Opening the black box: the politics of allocating public resources for health in Barbados

Within the field of public health, there has been increasing interest in the factors that influence national priorities in health in low- and middle-income countries (LMICs), where resources are often particularly scarce and decision-making processes are often ad- hoc. Understanding how priorities are set in these countries necessitates a look at the process concealed in the black box that transforms policy inputs into outputs. However, rigorous health policy analysis of macro-level priority setting in LMICs is rare. Using a case study approach, this thesis explores the drivers of priority for primary health care, sanitation and HIV/AIDS over the past five decades in Barbados. To do this I use process tracing techniques, drawing on analysis of public expenditure on health from 1960 to 2010, in-depth interviews with key policy actors, non-participant observation, archives, media reports, parliamentary records and other documents. I argue that powerful individual policy actors or 'policy entrepreneurs' act as necessary drivers of macro-level priority setting in Barbados, although they do not single- handedly determine the outcomes. In particular, I find that these actors are successful in generating priority when they are able to propagate powerful framing ideas and can effectively navigate the policy context by seizing windows of opportunity and managing negative constraints. Moreover, because resources are scarce, their ability to mobilize external financial support is also important. In particular, this thesis stresses the fact that allocating public resources for health is a political process and suggests that it is best explained by considering a set of interrelated factors. In doing so, it illustrates the utility of health policy analysis in helping to open the black box of macro-level priority setting in LMICs more broadly.</p

Opening the black box: the politics of allocating public resources for health in Barbados

Within the field of public health, there has been increasing interest in the factors that influence national priorities in health in low- and middle-income countries (LMICs), where resources are often particularly scarce and decision-making processes are often ad- hoc. Understanding how priorities are set in these countries necessitates a look at the process concealed in the black box that transforms policy inputs into outputs. However, rigorous health policy analysis of macro-level priority setting in LMICs is rare. Using a case study approach, this thesis explores the drivers of priority for primary health care, sanitation and HIV/AIDS over the past five decades in Barbados. To do this I use process tracing techniques, drawing on analysis of public expenditure on health from 1960 to 2010, in-depth interviews with key policy actors, non-participant observation, archives, media reports, parliamentary records and other documents. I argue that powerful individual policy actors or 'policy entrepreneurs' act as necessary drivers of macro-level priority setting in Barbados, although they do not single- handedly determine the outcomes. In particular, I find that these actors are successful in generating priority when they are able to propagate powerful framing ideas and can effectively navigate the policy context by seizing windows of opportunity and managing negative constraints. Moreover, because resources are scarce, their ability to mobilize external financial support is also important. In particular, this thesis stresses the fact that allocating public resources for health is a political process and suggests that it is best explained by considering a set of interrelated factors. In doing so, it illustrates the utility of health policy analysis in helping to open the black box of macro-level priority setting in LMICs more broadly.This thesis is not currently available via ORA

Ending Pandemics: US Foreign Policy to Mitigate Today’s Major Killers, Tomorrow’s Outbreaks, and the Health Impacts of Climate Change

Every U.S. President in recent decades has had to respond to at least one pandemic disease. Political leadership has proven decisive. In the coming years, U.S. foreign policy will face at least three inter-related issues: today’s major pandemics of AIDS, TB, and Malaria; future outbreaks with the potential to become pandemics; and rising risk from infectious diseases associated with climate change. A review of epidemiologic data shows global progress on each issue is threatened. A coordinated U.S. effort, across agencies and engaged with national and multilateral partners, could save lives and address significant foreign policy interests. Such an effort could boost economic prosperity by reducing disease-related lost productivity, which we estimate at $1.7 trillion, with returns to investment in pandemic-related global health efforts averaging 17–20 to 1. Foreign policy focus on pandemics could also address gender and social inequalities and support climate adaptation and mitigation. Pandemic-related global health spending is 0.19% of the U.S. budget—a figure that has been flat in recent years even with growing needs and significant potential gains from investment

Ending Pandemics: US Foreign Policy to Mitigate Today’s Major Killers, Tomorrow’s Outbreaks, and the Health Impacts of Climate Change

Every U.S. President in recent decades has had to respond to at least one pandemic disease. Political leadership has proven decisive. In the coming years, U.S. foreign policy will face at least three inter-related issues: today’s major pandemics of AIDS, TB, and Malaria; future outbreaks with the potential to become pandemics; and rising risk from infectious diseases associated with climate change. A review of epidemiologic data shows global progress on each issue is threatened. A coordinated U.S. effort, across agencies and engaged with national and multilateral partners, could save lives and address significant foreign policy interests. Such an effort could boost economic prosperity by reducing disease-related lost productivity, which we estimate at $1.7 trillion, with returns to investment in pandemic-related global health efforts averaging 17–20 to 1. Foreign policy focus on pandemics could also address gender and social inequalities and support climate adaptation and mitigation. Pandemic-related global health spending is 0.19% of the U.S. budget—a figure that has been flat in recent years even with growing needs and significant potential gains from investment

An assessment of interactions between global health initiatives and country health systems

Since 2000, the emergence of several large disease-specific global health initiatives (GHIs) has changed the way in which international donors provide assistance for public health. Some critics have claimed that these initiatives burden health systems that are already fragile in countries with few resources, whereas others have asserted that weak health systems prevent progress in meeting disease-specific targets. So far, most of the evidence for this debate has been provided by speculation and anecdotes. We use a review and analysis of existing data, and 15 new studies that were submitted to WHO for the purpose of writing this Report to describe the complex nature of the interplay between country health systems and GHIs. We suggest that this Report provides the most detailed compilation of published and emerging evidence so far, and provides a basis for identification of the ways in which GHIs and health systems can interact to mutually reinforce their effects. On the basis of the findings, we make some general recommendations and identify a series of action points for international partners, governments, and other stakeholders that will help ensure that investments in GHIs and country health systems can fulfil their potential to produce comprehensive and lasting results in disease-specific work, and advance the general public health agenda. The target date for achievement of the health-related Millennium Development Goals is drawing close, and the economic downturn threatens to undermine the improvements in health outcomes that have been achieved in the past few years. If adjustments to the interactions between GHIs and country health systems will improve efficiency, equity value for money, and outcomes in global public health, then these opportunities should not be missed