The rapid proliferation of international institutions has been a defining feature of the postwar international architecture. Since the end of the Second World War, the international system has seen the creation of thousands of international treaties and organizations that have established rules governing a multitude of issues that range from international security to human rights, and from international trade to the environment.
The concept of an institutional bypass—that is, creating a parallel institution that performs exactly the same function of the dysfunctional institution—has already proven useful for analyzing institutional reforms undertaken at the domestic level. However, it has only recently been suggested as potentially applicable to the global governance context as well. To explore this possibility further, this project brought together a group of researchers who specialize in international governance and asked them whether the concept could be applied to their respective areas of expertise.
Among other things, these discussions revealed at least one major challenge with the use of institutional bypasses in the international context: while the possibility of “bypassing” existing institutions may be counterintuitive in the domestic sphere, it may actually constitute the norm, rather than the exception, in international governance. This is because sovereign states are often assumed to hold a monopoly in the provision of certain services and the performance of certain functions at the domestic level, as is notably the case with policing. Thus, recognizing that states can operate parallel institutions side by side, and in some cases even make them compete with each other, may constitute a paradigm shift for those concerned with institutional reforms and good governance in the domestic sphere. However, this same assumed monopoly does not exist in international governance, where academic researchers have extensively documented the related phenomena of institutional proliferation and duplication.
Accordingly, a question arises as to what value, if any, the concept of institutional bypasses can provide to the existing international governance literature. This is the first—and perhaps the main—challenge in applying the concept of institutional bypasses at the international level, especially since the phenomenon of institutional proliferation and duplication has already been extensively described and scrutinized across multiple disciplines, including law, political science, and sociology. The framing essay in this symposium attempts to provide an answer to this question by presenting a definition of international institutional bypasses, all the while articulating why this concept may prove useful to work on global governance.
Having framed the scope of our project, the other essays in this symposium provide three sets of examples that illustrate the application of international institutional bypasses. The first takes the form of the New Development Bank and the Asian Infrastructure Investment Bank, which serve as bypasses of the World Bank and the Asian Development Bank, respectively. The second set of examples are regional swap lines and regional central banks, which are presented as bypasses of the International Monetary Fund (IMF). Finally, regional institutions in West Africa, and particularly those providing health services, are framed as bypasses of domestic institutions that serve the same functions.
Taken together, these three sets of examples offer interesting illustrations of what we call “horizontal” and “vertical” international bypasses. The former refers to those bypasses that operate within the same jurisdiction as the dominant institution, as in the case of the China-led multilateral development banks that serve as international bypasses of a dominant international institution. By contrast, a vertical bypass means that the dominant institution and the bypass are located at different jurisdictional levels. This notion includes a domestic or a regional institution that tries to bypass an international one, or vice-versa. The international institution can thus be either the dominant institution being bypassed, as illustrated by the IMF essay, or the bypassing one, as illustrated by the West African Health Organization essay.
In summary, our aim in this symposium is to introduce readers to the concept of international institutional bypasses, provide concrete examples, and show that this concept can be of great value in attempts to understand and analyze changes and innovations in global governance. That being said, this is only the first step in a much larger and more ambitious project. Thus, we hope it will also serve as an invitation for readers to further explore the many interesting questions and implications of institutional bypasses in the international context
Background: Antimicrobial resistance (AMR) is a global issue. International trade, travel, agricultural practices, and environmental contamination all make it possible for resistant microbes to cross national borders. Global collective action is needed in the form of an international agreement or other mechanism that brings states together at the negotiation table and commits them to adopt or implement policies to limit the spread of resistant microorganisms. This article describes an approach to assessing whether political and stakeholder interests can align to commit to tackling AMR.
Methods: Two dimensions affecting political feasibility were selected and compared across 82 countries: 1) states’ global influence and 2) self-interest in addressing AMR. World Bank GDP ranking was used as a proxy for global influence, while human antibiotic consumption (10-year percent change) was used as a proxy for self-interest in addressing AMR. We used these data to outline a typology of four country archetypes, and discuss how these archetypes can be used to understand whether a proposed agreement may have sufficient support to be politically feasible.
