PHM-Exch> Political Economy of Non‐Communicable Diseases: From Unconventional to Essential.

[Claudio Schuftan]

*Political Economy of Non‐Communicable Diseases: From Unconventional to
Essential. *(excerpts)

Michael R. Reich, Harvard T.H. Chan School of Public Health



This commentary argues that political economy should become viewed as a
conventional, indeed, an essential outlook for NCDs, and more broadly

for global health. Political economy factors are integral to the problems
of NCDs and

therefore must also be integral to the policy responses.

I have often argued in my career for more attention to political economy in
public

health—for more attention to the political dimensions of health policy,
especially for low and middle‐income countries.2

The study of politics remains on the margins in the global health
community, despite decades of scholarship on this topic, while economics
and economic analysis are squarely situated at the center.

Some consideration of definitions is necessary to ensure clarity. In
general, most definitions of political economy focus on how the
distributions of political

and economic resources affect something we care about: inequality, economic
growth, some specific policy, who controls a country, or health.3,4 The
analysis of the political economy typically involves consideration of
power, along with interests, ideas, ideologies, and institutions.5

Let me suggest a definition of political economy, based on the definition
of “politics” that comes from Harold Lasswell, who used it as the title of
his 1936 book: Politics: Who Gets What, When, and How.7

Lasswell reminds us that any process affecting the allocation of resources
in society

inevitably involves politics. The same principle holds for NCD
policies—since NCD policies seek to change who gets what in the health
system and in society. This commentary thus concerns “how the allocations
of political resources and economic resources affect who gets what, when,
and how in relation to NCDs.”


*USING POLITICAL ECONOMY TO ANALYZE NCDs*

Three themes: a) commercial enterprises and their role as drivers of NCDs.

b) patient organizations and their role in creating solutions to NCDs. and

c) government agencies and their role in changing the institutions and
actions for NCDs.

This approach proposes that any effort to discuss the political economy of
NCDs should examine these three actors and how they shape both the problems
and the solutions for NCDs.

This approach disaggregates society into specific actors and their
different political

economy roles. This disaggregation is necessary, because there are so many
actors that can obstruct and facilitate change for NCDs. With this
approach, political economy analysis helps us learn from the past to design
strategies that facilitate the changes we seek in health systems.

This approach highlights the main point of why scientific evidence about
NCDs is not enough to improve health. Political economy analysis and
strategies are also needed to make progress.


*Theme #1:* Political economy of changing the determinants of NCDs

In global health today, the promotion of targeted taxes on harmful
products—“sin taxes”—ranks high on the global health policy agenda for
addressing the determinants of NCDs. The taxes focus on particular
products—especially tobacco, sugary beverages, and alcohol.

These commercial products have health impacts on NCDs: cancer,
cardiovascular diseases,

respiratory diseases, and diabetes.

The new taxes promise a seemingly magical policy solution: increased flows
of new

revenues for the government budget and reduced disease burden and related
health

expenditure for the targeted NCDs.

Recently global policy attention has increased on sin taxes and NCDs—but
that

attention has focused on the technical economic aspects of policy
solutions, and overlooked the political economy challenges of introducing
sin taxes.

Introducing sin taxes requires political economy analysis, because there
are huge

commercial interests that benefit from the production, sale, and
consumption of those products. Introducing sin taxes inevitably triggers a
political struggle with commercial organizations. These industries have
much greater economic and political resources than perpetually
under‐resourced public health advocates. Understanding when and how public
health can win—despite powerful commercial forces—requires political
economy analysis.

The primary opposition to taxation is transnational companies and their
economically interested allies.

What does this look like in practice? One example of this kind of analysis
is research

on the successful passage of a soda tax in Mexico. In examining this topic,

colleagues show how advocates achieved legislative success with this
politically difficult proposal, using political economy analysis, as one
important factor, to decide on strategies to promote the tax and push the
tax through the Mexican Congress.

It is equally important to understand how industry interests overpower
public

health. Susan Greenhalgh recently demonstrated how Coca‐Cola created a
non‐governmental organization in China to shape scientific researchand
public policy over a 15‐year period, as she put it, “making China safe for
Coke” “through a complex web of institutional, financial, and personal
linkages.”

We thus need better understanding of the political economy of the commercial

determinants of health, including actions that can advance sin taxes—along
with other effective interventions—to promote public health.


*Theme #2: *Political economy of using a systems approach to address NCDs.

Changing a health system’s orientation often requires political struggle.
Technical

evidence is usually useful, and frequently necessary, but evidence alone
rarely produces sufficient system change. One key force for change comes
from the people directly harmed by the existing system.

One lesson from the world’s experiences with HIV and AIDS is the critical
role of

affected people in organizing social movements to change public policies.
We can draw many lessons about the political economy of NCDs from their
past experiences. Social movements of people living with HIV/AIDS have
played catalytic roles in changing government rules, regulatory policies,
health care delivery, accountability structures, public perceptions, and
corporate decisions—through direct action, public protest, political
lobbying, and strategic negotiation.

I am not suggesting that the social mobilization of people who are directly
affected

by a disease alone can achieve these policy changes. But I do believe that
civil society’s political pressure (related to their creative use of
symbolic politics, to increase political power) is often a catalytic factor
to change institutions. The question is how do less powerful groups in
society go about changing the policies and the narratives related to NCDs?

Perhaps the world needs mobilizations of those living with NCDs, in order
to change

the political economy of NCDs and change resistant government and corporate
policies.

Think about breast cancer. Women with breast cancer and their families have
been

a major force worldwide in putting the issue on national policy agendas and
compelling governments to devote more resources to screening, diagnosis,
and treatment.

