Global Health Governance and Commercialisation of Public Health in India

Actors, Institutions and the Dialectics of Global and Local

Anuj Kapilashrami, Rama V. Baru, Anuj Kapilashrami, Rama V. Baru

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9780367147693
• eBook ISBN: 9781351049009
• Edition: 1
• Topic: Social Sciences
• Subtopic: Ethnic Studies
• Index: Social Sciences

Global health governance has been the subject of wide scholarship, more recently brought to the fore by priorities for global health defined by the Sustainable Development Agenda. The health landscape itself has changed dramatically in the last two decades, shaped by cross-border flows of capital, ideas, technology intermediated through the complex interaction between global, national and local actors and institutions.

This book analyses the complex terrain of global health governance and local responses to new global forms of integration and fragmentation in India. It unpacks, both conceptually and empirically, local manifestation and translation of global health architecture and regimes and how these processes influence public health policy and practice; as well as to what extent rules and flows are complied with, resisted and transformed at national and sub-national levels. Drawing together critical scholarship on interactions between global and local actors, focusing on processes, dilemmas, conflicts and trade-offs that such engagement presents for national health policies and health systems, it speaks to this interface between the global, national and local.

Filling an important gap in global health governance scholarship in India, the book is a useful contribution to the fields of global health policy, international health and development, health systems, health inequalities, public health, public administration, development studies, social work, nursing, management studies and mainstream social science disciplines that engage with globalisation and health.

1 Introduction

Global Health Governance and Commercialisation of Public Health in India: Actors, Institutions and the Dialectics of Global and Local

Anuj Kapilashrami and Rama V. Baru

Introduction

Global health governance has been the subject of wide scholarship, more recently brought to the fore by renewed attention to global health in the Sustainable Development Agenda. The 17 goals and 169 targets adopted by the United Nations in 2015 reflect a shift in global health priorities from discrete goals around selective diseases to a more broad-based and diversified agenda including tackling health inequalities, ensuring universal coverage and addressing a broad spectrum of non-communicable diseases. Such reframing has implications for the global health landscape, as it demands new ways of defining the problem, and new forms of engagement between actors, funding streams and institutions. While the global health community contends with the changing landscape, there has been little systematic attempt in low- and middle-income countries to examine and collectively debate the myriad ways in which the health landscape, both locally and globally, is being shaped by global- and country-level actors, processes, regulatory environment and the changing nature of health systems.

A defining aspect of globalisation lies in its political sphere. Past decades have witnessed dramatic changes in the world political system and international relations across the globe. This is characterised by growth in number and power of institutions beyond the nation state and intensified engagement between nation states, transnational corporations, multilateral and bilateral agencies, philanthropic institutions and a conglomeration of entities that include grassroot organisations, advocacy networks and academic institutions, often loosely described as ‘civil society’ organisations.

Why is governance important for population health debates?

The health landscape itself has changed dramatically in the last two decades. The drivers of ill health and the disease burden experienced by countries have become globalised for both infectious and non-communicable diseases. New infectious diseases such as Ebola, SARS, pandemic influenza, among others, have emerged and conditions endemic to one region have rapidly spread to newer areas. The responses to these pandemics are no longer traditional mandates of nation states. Several multilateral agencies, private American foundations and other non-state actors are playing an increasingly important role in shaping national policy response to emerging and chronic diseases and in the creation of new regimes of regulation. A variety of commercial actors, mainly transnational corporations, like pharmaceutical companies, the food and beverage industry and financial capital firms have found a prominent place in the architecture of these institutions, while international non-governmental organisations (NGOs) are central to their governance structures. This has given rise to a greater role for public-private partnerships in global health governance. The nature of interactions between the public and the private sector is further changing against the backdrop of progressive liberalisation of trade, through joint ventures and foreign direct investments in healthcare markets. The importance of governance in influencing and regulating these interactions is a neglected topic (Mikkelsen-Lopez et al. 2011) in international, and more so, national public health policy debates.

