to end the epidemics of HIV/AIDS, tuberculosis and malaria and to support attainment of the Sustainable Development Goals established by the United Nations’ (www.theglobalfund.org). The Fund with the Bill and Melinda Gates Foundation as one of its first donors supports various programs run by local experts to accelerate the end of AIDS, tuberculosis, and malaria as epidemics in more than a hundred countries.
Another example of a global network is the Global Outbreak Alert and Response Network (GOARN). In evaluating this network, Ansell gives an informative overview of its strengths and weaknesses. The claim is that these strengths and weaknesses are not unique to GOARN but characteristic of the potential and limits of global network governance (Box 5.5).
The next two sections discuss the role of the World Health Organization and the European Union in global health. Specific attention will be given to their involvement in the fight against the COVID-19 pandemic.
Box 5.5 The Global Outbreak Alert and Response Network
The Global Outbreak Alert and Response Network (GOARN) is a coordinating mechanism for rapid response to infectious disease outbreaks of international concerns. It has more than 100 partner organizations and is housed by the World Health Organization which acts as the lead organization of the network. Because several of the partner organizations are network organizations themselves, GOARN describes itself as a ‘network of networks'’. The main activities of GOARN are the mobilization and coordination of multilateral resources and experts providing technical and operational support to countries and areas struggling with an outbreak of an infectious disease. Contrary to many other global networks, GOARN is not set up as a policymaking body. It does not formulate or enforce global standards or seek to mobilize the international community to take action.
Since its establishment in 2000, the network has been active in over seventy global disease outbreaks in over forty countries. According to Ansell, GOARN has been relatively successful. By mobilizing partner organizations as a technical community, GOARN facilitates rapid coordination of support. Moreover, GOARN operates as the carrier for nations preferring bilateral aid during an outbreak. However, the experiences of GOARN cast light upon several problems global networks encounter in carrying out their activities. First, the coordination of the activities of many partner organizations appears an immense task in itself. Internal rivalries and preference for bilateral deployment can frustrate the cooperation between the partner organizations. The second problem is that GOARN has no clear face of itself. Confusion exists about its status. Though GOARN is formally an independent network, local authorities often perceive the network as the operational arm of the WHO. The fact that the WHO acts as the lead organization and houses GOARN reinforces this perception. What further complicates its activities are problems with information sharing. Though timely information sharing is critical in fighting the outbreak of an infectious disease of international concern, countries can be reluctant to share information for political, economic, and social reasons. The International Health Regulations also constrain early access to information via GOARN because the release of information is bound to strict conditions (see next chapter for further details).
Source: Ansell et al., 2012.
The World Health Organization (WHO) was founded in 1948 as a specialized agency of the United Nations. Its mission, defined in Article 1 of its constitution, is ‘the attainment by all peoples of the highest possible level of health’. The organization is governed by an executive board, a secretariat (both based in Geneva), and the World Health Assembly in which all member states have a representative. As the agency’s decision-making body, the Assembly elects the Director-General, sets goals and priorities, approves the organization’s budget and activities, and elects an executive body consisting of health specialists. A great deal of operations are devolved to six semiautonomous regional offices.
In the aftermath of the SARS pandemic, WHO started negotiations with its members on the need for a system of International Health Regulations (IHR) to ensure a quick and adequate response to the outbreak of infectious diseases of international concern. The regulations, introduced in 2005, obligate states to share information about outbreaks within their borders, to give WHO powers to gather and share data, and to declare ‘public health emergencies of international concern’ (PHEIC). States are required to 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’ (article 2 on the purpose and scope of IHR). A weak element of the regulations is the absence of an effective enforcement mechanism. The regulations recognize the states’ sovereignty in health affairs. WHO has no enforcement power.
The organization carries out a wide range of activities to ensure that ‘a billion more people have universal health coverage, to protect a billion more people from health emergencies, and provide a further billion people with better health and well-being’ (www. who.int/about/what-we-do). WHO has sought a leading role in public health, among others, through the eradication of smallpox, the near-eradication of polio, and the development of an Ebola vaccine. Its current priorities include various communicable and non-communicable diseases, healthy diet and food security, occupational health, and substance abuse.
WHO faces fundamental challenges (Kavanagh et al., 2021). First, it struggles with a balkanized governance structure. The General-Director has remarkably weak authority over the regional offices. Second, the organization has always been subject to competing priorities of its 196 member states and non-state donors. The organization must act diplomatically to avoid that states feel brushed off. The optimistic atmosphere of international cooperation in the immediate post-war period has largely waned. Third, its budget bears no relation to its immense tasks. The organization is heavily dependent on unstable voluntary contributions, which at present account for up to 80 percent of its budget. The spending of these grants is constrained by the priorities of the donors.
