Gopinathan, U., et al., 2015. Conceptual and Institutional Gaps: Understanding How the WHO can Become a More Effective Cross-Sectoral Collaborator. Globalization and Health , 11 (46) , pp. 1-13. PDFAbstract

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

Tan, C. & Hoffman, S.J., 2015. Overview of Systematic Reviews on the Health-Related Effects of Government Tobacco Control Policies. BMC Public Health , 15 (744) , pp. 1-11. PDFAbstract

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.

Hoffman, S.J., et al., 2015. Strategies for Achieving Global Collective Action on Antimicrobial Resistance. Bulletin for the World Health Organization , 93 (12) , pp. 867-876. PDFAbstract

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. 

Hoffman, S.J. & Silverberg, S.L., 2015. Training the next generation of global health advocates through experiential education: A mixed-methods case study evaluation. Canadian Journal of Public Health , 106 (6) , pp. 442-449. PDFAbstract

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.

Hutton, F.G., et al., 2015. Global Challenges: An Innovative Journal for Tackling Humanity's Major Challenges. Global Challenges. PDF
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.