This changing global health landscape is marked by an unprecedented growth in funding for global health, and growing salience of global health as ‘high politics’ or a foreign policy issue of first-order importance (Fidler and Calamaras 2010). A plethora of new actors – hybrid institutions, networks, alliances and front-line groups – with a ‘global health’ remit have emerged while the old ones have renewed their mandates in alignment with a focus on health. These institutions are actively shaping the global health landscape by exerting influence on policy, choice of technology and health governance at country level through their country presence and structures of implementation. At global level, the rise of these new actors has transformed the role of the World Health Organization (WHO), which until now was the only multilateral agency with the mandate of coordinating efforts to report on and eradicate diseases along with nation states (Ng and Ruger 2011). At country level, these new actors in global health are viewed as leveraging new resources and raising the profile of selective diseases and conditions. However, the new forms of organisation and ‘innovation’ they facilitate have led to the creation of uncoordinated structures and blurred lines of accountability (Kickbush 2000). That said, a more nuanced understanding of the implications of processes of globalisation for population health at country level needs to be situated in the dialectic of the global, the national and the ‘local’, for which an anti-globalist or sceptic vs hyper-globalists dichotomy is unhelpful. An imperialist or impositional perspective has dominated the scant body of international literature that explores country-level implications of donor aid or practices. Such a perspective, one that regards global actors and interests as exerting extraordinary power and influence on the nation state, undermining its sovereignty in the process, is inadequate in capturing this complex relationship.

There is a need to acknowledge that the complex and dialectical interaction between global actors and the nation state or between state and non-state actors is constantly being negotiated, resisted and redefined at multiple levels. A dialectical approach to conceptualising the interaction between global, national and local actors allows an assessment of the multiple sites of power within which these relations are embedded, and the overt and covert ways in which both global and national elites wield such power. These multiple sites and exercises of power are vividly illustrated in the chapter on nutrition policy in India. This chapter reveals technical assistance as one mechanism by which global financial institutions and new age philanthropies direct policy spaces and influence agendas. It also highlights how social movements in health and food security have resisted these developments and policy capture by global agencies and commercial actors. At the same time, several chapters in this book reveal the complicity of not-for-profit actors (global and local) within global public-private assemblages (e.g. PATH in HPV vaccine trials, Save the Children Fund, as well as national NGOs partnering with Coca-Cola and other transnational corporate giants). Here, we contest the divide between for-profit and non-profit civil society entities and reveal diverse interests (and their co-optation) within the ‘civil society’ space. Acknowledging these complex interactions and power dynamics that transcend the global-local as well as the state-market-civil society divide helps to unpack interests and the influence of diverse actors and the resulting contradictions and conflicts that arise in health policy.

The new momentum generated in global health has revealed several deficiencies and challenges to governance, generating sub-optimal outcomes for individual and population health (Fidler 2010). It raises important questions around effectiveness, legitimacy, accountability and (im)balance of power among actors. The new urgency created by the changing landscape and mediocre, at best, progress in health outcomes necessitates an improved understanding of the interactions between global, national and local health governance landscapes and their implications for public health.

We adopt the lens of commercialisation to examine these transformations in the global health landscape and its implications for policy at the national level. The concept of commercialisation allows us to examine the ways in which the rise and diversification of market forces have transformed the public, private ‘for-profit’ and ‘non-profit’ sectors in public health. This has broken down and redefined the rigid boundaries between the three sectors (Mackintosh and Koivusalo 2005), increasing porosity and leading to ‘blurred boundaries’ across the three sectors. The concept of commercialisation is needed in order to capture the complexities in the interaction and intersection between the sectors (Baru and Nundy 2008; Hort and Bloom 2013). Commercialisation and the discourse of new public management served as the premise for the health sector reform (HSR) ideology and agenda of the 1980s. It privileged markets in restructuring the role of the State and its engagement with public health and healthcare policy. The HSR agenda introduced market principles in the health service system and redefined the role of the State in the provisioning of preventive and curative services. Preventive services emphasised the promotion of technologies like vaccines for disease control. This provided opportunities for pharmaceutical and biotechnology companies to expand their markets by engaging with the WHO and national governments. Public health services were restructured. While primary healthcare was still viewed as the responsibility of the State, secondary and tertiary levels were opened to market forces. In low- and middle-income countries, these included the introduction of user fees, contracting in and out of human resources and diagnostics, and fiscal decentralisation. After over three decades of reform in India there is evidence to suggest that these measures further weakened public provisioning leading to inequalities in access and high out-of-pocket expenditures for both out-patient and in-patient care (Baru et al. 2010). These reforms have also restructured public institutions administratively, undermining the normative values that it once represented.