In its early days, WHO functioned as a pragmatic and mainly biomedical-oriented organization. However, after the organization had embraced the concept of the new public health (Chapter 1) and underscored the need for strengthening the focus on primary care, some of its activities have become contested (Siddiqi, 1995). The activities of the organization take place in a polarizing political context. On some occasions, the organization faced ferocious opposition from industrial sources. For instance, WHO’s promotion of infant foods met heavy resistance from the food industry, and its Action Program on Essential Drugs met heavy resistance from the pharmaceutical industry (Walt, 1996).
Managing the outbreak of infectious diseases is a core task of the World health Organization. The organization has done much work in the past by collecting epidemiological data, issuing recommendations on strategies to contain the impact of the outbreak, and providing technical assistance. An important step was the introduction of the International Health Regulations in 2005 to streamline international coordination. The IHR are ‘an international instrument to help countries work together to save lives and minimize the impact on livelihoods by events that cause the international spread of diseases’ (www.who.int/ihr).
However, the organization’s track record in managing the outbreak of pandemics is not without failures (Kamradt-Scott, 2018). One of these failures was the management of the outbreak of the H1N1 pandemic in 2009. To avoid the label of ‘Mexican Flu’ (the pandemic had emerged in La Gloria in Mexico), the organization chose ‘Swine Flu’ as an alternative label. This unfortunate decision motivated some governments to order the mass slaughtering of pigs or impose bans on importing pigs and pork products to stop the spread of the virus. All this happened without any scientific evidence for the transmittance of the virus from pigs to humans. When it became clear that the H1N1 virus had caused only mild illness in the majority of the cases and that its death toll had turned out to be relatively moderate, the organization removed its guidelines from the organization’s website. This was a remarkable move in the context of its earlier decision to declare the outbreak a public health emergency of international concern (Kamrath-Scott, 2013).
The organization’s management of the 2014 West African Ebola outbreak crisis has also been criticized. One reason for criticism was its slowness in responding to the outbreak which concentrated in Liberia, Sierra Leone, and Guinea. It took several months before WHO declared the outbreak a pandemic. Rather than challenging the data of the respective governments which had an economic interest in mitigating the seriousness of the outbreak, the WHO secretariat took the government’s statistics at face value. It failed to collect reliable data about the size and unfolding of the Ebola virus. Another failure was the poor coordination of efforts to stop the spread of the virus. Miscommunication and rivalries between the Geneva-based headquarter and the African headquarter have been mentioned as an important explanation for this failure (Kamrath-Scott, 2013; Ebola Interim Panel, 2015).
These failures exemplify the organizational and political complexity WHO must cope with in daily practice. Lack of resources, economic interests, and political circumstances complicate its activities. Countries may give political and economic considerations higher priority than the pursuance of public health. The failures also demonstrate that the International Health Regulations did not work well. Various countries ignored the regulations they had signed only a few years ago.
The World Health Organization had a hard job in tackling COVID-19 (Kavanagh et al., 2021). Many of the problems mentioned in the previous section re-emerged in its management of the new pandemic that allegedly broke out in late 2019 in Wuhan in China. Sharing epidemiological data was a major problem in the early stage of the pandemic. Particularly, the role of China proved problematic. Since openly criticizing China for its lack of complete openness was politically risky, the Secretary-General chose the alternative route of negotiating information and seeking collaboration with China in investigating the pandemic outbreak. He praised China for its rapid response to the pandemic. Not everyone, however, appreciated this attitude. The secretary-general was criticized for being close to China, and the organization’s independence was said to be at stake. President Trump even announced the withdrawal of the United States from the organization, but this decision has been revoked by his successor Biden.
Another vital task was to issue evidence-based guidelines on how to respond to the pandemic. Here, too, the organization faced problems. Technical recommendations quickly became political. Countries neglected the advice to abstain from travel restrictions and quarantine, even though there was no evidence of the effectiveness of these measures and much evidence of their disruptive effect upon global trade. As had happened before, countries did not follow the International Health Regulations. Furthermore, the organization created much confusion about the effectiveness of some interventions. For instance, it advised for many months against mask mandates but later changed its position on this issue. Similarly, WHO was initially critical of whether COVID-19 was technically airborne (Kavanagh et al., 2021).
