Hoffman, S.J. & Røttingen, J.-A., 2015. Global Challenges: Global Health. Global Challenges. PDF
Hoffman, S.J. & Ottersen, T., 2015. Addressing Antibiotic Resistance Requires Robust International Accountability Mechanisms. Journal of Law, Medicine & Ethics , 43 (2) , pp. 53-64. PDFAbstract

A proposed international agreement on antibiotic resistance will depend on robust accountability mechanisms for real-world impact. This article examines the central aspects of accountability relationships in international agreements and lays out ways to strengthen them. We provide a menu of accountability mechanisms that facilitate transparency, oversight, complaint, and enforcement, describe how these mechanisms can promote compliance, and identify key considerations for a proposed international agreement on antibiotic resistance. These insights can be useful for bringing about the revolutionary changes that new international agreements aspire to achieve.

Hoffman, S.J. & So, K., 2015. Assessing 15 Proposals for Promoting Innovation and Access to Medicines Globally. Annals of Global Health , 80 (6) , pp. 432-443. PDFAbstract


There is widespread recognition that the existing global systems for innovation and access to medicines need reform. Billions of people do not have access to the medicines they need, and market failures prevent new drugs from being developed for diseases that primarily affect the global poor. The World Health Organization's Consultative Expert Working Group on Research and Development: Financing and Coordination (CEWG) analyzed numerous proposals for reform. The aim of this article is to build on these previous inquiries.


We conducted a structured analysis that grouped proposals into five broad opportunities for global policy reform to help researchers and decision makers to meaningfully evaluate each proposal in comparison with similar proposals. Proposals were also analyzed along three important dimensions—potential health impact, financial implications, and political feasibility—further facilitating the comparison and application of this information.


Upon analysis, no one solution was deemed a panacea, as many (often competing) considerations need to be taken into account. However, some proposals, particularly product development partnership and prizes, appeared more promising and feasible at this time and deserve further attention.


More research is needed into the effectiveness of these mechanisms and their transferability across jurisdictions.

Hoffman, S.J., Røttingen, J.-A. & Frenk, J., 2015. Assessing Proposals for New Global Health Treaties: An Analytic Framework. American Journal of Public Health , pp. e1-e8. PDFAbstract

We have presented an analytic framework and 4 criteria for assessing when global health treaties have reasonable prospects of yielding net positive effects.

First, there must be a significant transnational dimension to the problem being addressed. Second, the goals should justify the coercive nature of treaties. Third, proposed global health treaties should have a reasonable chance of achieving benefits. Fourth, treaties should be the best commitment mechanism among the many competing alternatives.

Applying this analytic framework to 9 recent calls for new global health treaties revealed that none fully meet the 4 criteria. Efforts aiming to better use or revise existing international instruments may be more productive than is advocating new treaties.

Rizvi, Z. & Hoffman, S.J., 2015. Effective Global Action on Antibiotic Resistance Calls for Careful Consideration of Convening Forums. Journal of Law, Medicine & Ethics , 43 (2) , pp. 74-78. PDFAbstract

Global collective action is needed to address the growing transnational threat of antibiotic resistance (ABR). Some commentators have recommended an international legal agreement as the most promising mechanism for coordinating such action. While much has been said about what must be done to address ABR, far less work has analyzed how or where such collective action should be facilitated - even though the success of any international agreement depends greatly on where it is negotiated and implemented. This article evaluates four different forums that states may use to develop an international legal agreement for antibiotic resistance: (1) a self-organized venue; (2) the World Health Organization; (3) the World Trade Organization; and (4) the United Nations General Assembly. The need for a multisectoral approach and the diverse institutional landscape suggest that an effective response may best be coordinated through linked action pursued through multiple forums.

Hoffman, S.J., Røttingen, J.-A. & Frenk, J., 2015. International Law Has a Role to Play in Addressing Antibiotic Resistance. Journal of Law, Medicine & Ethics , 43 (2) , pp. 65-67. PDFAbstract

If an international legal agreement is needed for any of today's global health challenges, it would be antibiotic resistance (ABR). This challenge is transnational, its solution justifies coercion, tangible benefits are likely to be achieved, and other commitment mechanisms have thus far not been successful. Since addressing ABR depends on near-universal and interdependent collective action across sectors, states should utilize an international legal agreement - which formally represents the strongest commitment mechanism available to them.