Results: Four types of countries exist within our proposed typology: 1) wealthy countries who have the expertise and financial resources to push for global collective action on AMR, 2) wealthy countries who need to act on AMR, 3) countries who require external assistance to act on AMR, and 4) neutral countries who may support action where applicable. Any international agreement will require substantial support from countries of the first type to lead global action, and from countries of the second type who have large increasing antimicrobial consumption levels. A large number of barriers exist that could derail efforts towards global collective action on AMR; issues of capacity, infrastructure, regulation, and stakeholder interests will need to be addressed in coordination with other actors to achieve an agreement on AMR.
Conclusions: Achieving a global agreement on access, conservation, and innovation – the three pillars of AMR – will not be easy. However, smaller core groups of interested Initiator and Pivotal Countries could develop policy and resolve many issues. If highly influential countries take the lead, agreements could then be scaled up to achieve global action.
Keywords: AMR, Antibiotic Resistance, Global Health, Political Feasibility, International Affairs
Shortages of health workers in low-income countries are exacerbated by the international migration of health workers to more affluent countries. This problem is compounded by the active recruitment of health workers by destination countries, particularly Australia, Canada, UK and USA. The World Health Organization (WHO) adopted a voluntary Code of Practice in May 2010 to mitigate tensions between health workers’ right to migrate and the shortage of health workers in source countries. The first empirical impact evaluation of this Code was conducted 11-months after its adoption and demonstrated a lack of impact on health workforce recruitment policy and practice in the short-term. This second empirical impact evaluation was conducted 4-years post-adoption using the same methodology to determine whether there have been any changes in the perceived utility, applicability, and implementation of the Code in the medium-term.
Forty-four respondents representing government, civil society and the private sector from Australia, Canada, UK and USA completed an email-based survey evaluating their awareness of the Code, perceived impact, changes to policy or recruitment practices resulting from the Code, and the effectiveness of non-binding Codes generally. The same survey instrument from the original study was used to facilitate direct comparability of responses. Key lessons were identified through thematic analysis.
The main findings between the initial impact evaluation and the current one are unchanged. Both sets of key informants reported no significant policy or regulatory changes to health worker recruitment in their countries as a direct result of the Code due to its lack of incentives, institutional mechanisms and interest mobilizers. Participants emphasized the existence of previous bilateral and regional Codes, the WHO Code’s non-binding nature, and the primacy of competing domestic healthcare priorities in explaining this perceived lack of impact.
The Code has probably still not produced the tangible improvements in health worker flows it aspired to achieve. Several actions, including a focus on developing bilateral codes, linking the Code to topical global priorities, and reframing the Code’s purpose to emphasize health system sustainability, are proposed to improve the Code’s uptake and impact.
Health worker recruitment Migration Health systems sustainability Impact evaluation World Health Organization
In the fall of 2014, the Government of Canada formally split the role of the Chief Public Health Officer (CPHO) into two positions: the CPHO and the President of the Public Health Agency of Canada. Despite concerns raised by the public health community, these changes are consistent with the CPHO's authority. However, the nature of responsible government means that the CPHO cannot simultaneously serve as an independent advocate for policies and programs that might prevent disease and as a senior advisor to the government of the day.
À l'automne 2014, le gouvernement du Canada a annoncé le dédoublement officiel du rôle de l'Administrateur en chef de la santé publique (ACSP) en deux postes : l'ACSP et le président de l'Agence de la santé publique du Canada. Malgré les inquiétudes exprimées dans les milieux de la santé publique, ces changements sont compatibles avec le mandat original de l'ACSP. La nature d'un gouvernement responsable suppose que l'ACSP ne peut à la fois s'instituer en champion indépendant de politiques ou de programmes favorables à la santé et conserver son rôle de conseiller principal du gouvernement du jour.
Epidemics are among the greatest threats to humanity, and the International Health Regulations are the world's key legal instrument for addressing this threat. Since their revision in 2005, the IHR have faced two big tests: the 2009 H1N1 influenza pandemic and the 2014 Ebola epidemic in West Africa. Both exposed major shortcomings of the IHR, and both offered profound lessons for the future.
The objective of this Article is twofold. First, we seek to compare the lessons learned from H1N1 and Ebola for reforming the IHR in order to test the hypothesis that they are similar. Second, we seek to examine the barriers to implementing these lessons and to identify strategies for overcoming those barriers.