Apart from the health services, public health policy and programmes evidence the multiple ways in which influence is exercised by global and commercial actors and agendas. As discussed earlier, the choice of technologies for prevention have been influenced by pharmaceutical and biotechnology companies. Their links with global and national institutions accord legitimacy for shaping public health policies around the world. Often research funding for newer technologies flows from corporations, multilateral and bilateral agencies to scientific and medical establishments, who in turn influence agenda setting. This is specially noted in the recent initiatives to include several more vaccines into the Indian immunisation programme.

Why India?

According to a leading Indian business national daily, “half the country’s population may not have a toilet at home but is not without a mobile phone” (March 15th, 2012). A similar concern was echoed by the UNDP in research that pointed out that a large share of the Indian population was denied basic sanitation but had access to information technology. It is estimated that India may have more than 314 million mobile phone users (KPMG, 2015) and has surpassed the US to become the world’s second-largest market for smartphones. According to another estimate, the number of internet users totalled nearly 278 million by the end of 2017. The use of the mobile phone epitomises the far reach and deep penetration of information technology in Indian society, not least through its multiple application in banking, commerce, agriculture and more recently, in social sectors such as education and health. The technological revolution in India is seen as a cornerstone for not only its economic growth but also its social development. A case in point is the widespread adoption and use of mobiles and other technology by health workers in rural India to deliver healthcare and information. As we write, India together with China is seen as leading the ‘mobile healthcare revolution’.

Symbols of globalisation abound in daily life in India. Notwithstanding the global diffusion of technologies and advancement of the informational age, significant disparities in health remain and are widening in India. As the opening quote in the preceding paragraph illustrates, India staggers behind in meeting the most basic health needs of its population, while globalisation and liberalisation intensify and deepen the entry of markets in the economic and social sectors including health services.

Global health governance not only provides a framework to analyse the actors and processes of commercialisation but also the challenges that arise out of these complex arrangements involving multiple actors, for governance at the local, national and international levels.

Among developing countries, India is an interesting case where the interaction between global, national and local actors has fundamentally restructured public health policy during the last three decades. This has impacted the choices of technology and diagnostics within communicable and non-communicable disease control programmes. During the same period the health service system was restructured with the introduction of the reform agenda. The health sector reform (HSR) was part of the Structural Adjustment Programme (SAP) of the World Bank in the 1990s that led to the splitting of the State’s role in health services along the lines of ‘public’ and ‘private’ goods. The former was focused on preventive services while in the latter, the role of markets was given greater prominence. The history of SAP and HSR in a democratic polity like India has been fundamentally different from some African countries that had higher debts, greater aid dependency (Michaud & Murray 1994) and authoritarian and dictatorial regimes. In India, the HSR agenda has been marked by contestation and resistance. Resistance came from several quarters of civil society that included political parties, alliances of progressive non-governmental organisations and the academic community. However, the juggernaut of commercialisation has gained a momentum of its own and plays an important role in shaping health policy.

