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<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><b><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">Political
Economy of Non‐Communicable Diseases: From Unconventional to Essential. </span></b><span style="font-size:10pt;font-family:"`\0002da\0000c2\00275c\0002c7"">(excerpts)<b><span></span></b></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">Michael R. Reich, Harvard T.H. Chan School of Public Health<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-size:11pt;font-family:"`\0002da\0000c2\00275c\0002c7""><span> </span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">This commentary argues that political economy should become
viewed as a conventional, indeed, an essential outlook for NCDs, and more
broadly<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">for global health. Political economy factors are integral to
the problems of NCDs and<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">therefore must also be integral to the policy responses.<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">I have often argued in my career for more attention to
political economy in public<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">health—for more attention to the political dimensions of health
policy, especially for low and middle‐income countries.</span><span style="font-size:8pt;font-family:"`\0002da\0000c2\00275c\0002c7"">2
</span><span style="font-family:"`\0002da\0000c2\00275c\0002c7""><span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">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. <span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">Some consideration of definitions is necessary to ensure
clarity. In general, most definitions of political economy focus on how the
distributions of political<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">and economic resources affect something we care about:
inequality, economic growth, some specific policy, who controls a country, or
health.</span><span style="font-size:8pt;font-family:"`\0002da\0000c2\00275c\0002c7"">3,4 </span><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">The analysis of the political economy
typically involves consideration of power, along with interests, ideas,
ideologies, and institutions.</span><span style="font-size:8pt;font-family:"`\0002da\0000c2\00275c\0002c7"">5 <span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">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.</span><span style="font-size:8pt;font-family:"`\0002da\0000c2\00275c\0002c7"">7
</span><span style="font-family:"`\0002da\0000c2\00275c\0002c7""><span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">Lasswell reminds us that any process affecting the allocation
of resources in society<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">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.”<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><b><span style="font-family:"`\0002da\0000c2\00275c\0002c7""><br></span></b></p><p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><b><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">USING
POLITICAL ECONOMY TO ANALYZE NCDs<span></span></span></b></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">Three themes: a) commercial enterprises and their role as
drivers of NCDs.<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">b) patient organizations and their role in creating solutions
to NCDs. and<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">c) government agencies and their role in changing the
institutions and actions for NCDs.<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">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. <span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">This approach disaggregates society into specific actors and their
different political<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">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.<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">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.<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><b><span style="font-family:"`\0002da\0000c2\00275c\0002c7""><br></span></b></p><p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><b><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">Theme
#1:</span></b><span style="font-family:"`\0002da\0000c2\00275c\0002c7""> Political economy of changing the determinants of NCDs<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">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.<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">These commercial products have health impacts on NCDs: cancer,
cardiovascular diseases,<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">respiratory diseases, and diabetes. <span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">The new taxes promise a seemingly magical policy solution:
increased flows of new<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">revenues for the government budget and reduced disease burden
and related health<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">expenditure for the targeted NCDs.<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">Recently global policy attention has increased on sin taxes and
NCDs—but that<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">attention has focused on the technical economic aspects of
policy solutions, and overlooked the political economy challenges of
introducing sin taxes. <span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">Introducing sin taxes requires political economy analysis, because
there are huge<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">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.<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">The primary opposition to taxation is transnational companies
and their economically interested allies.<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">What does this look like in practice? One example of this kind
of analysis is research<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">on the successful passage of a soda tax in Mexico. In examining
this topic, <span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">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.<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">It is equally important to understand how industry interests
overpower public<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">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.”</span><span style="font-size:8pt;font-family:"`\0002da\0000c2\00275c\0002c7"">
<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">We thus need better understanding of the political economy of
the commercial<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">determinants of health, including actions that can advance sin
taxes—along with other effective interventions—to promote public health.<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><b><span style="font-family:"`\0002da\0000c2\00275c\0002c7""><br></span></b></p><p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><b><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">Theme
#2: </span></b><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">Political economy of using a systems approach to address NCDs.<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">Changing a health system’s orientation often requires political
struggle. Technical<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">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.<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">One lesson from the world’s experiences with HIV and AIDS is
the critical role of<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">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.<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">I am not suggesting that the social mobilization of people who