Andresen, S. & Hoffman, S.J., 2015. Much Can Be Learned about Addressing Antibiotic Resistance from Multilateral Environmental Agreements. Journal of Law, Medicine & Ethics , 43 (2) , pp. 46-52. PDFAbstract

One of the major global health security issues of our time is antibiotic resistance (ABR). To address this problem much can be learned from our attempts to deal with a different but serious global issue: the environment. Like the environment antibiotic effectiveness can be seen as a common good, since it is finite and it is very difficult to stop people from abusing them inappropriately. Environmental issues have traditionally been handled using multilateral environmental agreements (MEA) between partner nations, political regions, and in some cases the whole globe. Studying these agreements and understanding what works and what does not work can provide a guide of where to begin with the ABR crisis. A brief examination of environmental agreements reveals five institutional design features that appear to be very relevant to the global threat of ABR: (1) robust reporting and verification procedures; (2) must include both sanctions for non-compliance and assistance for implementation; (3) must be designed in such a way to allow maximally ambitious content; (4) should include implementation mechanisms for strengthening political decision-making and securing independent scientific advice; and (5) must contain provisions, obligations, and targets that are as specific, precise, and clear as possible.

Behdinan, A., Hoffman, S.J. & Pearcey, M., 2015. Some Global Policies for Antibiotic Resistance Depend on Legally Binding and Enforceable Commitments. Journal of Law, Medicine & Ethics , 43 (2) , pp. 68-73. PDFAbstract

To address the challenge of antibiotic resistance (ABR), the international community must ensure access, conservation and innovation of antibiotics. These goals can be significantly advanced through ten global policies that have been recommended to form part of an international legal agreement. Policies that could be central to this agreement include the establishment of standards, responsible antibiotic use regulations, and strengthening global surveillance systems. Funding for access, mobilizing resources for infrastructure, strengthening infection control practices, and regulating antibiotic marketing could also be helpful if included in a legal agreement. Incentives for innovation could also be included to mobilize support for its implementation. The inclusion of these policies in an international legal agreement could effectively support global collective action towards several ABR policy goals, some of which may depend on it for their achievement.

Hoffman, S.J. & Røttingen, J.-A., 2015. Assessing the Expected Impact of Global Health Treaties: Evidence from 90 Quantitative Evaluations. American Journal of Public Health , 105 (1) , pp. 26-40. PDFAbstract

We assessed what impact can be expected from global health treaties on the basis of 90 quantitative evaluations of existing treaties on trade, finance, human rights, conflict, and the environment.

It appears treaties consistently succeed in shaping economic matters and consistently fail in achieving social progress. There are at least 3 differences between these domains that point to design characteristics that new global health treaties can incorporate to achieve positive impact: (1) incentives for those with power to act on them; (2) institutions designed to bring edicts into effect; and (3) interests advocating their negotiation, adoption, ratification, and domestic implementation.

Experimental and quasiexperimental evaluations of treaties would provide more information about what can be expected from this type of global intervention.

Hoffman, S.J. & C., T., 2015. Biological, Psychological and Social Processes that Explain Celebrities' Influence on Patients' Health-Related Behaviors. Archives of Public Health , 73 (3) , pp. 1-11. PDFAbstract

BackgroundCelebrities can have substantial influence as medical advisors. However, their impact on public health is equivocal: depending on the advice’s validity and applicability, celebrity engagements can benefit or hinder efforts to educate patients on evidence-based practices and improve their health literacy. This meta-narrative analysis synthesizes multiple disciplinary insights explaining the influence celebrities have on people’s health-related behaviors.

Methods: Systematic searches of electronic databases BusinessSource Complete, Communication & Mass Media Complete, Humanities Abstracts, ProQuest Political Science, PsycINFO, PubMed, and Sociology Abstracts were conducted. Retrieved articles were used to inform a conceptual analysis of the possible processes accounting for the substantial influence celebrities may have as medical advisors.