We find that the lessons from H1N1 and Ebola are indeed similar, and that opportunities to act on lessons from H1N1 were woefully missed. We identify many political barriers to global collective action and implementation of lessons for the IHR. On that basis, we describe strategies to overcome these barriers, which will hopefully be deployed now to reform the IHR before the policy window following Ebola closes, and before the inevitable next epidemic comes. The emerging threat of the Zika virus underscores that we have no time to waste.
It is widely agreed that the practices of clinicians should be based on the best available research evidence, but too often this evidence is not reliably disseminated to people who can make use of it. This “know-do” gap leads to ineffective resource use and suboptimal provision of services, which is especially problematic in low- and middle-income countries (LMICs) which face greater resource limitations. Family planning, including intrauterine device (IUD) use, represents an important area to evaluate clinicians’ knowledge and practices in order to make improvements.
A questionnaire was developed, tested and administered to 438 individuals in China (n = 115), Kazakhstan (n = 110), Laos (n = 105), and Mexico (n = 108). The participants responded to ten questions assessing knowledge and practices relating to contraception and IUDs, and a series of questions used to determine their individual characteristics and working context. Ordinal logistic regressions were conducted with knowledge and practices as dependent variables.
Overall, a 96 % response rate was achieved (n = 438/458). Only 2.8 % of respondents were able to correctly answer all five knowledge-testing questions, and only 0.9 % self-reported “often” undertaking all four recommended clinical practices and “never” performing the one practice that was contrary to recommendation. Statistically significant factors associated with knowledge scores included: 1) having a masters or doctorate degree; and 2) often reading scientific journals from high-income countries. Significant factors associated with recommended practices included: 1) training in critically appraising systematic reviews; 2) training in the care of patients with IUDs; 3) believing that research performed in their own country is above average or excellent in quality; 4) being based in a facility operated by an NGO; and 5) having the view that higher quality available research is important to improving their work.
This analysis supports previous work emphasizing the need for improved knowledge and practices among clinicians concerning the use of IUDs for family planning. It also identifies areas in which targeted interventions may prove effective. Assessing opportunities for increasing education and training programs for clinicians in research and IUD provision could prove to be particularly effective.
Keywords: Family planning, Intrauterine device, Global health, Knowledge translation, Health professionals, Medical education, Systematic reviews, Health systems, Health human resources
To develop and validate a method for automatically quantifying the scientific quality and sensationalism of individual news records.
After retrieving 163,433 news records mentioning the Severe Acute Respiratory Syndrome (SARS) and H1N1 pandemics, a maximum entropy model for inductive machine learning was used to identify relationships among 500 randomly sampled news records that correlated with systematic human assessments of their scientific quality and sensationalism. These relationships were then computationally applied to automatically classify 10,000 additional randomly sampled news records. The model was validated by randomly sampling 200 records and comparing human assessments of them to the computer assessments.
The computer model correctly assessed the relevance of 86% of news records, the quality of 65% of records, and the sensationalism of 73% of records, as compared to human assessments. Overall, the scientific quality of SARS and H1N1 news media coverage had potentially important shortcomings, but coverage was not too sensationalizing. Coverage slightly improved between the two pandemics.
Automated methods can evaluate news records faster, cheaper, and possibly better than humans. The specific procedure implemented in this study can at the very least identify subsets of news records that are far more likely to have particular scientific and discursive qualities.
Research evidence continues to reveal findings important for health professionals' clinical practices, yet it is not consistently disseminated to those who can use it. The resulting deficits in knowledge and service provision may be especially pronounced in low- and middle-income countries that have greater resource constraints. Tuberculosis treatment is an important area for assessing professionals' knowledge and practices because of the effectiveness of existing treatments and recognized gaps in professionals' knowledge about treatment. This study surveyed 384 health professionals in China, India, Iran, and Mexico on their knowledge and practices related to tuberculosis treatment. Few respondents correctly answered all five knowledge questions (12%) or self-reported performing all five recommended clinical practices “often or very often” (3%). Factors associated with higher knowledge scores included clinical specialization and working with researchers. Factors associated with better practices included training in the care of tuberculosis patients, being based in a hospital, trusting reviews of randomized controlled double-blind trials, and reading summaries of articles, reports, and reviews. This study highlights several strategies that may prove effective in improving health professionals' knowledge and practices related to tuberculosis treatment. Facilitating interactions with researchers and training in acquiring systematic reviews may be especially helpful.