The organization’s call for international solidarity and a worldwide strategy has largely fallen on deaf ears, despite public manifestations to the contrary and some praiseworthy initiatives such as the Access to COVID Tools Accelerator (ACT-A) to expedite the development and production of test materials, treatments, and vaccines. International solidarity is hard to organize if it contradicts the interests of powerful states. Actually, the organization’s struggle against ‘vaccine nationalism’ has largely failed.
In their analysis of how WHO has responded to COVID-19, Kavanagh and his co-authors underscore the strong political pressure the organization is subject to. Everything the organization does or does not do runs the risk of becoming political. The organization faces great challenges in combining science, politics, and diplomacy effectively. The notion of international cooperation and transparency leading just after World War II and a source of inspiration for its founding has largely dissipated. The rise of nationalist and populist rhetoric in some countries has stirred up resistance to international interference in domestic affairs. Populists see the International Health Regulations as a new piece of evidence for their claim that national interests are made subordinate to the interests of the international community and that crucial decision are taken by unaccountable international elites (Wilson et al., 2021).
In contrast to WHO, the European Union (EU) has the structure of a supranational organization. Its Member States have transferred a defined set of sovereign powers to the EU to establish a free internal market (free movement of people, goods, services, and capital). In areas where the Union is formally competent, national legislation is subordinate to EU legislation. Enforcement mechanisms are in place to sanction violations of EU regulations, directives, and decisions.
The key players are the European Commission, the European Parliament, the Council of Ministers, the European Council, and the European Court of Justice. The European Commission operates as the EU's executive body and has the right to take policy initiatives. The European Parliament acts together with the Council of Ministers as co-legislator. There are several councils: the Health Council consists of the health ministers of the member states. The European Council includes the heads of state and sets out, together with the Commission, the main directions in EU policymaking. The European Court of Justice acts as the final arbiter of European law (Greer et al., 2019).
The European Union has created several agencies to carry out specific tasks. Relevant agencies in the field of public health are the European Medicines Agency (EMA), the European Centre for Diseases Prevention and Control (ECDC), the European Food Safety Authority (EFSA), the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), the European Agency for Safety & Health at Work (OSHA) and the Consumers, Health, Agriculture and Food Executive Agency (CHAFEA) (Greer et al., 2019).
The protection of public health is declared an important goal of EU policymaking. Article 168 in the Lisbon Treaty (2009) mentions ‘a high level of public health protection’ as a leading principle in all Union policies and activities. Nevertheless, the formal competencies of the Union in the field of public health have always been restricted. Article 168 sub 7 of the Lisbon Treaty states that ‘Union action shall respect the responsibilities of the Member States for the definition of health policy and for the organization and delivery of health services and medical care. The responsibilities of the Member States shall include the management of health services and medical care and the allocation of resources assigned to them’.
Its restricted competencies have not withheld the European Union from starting activities to protect and promote public health since the mid-1980s. These measures were largely confined to encouraging cooperation between member states and issuing incentive measures designed to protect and promote public health. Two examples are the ‘Europe against Cancer’ program launched in 1985 and the program ‘Together for Health: a strategic approach for the EU 2008-2013’. Despite their appealing titles, the impact of these soft-measures programs on public health should not be overstated. Of much greater importance are the consequences of the regulations of the single market (Mossialos et al., 2010). With some exceptions, health care is not exempted from the basic principles of the free movement of people, goods, services, and capital. For instance, various rulings of the European Court of Justice on cross-border issues have confirmed that the principle of free movement of persons and services applies to cross-border care. As discussed earlier (section 5.10), Member States are only permitted to impose restrictions on cross-border care if the principles of free movement harm their healthcare system to a significant degree (Palm & Glinos, 2010). The European Union has also used the principle of free movement for issuing regulations directly impacting public health. Examples are EU regulations on tobacco control, food safety, pharmaceuticals, health and safety at work, the environment, and consumer protection (Greer et al., 2019).
At the beginning of the pandemic, coordination between the member states in controlling the spread of the virus was painfully absent. Each state took its measures to protect its population and care workers, such as the closure of their borders (a violation of the Schengen Agreement), and the solo purchase of personal protective equipment (PPE). France claimed all supplies and production lines of PPE, and Germany ordered an export ban on these materials. Each country implemented its measures to counter the spread of the virus and unlock the country after the infection rate had declined.