Results: Fourteen mechanisms of celebrity influence were identified. According to the economics literature, celebrities distinguish endorsed items from competitors and can catalyze herd behavior. Marketing studies tell us that celebrities’ characteristics are transferred to endorsed products, and that the most successful celebrity advisors are those viewed as credible, a perception they can create with their success. Neuroscience research supports these explanations, finding that celebrity endorsements activate brain regions involved in making positive associations, building trust and encoding memories. The psychology literature tells us that celebrity advice conditions people to react positively toward it. People are also inclined to follow celebrities if the advice matches their self-conceptions or if not following it would generate cognitive dissonance. Sociology explains how celebrities’ advice spreads through social networks, how their influence is a manifestation of people’s desire to acquire celebrities’ social capital, and how they affect the ways people acquire and interpret health information.

Conclusion: There are clear and deeply rooted biological, psychological and social processes that explain how celebrities influence people’s health behaviors. With a better understanding of this phenomenon, medical professionals can work to ensure that it is harnessed for good rather than abused for harm. Physicians can discuss with their patients the validity of celebrity advice and share more credible sources of health information. Public health practitioners can debunk celebrities offering unsubstantiated advice or receiving inappropriate financial compensation, and should collaborate with well-meaning celebrities, leveraging their influence to disseminate medical practices of demonstrated benefit.

Hoffman, S.J. & Røttingen, J.-A., 2014. Split WHO in Two: Strengthening Political Decision-Making and Securing Independent Scientific Advice. Public Health Journal , 128 (2) , pp. 188-94. PDFAbstract

The World Health Organization (WHO) has never fulfilled its original mission of simultaneously serving as the world's pre-eminent public health authority and intergovernmental platform for global health negotiations. While WHO's secretariat works hard to fulfill both functions, it is undermined by an institutional design that mixes technical and political mandates. This forces staff to walk uncomfortably along many fine lines: advising but never directing; guiding but never governing; leading but never advocating; evaluating but never judging. The result is mediocrity on both fronts. Instead, WHO should be split in two, separating its technical and political stewardship functions into separate entities, with collaboration in areas of overlap. The Executive Board and secretariat would be bifurcated, with technical units reporting to a Technical Board and political units reporting to a Political Board. Both boards would report to the World Health Assembly where all member states would continue to provide ultimate oversight. Such bold changes can be implemented either by revising WHO's constitution or through simpler mechanisms. Either way, structural governance reforms would need to be accompanied by complementary changes in culture that support strengthened political decision-making and scientific independence. States' inability to act on WHO's institutional design challenges will only lead them and non-state actors to continue bypassing the organization through the creation of new entities as they have done over the last 15 years. The key will be to mobilize those advocates and decision-makers who have the audacity to demand more from WHO and convince member states to elevate their ambitions in current WHO reform efforts. Continued progress in global health depends on it.

Hoffman, S.J. & Røttingen, J.-A., 2013. Dark Sides of the Proposed Framework Convention on Global Health’s Many Virtues: A Systematic Review and Critical Analysis. Health & Human Rights Journal , 15 (1) , pp. 117-134. PDFAbstract

The costs of any proposal for new international law must be fully evaluated and compared with benefits and competing alternatives to ensure adoption will not create more problems than solutions. A systematic review of the research literature was conducted to categorize and assess limitations and unintended negative consequences associated with the proposed Framework Convention on Global Health (FCGH). A critical analysis then interpreted these findings using economic, ethical, legal, and political science perspectives. Of the 442 documents retrieved, nine met the inclusion criteria. Collectively, these documents highlighted that an FCGH could duplicate other efforts, lack feasibility, and have questionable impact. The critical analysis reveals that negative consequences can result from the FCGH’s proposed form of international law and proposed functions of influencing national budgets, realizing health rights and resetting global governance for health. These include the direct costs of international law, opportunity costs, reducing political dialogue by legalizing political interactions, petrifying principles that may have only contemporary relevance, imposing foreign values on less powerful countries, forcing externally defined goals on countries, prioritizing individual rights over population-wide well-being, further complicating global governance for health, weakening the World Health Organization (WHO), reducing participation opportunities for non-state actors, and offering sub-optimal solutions for global health challenges. Four options for revising the FCGH proposal are developed to address its weaknesses and strengthen its potential for impact. These include: 1) abandoning international law as the primary commitment mechanism and instead pursuing agreement towards a less formal “framework for global health”; 2) seeking fundamental constitutional reform of WHO to address gaps in global governance for health; 3) mobilizing for a separate political platform that completely bypasses WHO; or 4) narrowing the scope of sought changes to one particular governance issue such as financing for global health needs.