Disclaimer: The views expressed in this article are those of the authors and do not necessarily represent the decisions, policies, or views of the World Health Organization.
Background: In recent years, there have been numerous calls for global institutions to develop and enforce new international laws. International laws are, however, often blunt instruments with many uncertain benefits, costs, risks of harm, and trade-offs. Thus, they are probably not always appropriate solutions to global health challenges. Given these uncertainties and international law’s potential importance for improving global health, the paucity of synthesized evidence addressing whether international laws achieve their intended effects or whether they are superior in comparison to other approaches is problematic.
Methods: Ten electronic bibliographic databases were searched using predefined search strategies, including MEDLINE, Global Health, CINAHL, Applied Social Sciences Index and Abstracts, Dissertations and Theses, International Bibliography of Social Sciences, International Political Science Abstracts, Social Sciences Abstracts, Social Sciences Citation Index, PAIS International, and Worldwide Political Science Abstracts. Two reviewers will independently screen titles and abstracts using predefined inclusion criteria. Pairs of reviewers will then independently screen the full-text of articles for inclusion using predefined inclusion criteria and then independently extract data and assess risk of bias for included studies. Where feasible, results will be pooled through subgroup analyses, meta-analyses, and meta-regression techniques.
Discussion: The findings of this review will contribute to a better understanding of the expected benefits and possible harms of using international law to address different kinds of problems, thereby providing important evidence-informed guidance on when and how it can be effectively introduced and implemented by countries and global institutions.
Securing access to effective antimicrobials is one of the greatest challenges today. Until now, efforts to address this issue have been isolated and uncoordinated, with little focus on sustainable and international solutions. Global collective action is necessary to improve access to life-saving antimicrobials, conserving them, and ensuring continued innovation. Access, conservation, and innovation are beneficial when achieved independently, but much more effective and sustainable if implemented in concert within and across countries. WHO alone will not be able to drive these actions. It will require a multisector response (including the health, agriculture, and veterinary sectors), global coordination, and financing mechanisms with sufficient mandates, authority, resources, and power. Fortunately, securing access to effective antimicrobials has finally gained a place on the global political agenda, and we call on policy makers to develop, endorse, and finance new global institutional arrangements that can ensure robust implementation and bold collective action.
Background: Two themes consistently emerge from the broad range of academics, policymakers and opinion leaders who have proposed changes to the World Health Organization (WHO): that reform efforts are too slow, and that they do too little to strengthen WHO’s capacity to facilitate cross-sectoral collaboration. This study seeks to identify possible explanations for the challenges WHO faces in addressing the broader determinants of health, and the potential opportunities for working across sectors.
Methods: This qualitative study used a mixed methods approach of semi-structured interviews and document review. Five interviewees were selected by stratified purposive sampling within a sampling frame of approximately 45 potential interviewees, and a targeted document review was conducted. All interviewees were senior WHO staff at the department director level or above. Thematic analysis was used to analyze data from interview transcripts, field notes, and the document review, and data coded during the analysis was analyzed against three central research questions. First, how does WHO conceptualize its mandate in global health? Second, what are the barriers and enablers to enhancing cross-sectoral collaboration between WHO and other intergovernmental organizations? Third, how do the dominant conceptual frames and the identified barriers and enablers to cross-sectoral collaboration interact?
Results: Analysis of the interviews and documents revealed three main themes: 1) WHO’s role must evolve to meet the global challenges and societal changes of the 21st century; 2) WHO’s cross-sectoral engagement is hampered internally by a dominant biomedical view of health, and the prevailing institutions and incentives that entrench this view; and 3) WHO’s cross-sectoral engagement is hampered externally by siloed areas of focus for each intergovernmental organization, and the lack of adequate conceptual frameworks and institutional mechanisms to facilitate engagement across siloes.
Conclusion: There are a number of external and internal pressures on WHO which have created an organizational culture and operational structure that focuses on a narrow, technical approach to global health, prioritizing disease-based, siloed interventions over more complex approaches that span sectors. The broader approach to promoting human health and wellbeing, which is conceptualized in WHO’s constitution, requires cultural and institutional changes for it to be fully implemented.