Despite the Union’s restricted competence concerning public health, the Commission sought an active role by taking initiatives in response to the outbreak of the largest public health crisis in recent history. Its initiatives in collaboration with the member states radiated a high degree of improvisation (Van Middelaar, 2021). Examples are the coordination of the repatriation of some 500.000 worldwide stranded EU citizens in the first stage of the pandemic; the coordination of national measures to ensure the cross-border travel of vital workers; the launch of financial programs to support research on the coronavirus and investments in the development of effective and safe vaccines; the organization of a joint procurement procedure for the purchase of vaccines resulting in contracts with pharmaceutical companies on the delivery of vaccines to the member states and the distribution of the vaccines across the member states. These initiatives can be qualified as an unprecedented example of collective action without experience and formal competences in the field of public health.
The Commission also launched a massive financial program to counter the consequences of the fall-out of the economy and gave financial support to non-EU member states. Another decision was to activate the general escape clause of the Stability and Growth Pact to enable member states to take necessary financial measures to support those parts of the economy which were hit most by the lockdown. A detailed overview of all measures taken can be found on Timeline of EU action | European Commission.
In its document ‘EU Strategy for COVID-19 Vaccines’ published in June 2020, the Commission unveiled its strategy to accelerate the development, manufacturing, and deployment of vaccines against COVID. The Commission’s goals were to secure swift access to vaccines in member states and accomplish an equal distribution of these vaccines among member states. There would be no room for unilateral decision-making and lack of coordination that had dominated the member states’ approach in the first stage of the crisis. Instead, the crisis required a common approach based on cooperation and solidarity. The protection of public health was defined as a collective interest that could only be effectively addressed through collective action orchestrated by the EU (Van Middelaar, 2021).
An instrument to achieve its policy goals and suppress vaccine nationalism was the Advanced Purchase Agreement with the pharmaceutical industry. In this contract with the industry, the Commission agreed to finance in part the upfront costs of vaccine developers in return for the right to purchase a specified number of vaccines. Furthermore, the Commission approved an accelerated procedure for the market authorization of COVID-19 vaccines by the European Medicine Agency (EMA). After an intense political dispute, the Commission also announced a financial support and recovery package of EURO 750 billion and a contribution of EURO 2,2 billion to COVAX – a worldwide initiative for an equitable delivery and distribution of vaccines and other essential products.
In June 2021, the Commission released a new document with ten key lessons from the pandemic. The central message in this document was that the EU had to build up an effective surveillance system to increase its preparedness for future pandemics and that ‘coordinated measures should become a reflex for Europe’ to avoid the practice of unilateral action that had dominated the approach of Member States during the first stage of the crisis. The Commission underscored the strategic need for building a ' European Health Union ' to improve the coordination of public health measures across the EU and make a swift crisis response possible. Another central message was the need for reinforced public-private partnerships and stronger supply chains to avoid the shortfall and inequalities in the supply of key products such as medicines, ventilators, and face masks.
Health policymaking in a pluralistic society is the work of numerous people and organizations. Nowadays, dozens of policymakers, experts, interest organizations, and many other types of organizations are involved in health policymaking. Health policymaking is no exclusive domain of the Health Department and health professionals. Health policymaking takes place in complex national, subnational, and global policy networks with complex relationships between these levels. Interest organizations seek to influence health policymaking and ward off ‘unwelcome’ decisions. The media report on health policymaking and are involved in frame contests by their selection and presentation of the news. Courts are involved in health policymaking by arbitrating conflicts and judging the lawfulness of state intervention (public law litigation). They must also decide on policy issues in unchartered terrains. The globalization of public health and the creation of global policy networks signify that health policymaking is no longer a mainly local or national issue. The simple fact that viruses do not respect national borders reminds policymakers of the necessity of international coordination in handling the large-scale outbreak of infectious diseases. However, international coordination has remained a politically sensitive topic despite the introduction of the International Health Regulations. Nevertheless, the European Union has seized COVID-19 as an opportunity to intensify the coordination of health policymaking between the member states, particularly through the joint purchase and distribution of COVID-vaccines.
Insight into health policymaking requires insight into who is involved in which role in the policymaking process. Identifying actors and examining their role and interaction in the health policy arena and policy networks are two important elements of health policy analysis. Other main research topics are the structure and type of policy networks, the structure and impact of interest representation on health policymaking, and the impact of the media, including social media and court rulings, on health policymaking. A final topic of research concerns the global dimension of health policymaking. What is the degree of involvement of non-governmental organizations, the World Health Organization, and the European Union in health policymaking, and how has their involvement extended over the last few decades? The next step in health policy analysis is the investigation of the formal and informal rules of the game for health policymaking. These rules will be discussed in the next chapter.
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