Today, India confronts a huge challenge of governance and democracy. Historically entrenched power hierarchies and divisions along caste, class, gender lines and state politics are compounded by injustices and inequalities deepened with economic globalisation. While India recorded a 30 percent growth in market capitalisation in 2016–2017 alone, inequalities are widening. The World Wealth Report (2017) highlights rapid increases in household debts as well as wealth poverty; over 90 percent of adult population falls in the base of the wealth pyramid with a net worth of less than USD10000 (2017: 51). Sustained medium to high economic growth over the last two decades has not translated into better human development outcomes. The role of the State has weakened in welfare provisioning. This has created a market for the social sectors and opened many newer avenues for the flow of private capital in both economic and social sectors. Consequently, there is a rise in out-of-pocket expenditure that is no longer disaggregated along a rich-poor divide. Rather, one sees a social gradient with a highly differentiated middle class. The power of markets is visible in the way in which the state and the non-state actors have been reconfigured with the intersection between global, national and local capital. Such restructuring has occurred within the context of competing norms and agendas (i.e. calls for self-reliance, swadeshi or economic sovereignty alongside aggressive liberalisation and privatisation) of the Indian state in ‘globalised India’.

Our focus

The collection of chapters in this book is an outcome of a symposium held in September 2014 in New Delhi, India. The symposium was organised by Advances in Research on Globally Accessible Medicine (AROGYAM), an Indo-European research network, and hosted by the Jawaharlal Nehru University, a collaborating institution in the network. The aim of this symposium was to develop shared understandings and sustained dialogue through a research and knowledge hub on global governance and health system issues (led by the editors of this book). Specifically, to examine the complex terrain of global health governance by focusing on global and local actors, mechanisms and processes through which influence is exerted at national and sub-national levels, and its implication for public health policy and practice (and growth in commercialisation) in the Global South, with a specific focus on India. The symposium drew together and facilitated exchange of scholarship from India and Europe that critically examines interactions between global and local actors, focusing on processes, dilemmas and conflicts that this engagement raises for national health policies. The symposium was structured around three plenaries, each introducing one of the three key themes explored in two and a half days through several panel presentations. The three themes were: changing governance paradigms and the role of global institutions in shaping global and national health landscape; the commercial sector’s role and influence in public health (mapped through health service systems, non-communicable diseases [NCDs] and pharmaceutical research); and the role of civil society in countering hegemonic discourses in global health. Full papers presented and discussed at the symposium engaged with substantive issues and questions of accountability, conflicting agendas and interests, and their equity implications at national and sub-national levels while simultaneously challenging the assumptions underpinning global prescriptions. A distinctive aspect of the structure and deliberations at the symposium was an appreciation of the intersections and overlaps in the themes, i.e. how institutions and governance mechanisms in the global health landscape constitute, reinforce and legitimise the growth and practices of the commercial sector and the civil society. It also managed to bring to the fore the contradictions and conflicts between commercial and public health interests and the extent to which governance debates and regimes acknowledge and address these tensions.

The chapters included in this book are a selection of papers presented at the symposium that both describe and analyse the complex interactions and power relations between the global, national and local actors. The common thread that binds these chapters is that they focus on contingencies and tensions arising at this interface of these interactions and how power is manifested and wielded through these. For the purpose of this book, papers are organised under two sections corresponding to two broad thematic strands.

Actors, institutions, practices and implicit agendas: This section focuses on the influx of stakeholders in the global health landscape and the effects produced at national and sub-national levels. It critically examines the institutional mechanisms and regimes that govern practices of global health actors, circulation of commercial interests within global-local and cross-sector interactions and their implications for public health policies. Actors in global health governance are seen as expanding resources and influence, and offering novel opportunities, solutions and innovative mechanisms for cooperation (Buse et al. 2009). New resources and opportunities for broadening decision-making notwithstanding, programmes initiated by these actors reportedly face problems of efficiency, transparency and activity scale-up. While scholarship highlights competition and fragmentation in health service systems and resulting challenges to equity and quality, a counter perspective attributes these effects to the very nature of engagements and institutional pr...

Table of contents

• Cover
• Title
• Copyright
• Contents
• List of tables and figures
• List of contributors
• Foreword by Barbara McPake
• Acknowledgements
• 1 Introduction: Global Health Governance and Commercialisation of Public Health in India: Actors, Institutions and the Dialectics of Global and Local
• Part I Actors, institutional practices and implicit agendas
• Part II The commercialisation of public health
• Index