are directly affected<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">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?<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">Perhaps the world needs mobilizations of those living with
NCDs, in order to change<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">the political economy of NCDs and change resistant government
and corporate policies.<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">Think about breast cancer. Women with breast cancer and their
families have been<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">a major force worldwide in putting the issue on national policy
agendas and compelling governments to devote more resources to screening,
diagnosis, and treatment. <span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">Think about lung cancer, emphysema and COPD. In social
movements to promote<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">tobacco control, people suffering from smoking‐related
illnesses have played important symbolic roles.<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">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.<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">Social movements of victims have played critical political
roles for major reform<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">efforts in many domains beyond public health. <span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">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.<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">These social movements also play a critical role in changing
the stigma associated<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">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 <span> </span>public issues.<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">It is not easy, however, to take personal troubles into the
public realm, to create a<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">group of common sufferers and transform a health issue into an
effective political<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">mobilization.</span><span style="font-size:8pt;font-family:"`\0002da\0000c2\00275c\0002c7""> </span><span style="font-family:"`\0002da\0000c2\00275c\0002c7""><span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">An additional factor that creates challenges for addressing
NCDs is the lack of<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">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.<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">In sum, we need better understanding of the political economy
of social movements<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">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.<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><b><span style="font-family:"`\0002da\0000c2\00275c\0002c7""><br></span></b></p><p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><b><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">Theme
#3: </span></b><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">Political economy of reforming governance of NCDs.<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">We know from social science that institutions tend to resist
change.</span><span style="font-size:8pt;font-family:"`\0002da\0000c2\00275c\0002c7""> </span><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">Every<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">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.<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">The gap in global governance for NCDs is striking for
international agencies. We<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">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.<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">How are development agencies, such as the World Health
Organization, the US<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">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.<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">At the national level, the governance of NCDs is weak and
confused. Many health<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">systems—particularly in low‐ and middle‐income countries—are
not oriented toward providing NCD‐related services, and remain focused on
infectious diseases. <span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">They all lack trained health workers and essential medicines for
NCDs, and these situations are distinctly worse in rural areas.</span><span style="font-size:8pt;font-family:"`\0002da\0000c2\00275c\0002c7"">2</span><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">In
short, huge gaps exist between what is needed for NCDs and what is provided.<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">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.<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">Many low‐ and middle‐income countries confront similar
challenges for cancer. Lack<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">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. </span><span style="font-size:8pt;font-family:"`\0002da\0000c2\00275c\0002c7""><span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">Deciding how to organize the ministry of health for NCDs is not
easy. One high<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">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?<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">An additional political economy challenge for national action
on NCDs is that<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">interventions are often needed outside the health sector, for
example, on food and<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">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.<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">Setting national priorities and organizing government agencies
for NCDs are<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">political economy processes that we need to understand better
in order to address the governance challenges for NCDs.<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-size:11pt;font-family:"`\0002da\0000c2\00275c\0002c7""><span> </span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><b><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">CONCLUDING
COMMENTS<span></span></span></b></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">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.<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">First, development agencies and foundations need to move from
slogans and<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">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. <span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">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<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">government structures and policies to provide effective
prevention, treatment, and<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">palliative care for NCDs.<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">Third, we need an accountability mechanism for assessing
political economy<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">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.<span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">These are doable efforts. In the short term. <span> </span><span></span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span style="font-family:"`\0002da\0000c2\00275c\0002c7"">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. </span><span></span></p>
<p class="MsoNormal" style="margin:0in 0in 0.0001pt;font-size:12pt;font-family:Cambria"><span> </span></p>
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