Keywords: World Health Organization, United Nations, Global governance, Global health governance, Global governance for health, Social determinants of health, Health in all policies, WHO reform, Cross-sectoral collaboration
Background: Government interventions are critical to addressing the global tobacco epidemic, a major public health problem that continues to deepen. We systematically synthesize research evidence on the effectiveness of government tobacco control policies promoted by the Framework Convention on Tobacco Control (FCTC), supporting the implementation of this international treaty on the tenth anniversary of it entering into force.
Methods: An overview of systematic reviews was prepared through systematic searches of five electronic databases, published up to March 2014. Additional reviews were retrieved from monthly updates until August 2014, consultations with tobacco control experts and a targeted search for reviews on mass media interventions. Reviews were assessed according to predefined inclusion criteria, and ratings of methodological quality were either extracted from source databases or independently scored.
Results: Of 612 reviews retrieved, 45 reviews met the inclusion criteria and 14 more were identified from monthly updates, expert consultations and a targeted search, resulting in 59 included reviews summarizing over 1150 primary studies. The 38 strong and moderate quality reviews published since 2000 were prioritized in the qualitative synthesis. Protecting people from tobacco smoke was the most strongly supported government intervention, with smoke-free policies associated with decreased smoking behaviour, secondhand smoke exposure and adverse health outcomes. Raising taxes on tobacco products also consistently demonstrated reductions in smoking behaviour. Tobacco product packaging interventions and anti-tobacco mass media campaigns may decrease smoking behaviour, with the latter likely an important part of larger multicomponent programs. Financial interventions for smoking cessation are most effective when targeted at smokers to reduce the cost of cessation products, but incentivizing quitting may be effective as well. Although the findings for bans on tobacco advertising were inconclusive, other evidence suggests they remain an important intervention.
Conclusion: When designing and implementing tobacco control programs, governments should prioritize smoking bans and price increases of tobacco products followed by other interventions. Additional studies are needed on the various factors that can influence a policy’s effectiveness and feasibility such as cost, local context, political barriers and implementation strategies.
Global governance and market failures mean that it is not possible to ensure access to antimicrobial medicines of sustainable effectiveness. Many people work to overcome these failures, but their institutions and initiatives are insufficiently coordinated, led and financed. Options for promoting global collective action on antimicrobial access and effectiveness include building institutions, crafting incentives and mobilizing interests. No single option is sufficient to tackle all the challenges associated with antimicrobial resistance. Promising institutional options include monitored milestones and an interagency task force. A global pooled fund could be used to craft incentives and a special representative nominated as an interest mobilizer. There are three policy components to the problem of antimicrobials – ensuring access, conservation and innovation. To address all three components, the right mix of options needs to be matched with an effective forum and may need to be supported by an international legal framework.
Objectives: This case study evaluates a global health education experience aimed at training the next generation of global health advocates. Demand and interest in global health among Canadian students is well documented, despite the difficulty in integrating meaningful experiences into curricula.
Methods: Global health advocacy was taught to 19 undergraduate students at McMaster University through an experiential education course, during which they developed a national advocacy campaign on global access to medicines. A quantitative survey and an analysis of social network dynamics were conducted, along with a qualitative analysis of written work and course evaluations. Data were interpreted through a thematic synthesis approach.
Results: Themes were identified related to students’ learning outcomes, experience and class dynamics. The experiential education format helped students gain authentic, real-world experience in global health advocacy and leadership. The tangible implications for their course work was a key motivating factor. While experiential education is an effective tool for some learning outcomes, it is not suitable for all. As well, group dynamics and evaluation methods affect the learning environment.
Conclusion: Real-world global health issues, public health practice and advocacy approaches can be effectively taught through experiential education, alongside skills like communication and professionalism. Students developed a nuanced understanding of many strategies, challenges and barriers that exist in advocating for public health ideas. These experiences are potentially empowering and confidence-building despite the heavy time commitment they require. Attention should be given to how such experiences are designed, as course dynamics and grading structure significantly influence students’ experience.
Key words: Experiential learning; education; global health; health policy.