Promoting Pro-health Policies Across Regimes: Global AIDS Institutions and the Harm Reduction Debate.

Author:Rushton, Simon

IN APRIL 2016, THE UN GENERAL ASSEMBLY HELD A SPECIAL SESSION ON the World Drug Problem (hereinafter, UNGASS 2016). As was probably inevitable, long-standing tensions between proponents of a "prohibitionist" approach to narcotic control and those promoting "harm reduction" resurfaced during this meeting. The major multilateral global AIDS institutions--the Joint UN Programme on HIV/AIDS (UNAIDS); the Global Fund to Fight AIDS, Tuberculosis, and Malaria (the Global Fund); and the World Health Organization (WHO)--have long been vocal participants in this debate, seeking to draw attention to the important role that harm reduction initiatives such as needle exchange programs and opioid substitution therapy (OST) play in HIV prevention, and highlighting the extent to which prohibitionist approaches exacerbate the stigma and discrimination that present barriers to effective HIV prevention. Yet these arguments so far have not been sufficient to deliver a fundamental change in the orientation of the global narcotics control regime.

In this article, I use this ongoing policy debate as a lens to examine the complex relationships between global health governance and the global governance of other issue areas at what has been termed global health governance's horizontal interfaces. I argue that both material and ideational power matter at these interfaces and that, despite adopting what might be expected to be a persuasive advocacy approach, the change that global health actors have so far achieved has been limited. Understanding how power and influence operate at such interfaces is crucial to understanding the potential for global health institutions to successfully promote prohealth policies.

I begin the article by briefly examining the existing literature's conceptualization of global health governance and its interfaces with other global regimes. I also introduce the concept of framing, which has been seen by many as being an effective strategy for forwarding pro-health policies. Next, I sketch out the historical development of a "prohibitionist orthodoxy" in relation to narcotics control, the ways in which that orthodoxy has been attacked by proponents of harm reduction, and the progress (limited, but not entirely absent) that harm reductionists have made in recent global discussions on narcotics control. Then I look at the ways in which UNAIDS, the WHO, and the Global Fund have promoted harm reduction and argue that they have collectively pursued a two-pronged advocacy strategy that seeks to reframe the debate in terms of public health and human rights rather than law and order and security. Finally, I propose a series of insights that this case can offer to scholars of global health governance. These relate to the agency of global health governance actors, the power of framing, and the extent to which material (resource-based) levers offer alternative avenues for precipitating policy change.

Global Health Governance, Interfaces, and Framing

Although global health governance has in recent years become a growing area of scholarly interest, (1) there remain significant gaps in our understanding. In particular, I argue that although the existing literature provides a good basis for understanding the internal dynamics of global health governance (including the range of actors involved, the key fora in which decisions are made, and the ways in which the governance architecture has developed over recent decades), far less progress has been made so far on interrogating the ways in which it relates to other areas of global governance.

Examining such interfaces rests on an ability to define the boundaries of global health governance in order to determine what falls "inside" and "outside" and, thus, where the interfaces lie. Much time and ink has been expended on defining global health governance without producing a single agreed definition. Indeed, in 2014, Kelley Lee and Adam Kamradt-Scott identified over a thousand scholarly works that had used the term and a wide range of ontological variation. They categorized this variation according to three broad concepts: (1) "globalization and global health governance," which concerns the ways in which global-level health institutions respond to the challenges of an increasingly globalized world; (2) "global governance and health," which addresses "how global governance institutions outside of the health sector have influenced the broad social and economic determinants of health"; and (3) "global governance for health," a more normative term that encompasses "seeking to achieve particular goals such as access to medicines, health equity or primary health care or principles such as human rights and social justice." (2)

While such variation under a single terminological banner may bring the danger of conceptual imprecision, one of the starting points of my analysis is that all three of the categories identified by Lee and Kamradt-Scott are important for understanding the contemporary global politics of health. Global health governance actors (in which we may include multilateral bodies such as the WHO but also transnational civil society groups, global health partnerships, philanthropies, and others whose remit focuses on achieving health goals) are indeed involved in attempting to respond to globalization-related health challenges. They do so within a context in which other state-level and global-level institutions outside of the health sector have significant health impacts, (3) and they are frequently engaged in forwarding particular normative ideas in pursuit of improving health, which we might call "pro-health policies." In this article, my primary concern is with the ways in which global health institutions (Lee and Kamradt-Scott's category 1) that are attempting to promote particular pro-health policies (category 3) relate to other global-level nonhealth regimes (category 2). In the remainder of this section, I utilize existing conceptual work on global health governance (much of which in turn draws on the wider global governance literature) to set out two concepts that provide a way of interrogating these dynamics: interfaces and framing.

Drawing on the literature on multilevel governance, (4) and particularly the application of those ideas at the global governance level, (5) as well as Norman Long's work on "social interfaces," (6) Wolfgang Hein, Sonja Bartsch, and Lars Kohlmorgen use the concept of "interfaces" to examine linkages within global health governance ("vertical" interfaces between global-and national-level policymaking processes) and "horizontal" interfaces between spheres of governance. (7) These interfaces, they argue, can sometimes be characterized by cooperation, sometimes by conflict. (8) In common with the vast majority of the work in global health that has examined the relationship between global health governance and nonhealth sectors, (9) they pay particular attention to the global governance of trade, especially issues around AIDS medicines and the intellectual property regime. (10) Hein found that in this area global health governance has made progress even in the face of a "World Trade Order," but also that power disparities across various kinds of interfaces--discoursive, legal, organizational, and resource-based--continue to strongly influence policy outcomes. (11) Thus, for a variety of reasons, global health governance actors can fail to successfully promote pro-health policies. These failures, however, are not always the result of material power asymmetries and cannot (as realist scholars might argue) always be explained through the operation of state power in pursuit of predetermined national interests. Central to Long's sociological work on interfaces (12) (and equally central to social constructivist approaches to international relations (13)) is the idea that during processes of interaction, the ideas and perceived interests of the various actors involved can be changed. Thus, in the area of access to medicines, it was possible, for example, for global health institutions (including civil society actors) to make headway in the face of an intellectual property regime initially opposed to their policy prescriptions.

A common claim in much of the existing social constructivist literature is that one of the ways in which ideas and interests may change is through successfully (re)framing an issue in persuasive ways (in Hein, Bartsch, and Kohlmorgen's terminology, this relates to the "discoursive interface" (14)). Frames are understood here as linguistic, cognitive, and symbolic devices used to identify, label, describe, and interpret problems and to suggest particular ways of responding to them. (15) The international relations literature on global health governance, much of which has explicitly pursued a social constructivist approach, has made extensive use of the concept of framing to analyze advocacy and policy change. (16) It has been argued that the concept can help us understand the ways in which global health problems are represented and come to be understood, which in turn can lead to an issue being prioritized (or not) and avenues for policy responses being opened up or foreclosed. (17)

A particular preoccupation of global health governance scholars has been with "discoursive interfaces," especially the way in which different framings of the same health problem (as an issue of security, economics, or human rights, for example (18)) compete, how some frames may be more influential than others in policy debates, and how the dominance of particular framings of a global health issue can shape global responses. The work of "norm entrepreneurs" or "policy entrepreneurs" in forwarding particular frames to justify their preferred responses has been widely studied within and beyond global health, (19) with frames being seen as important discursive tools for promoting particular courses of action either between global governance...

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