Hoffman, S.J. & Tan, C., 2013. Following Celebrities' Medical Advice: Meta-Narrative Analysis. British Medical Journal , 347 , pp. f7151. PDFAbstract

Objective: To synthesize what is known about how celebrities influence people’s decisions on health.

Design: Meta-narrative analysis of economics, marketing, psychology, and sociology literatures. 

Data Sources: Systematic searches of electronic databases: BusinessSource Complete (1886-), Communication & Mass Media Complete (1915-), Humanities Abstracts (1984-), ProQuest Political Science (1985-), PsycINFO (1806-), PubMed (1966-), and Sociology Abstracts (1952-). 

Inclusion Criteria: Studies discussing mechanisms of celebrities’ influence on people in any context. 

Results: Economics literature shows that celebrity endorsements act as signals of credibility that differentiate products or ideas from competitors and can catalyze herd behaviour. Marketing studies show that celebrities transfer their desirable attributes to products and use their success to boost their perceived credibility. Psychology shows that people are classically conditioned to react positively to the advice of celebrities, experience cognitive dissonance if they do not, and are influenced by congruencies with their self conceptions. Sociology helps explain the spread of celebrity medical advice as a contagion that diffuses through social networks and people’s desire to acquire celebrities’ social capital. 

Conclusion: The influence of celebrity status is a deeply rooted process that can be harnessed for good or abused for harm. A better understanding of celebrity can empower health professionals to take this phenomenon seriously and use patient encounters to educate the public about sources of health information and their trustworthiness. Public health authorities can use these insights to implement regulations and restrictions on celebrity endorsements and design counter marketing initiatives—perhaps even partnering with celebrities—to discredit bogus medical advice while promoting evidence based practices.

Edge, J.S. & Hoffman, S.J., 2013. Empirical Impact Evaluation of the WHO Global Code of Practice on the International Recruitment of Health Personnel in Australia, Canada, UK and USA. Globalization & Health , 9 (60) , pp. 1-10. PDFAbstract

Background: The active recruitment of health workers from developing countries to developed countries has become a major threat to global health. In an effort to manage this migration, the 63rd World Health Assembly adopted the World Health Organization (WHO) Global Code of Practice on the International Recruitment of Health Personnel in May 2010. While the Code has been lauded as the first globally-applicable regulatory framework for health worker recruitment, its impact has yet to be evaluated. We offer the first empirical evaluation of the Code's impact on national and sub-national actors in Australia, Canada, United Kingdom and United States of America, which are the English-speaking developed countries with the greatest number of migrant health workers.

Methods: 42 key informants from across government, civil society and private sectors were surveyed to measure their awareness of the Code, knowledge of specific changes resulting from it, overall opinion on the effectiveness of non-binding codes, and suggestions to improve this Code's implementation.

Results: 60% of respondents believed their colleagues were not aware of the Code, and 93% reported that no specific changes had been observed in their work as a result of the Code. 86% reported that the Code has not had any meaningful impact on policies, practices or regulations in their countries.

Conclusions: This suggests a gap between awareness of the Code among stakeholders at global forums and the awareness and behaviour of national and sub-national actors. Advocacy and technical guidance for implementing the Code are needed to improve its impact on national decision-makers.

Hoffman, S.J. & Røttingen, J.-A., 2013. Global Health Governance After 2015. The Lancet , 382 (9897) , pp. 1018. PDFAbstract

A proposal to reduce global health architecture to three actors (one to handle financing, one to set norms and standards, and one for advocacy and accountability) will likely not work. In this proposal, other core functions of the global health system, such as monitoring and multi-lateral negotiations, that will be neglected. Assigning advocacy and accountability to one party is not the most effective way to fulfill these functions.

Hoffman, S.J., Røttingen, J.-A. & Frenk, J., 2012. The Economics of New International Health Laws. The Lancet , 380. PDFAbstract

Background: New international laws have been proposed for various health issues, including those related to alcohol, biomedical research, chronic diseases, counterfeit drugs, and obesity. However, international law might not always be an appropriate response to global health challenges. We assessed the costs and consequences of international health law and developed criteria for its just use.

Methods: We used legal, political economy, and ethical frameworks to identify implications of international health laws that are not always considered, especially situations in which risks of negative consequences were particularly great.