Think about lung cancer, emphysema and COPD. In social movements to promote

tobacco control, people suffering from smoking‐related illnesses have
played important symbolic roles.

Patients and families help change the power dynamics related to NCD
policies, help change the social narrative about responsibility for NCDs,
and influence who gets what, when, anhow for NCDs.

Social movements of victims have played critical political roles for major
reform

efforts in many domains beyond public health.

Social movements of patients may not be necessary for the advancement of
each NCD; for diabetes, for each type of cancer, for different
cardiovascular disease, for mental illness. But I do believe that social
movements can play a catalytic role in changing social values and
narratives and in transforming government and corporate policies, in ways
that can advance efforts to address NCDs.

These social movements also play a critical role in changing the stigma
associated

with NCDs, making it more acceptable to discuss what were once considered
“private” or “family” matters such as mental illness, cancer, and other
NCDs—as  public issues.

It is not easy, however, to take personal troubles into the public realm,
to create a

group of common sufferers and transform a health issue into an effective
political

mobilization.

An additional factor that creates challenges for addressing NCDs is the
lack of

connections across different diseases. Social mobilization on breast cancer
or lung cancer, for example, does not transfer into activism on other NCDs,
such as diabetes or mental health.

In sum, we need better understanding of the political economy of social
movements

of NCDs in diverse national settings, especially understanding how social
movements can put specific illnesses on national policy agendas and can
compel changes in policies and resource allocations.


*Theme #3: *Political economy of reforming governance of NCDs.

We know from social science that institutions tend to resist change. Every

established social system is biased and resists reform. Every system
promotes attention to certain issues and avoids attention to others. Thus,
changing built‐in systemic bias is not easy. Once a system adopts a
particular policy, it is difficult to change that policy because the system
develops positive feedback loops and stakeholders develop strong interests
in maintaining that particular organization of benefits.

The gap in global governance for NCDs is striking for international
agencies. We

have many declarations about giving higher priority to NCDs. But
development assistance still provides very limited resources for NCDs in
low‐ and middle‐income countries.

How are development agencies, such as the World Health Organization, the US

Agency for International Development, and the World Bank, being held
accountable for their calls to increase attention to NCDs? The political
economy of holding multilateral organizations accountable for supporting
health system transitions to NCDs is a critical topic.

At the national level, the governance of NCDs is weak and confused. Many
health

systems—particularly in low‐ and middle‐income countries—are not oriented
toward providing NCD‐related services, and remain focused on infectious
diseases.

They all lack trained health workers and essential medicines for NCDs, and
these situations are distinctly worse in rural areas.2In short, huge gaps
exist between what is needed for NCDs and what is provided.

The core challenge is how to transform existing health systems, with a
continuing focus on infectious diseases, to meet changed patterns of
disease. The NCD tsunami is no longer something to expect; the tsunami has
arrived and most nations’ health systems are not ready. In short, the
epidemiological transition is happening faster than the governmental
transition.

Many low‐ and middle‐income countries confront similar challenges for
cancer. Lack

of resources, lack of equipment, lack of personnel, lack of priority, and
lack of data all add up to late detection, limited capacity to treat, and
large numbers of cancer deaths.

Deciding how to organize the ministry of health for NCDs is not easy. One
high

government official recently asked me: Should there be a separate
government “center” for each NCD? Or a single NCD center, with individual
directors for each NCD? If international aid is not available for NCDs, how
much domestic resources should be used for NCDs, and where can those funds
come from? Should the government introduce a separate sin‐tax for each NCD?
How should the government decide how much to allocate each of the major
diseases? According to the burden of disease, or according to the
effectiveness of interventions, or according to the pressures of different
provider or patient groups?

An additional political economy challenge for national action on NCDs is
that

interventions are often needed outside the health sector, for example, on
food and

agriculture regulation, or in changing the curriculum of schools. These
actions require cross‐ministry collaboration or conversations that can
create significant bureaucratic and budgetary obstacles to effective action.

Setting national priorities and organizing government agencies for NCDs are

political economy processes that we need to understand better in order to
address the governance challenges for NCDs.



*CONCLUDING COMMENTS*

In concluding, I would like to focus on this message: Let’s move political
economy from unconventional to essential in global health, starting with
NCDs. Here are three suggestions.

First, development agencies and foundations need to move from slogans and

lip service to actions and financial support on political economy. Donors
need to make funding available for political economy analyses in health
reform loans and grants, and make these analyses a required part of health
policy development. This will help create a demand for new and improved
methods of analysis and for people trained in political economy.

Second, global health researchers need to direct more attention to the
political economy of NCDs. There is significant room for expansion based on
real‐world practices. Researchers can help explain how effective NCD
policies overcome obstacles of corporate and bureaucratic resistance and
how social movements successfully pursue reforms. We need better insight
into how to change

government structures and policies to provide effective prevention,
treatment, and

palliative care for NCDs.

Third, we need an accountability mechanism for assessing political economy

analyses in practice and in research. In effect, we need a mechanism that
will improve the quality and effectiveness of political economy. This
accountability mechanism could include a clearinghouse of political economy
studies and researchers, a review process to assure high quality political
economy analyses, and an evaluation process to assess the impacts of
different kinds of political economy methods and strategies to assure
effective action.

These are doable efforts. In the short term.

Focused attention will help us advance the place of political economy in
global health. This in turn will help us support people working at the
frontlines in health systems to effectively address NCDs. Policy makers and
policy analysts need to give more attention to the role of political
economy factors in understanding the determinants of NCDs in their
countries and designing effective policy responses for NCDs, as argued in
this article.
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