Findings: International laws can be blunt instruments with many costs and they can be coercive and paternalistic. Direct costs include many meetings, air travel, legal fees, and support for decision-making bodies and secretariats. Indirect costs include lost opportunities to allocate limited resources to other important issues. Since all laws have costs, international laws cannot be exempt from normal priority-setting processes without justification. We identified four criteria for the use of international law to address global health challenges. The problem that a new international law addresses should be (1) transnational and (2) long term, and legal instruments should be (3) cost effective and (4) justify coercion. To be cost effective, the best-available research should suggest that a new law would provide a better cost to benefit ratio compared with other options. To justify coercion, the proposed law should either address multilateral challenges that cannot practically be addressed by one country only, enable collective action when the costs of common benefits are impractical for any individual state to pursue alone, or support humanitarian principles that are universally held. Use of international health law to dictate poor countries' policies and priorities from afar, or when less costly instruments (eg, non-binding soft laws) might be as effective, is inappropriate.

Interpretation: Not every global health challenge should be addressed with international law. Countries should consider our criteria before adopting new international laws. All available international instruments should be assessed to establish which is best for addressing each global health challenge.

Hoffman, S.J., 2012. Mitigating Inequalities of Influence among States in Global Decision Making: Mitigating Inequalities in Global Decision Making. Global Policy , 3 (4) , pp. 421-432. PDFAbstract

International institutions should be as equal as they claim to be, especially since many of them assert superordinate normative authority based on having egalitarian governance structures. However, when defining equality with respect to states’ real-world influence in determining substantive outcomes, it is evident that there is an equality-influence gap between the rhetoric of parity among states and the reality of international politics. This is problematic because it undermines trust in those international institutions that falsely claim to embody equality among states when empirically they do not. Focusing on the United Nations System, this paper identifies three main causes of this disproportional influence among states in global decision making: (a) external imbalances in political capital; (b) internal economic barriers; and (c) surreptitious influence through non-state actors, funding and training. Six pragmatic strategies are proposed for mitigating these inequalities: (1) building capacity for leadership in global advocacy; (2) supporting global networks owned by developing countries; (3) equalizing multi-party partnerships; (4) facilitating evidence-informed global decision making; (5) enhancing accountability and independent evaluation; and (6) encouraging further discussion on institutional reforms. Notwithstanding sovereign equality’s deep flaws, it is hoped that challenging the egalitarian presumptions of global decision making will encourage further debate on this issue among those who can act upon it.

Hoffman, S.J. ed., 2012. Student Voices 4: Assessing Proposals for Access to Medicines Reform, Hamilton, Ontario, Canada: McMaster Health Forum. PDF
Hoffman, S.J. & Røttingen, J.-A., 2012. Assessing Implementation Mechanisms for an International Agreement on Research and Development for Health Products. Bulletin of the World Health Organization , 90 (11) , pp. 854-63. PDFAbstract

The Member States of the World Health Organization (WHO) are currently debating the substance and form of an international agreement to improve the financing and coordination of research and development (R&D) for health products that meet the needs of developing countries. In addition to considering the content of any possible legal or political agreement, Member States may find it helpful to reflect on the full range of implementation mechanisms available to bring any agreement into effect. These include mechanisms for states to make commitments, administer activities, manage financial contributions, make subsequent decisions, monitor each other's performance and promote compliance. States can make binding or non-binding commitments through conventions, contracts, declarations or institutional reforms. States can administer activities to implement their agreements through international organizations, sub-agencies, joint ventures or self-organizing processes. Finances can be managed through specialized multilateral funds, financial institutions, membership organizations or coordinated self-management. Decisions can be made through unanimity, consensus, equal voting, modified voting or delegation. Oversight can be provided by peer review, expert review, self-reports or civil society. Together, states should select their preferred options across categories of implementation mechanisms, each of which has advantages and disadvantages. The challenge lies in choosing the most effective combinations of mechanisms for supporting an international agreement (or set of agreements) that achieves collective aspirations in a way and at a cost that are both sustainable and acceptable to those involved. In making these decisions, WHO's Member States can benefit from years of experience with these different mechanisms in health and its related sectors.

Hoffman, S.J. & Røttingen, J.-A., 2012. Be Sparing with International Laws. Nature , 483 (7389) , pp. 275. PDF