'State activity is vital to global health success'
Our increasingly globalized world is shifting and shaping the discourse of global health governance. This ever-changing landscape has massive implications for policies and health governance (Buse, Mays, and Walt 2009). Walt and Gilson conceptualize how policies are created by using the policy analysis "triangle" (Walt and Gilson 1994). At each point of the triangle stands one concept, for example, 'content' referring to the content of the health policy, 'context' for the climate within which the policy takes form, and 'policy process,' where governance resides (Walt and Gilson 1994). At the center of the triangle are 'policy actors.'
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The crowding of this section of the triangle pushes researchers and critics to question the role of the nation-state. Furthermore, the literature on global health governance increasingly questions the value of "state-based frameworks in the provision of health" (Ricci 2009). Because other policy actors mirror the role of nation-states in the provision of care, it creates some confusion around the exact role played by nation-states in the governance of global health (Ricci 2009). We can see this play out especially in low and middle-income countries (LMICs) where the relationship between the state and aid agencies is unclear (Galway, Corbett, and Zeng 2012). Thus, it becomes evident as to why the literature seeks to stress and question the role of the state in global health; "with the increased participation by a range of nonstate and transnational actors as primarily driven by globalization, the international has become the global" and structures of governance are unclear (Ricci 2009).
While global health actors like the private sector and philanthropic organizations, such as The Bill and Melinda Gates Foundation, may contribute to the decision-making process, nation-states' participation is vital in setting the agenda, formulating the policy, adopting said policy, implementing and, finally, evaluating the policy (Walt and Gilson 1994; Ricci 2009).
Ricci notes that the global health community lost confidence in states being major global health actors after the 2003 severe acute respiratory syndrome (SARS) outbreak and its mismanagement in China and around the world (Ricci 2009). Ricci goes on to argue that despite all the missteps by nation-states, they remain key players in the governance of global health while the literature places too much weight on the notion that health authority and activity is moving from the control of sovereign states and into the lap of other global health actors (Ricci 2009).
Regardless of the complex nature of global health governance, it "should not obscure the fact that the state, irrespective of practical, ethical, or moral failings, still remains the organizing principle to which individuals and social units aspire and, importantly, through which international health issues are addressed" (Ricci 2009). Furthermore, Harnan posits that nation-states are the "primary site of global health governance" (Harman 2012). She elaborates by claiming that the state's key role in global health is by being the arena in which global health activities are enacted (Harman 2012). I am in alignment with Harnan and argue that state activity is vital to the success of global health.
Once a key player among a handful of global health actors, the effects of globalization and the various frameworks used to discuss health concerns sparked a new wave of actors onto the scene. The phenomenon shifts the governance structure from a Westphalian model where states are the dominant actors to a Post-Westphalian system in which other actors are seen as 'competitors' to nation-states (Buse, Mays, and Walt 2009). This begs the question, what is the role of nation-states? Gerth and Mills describe the state as "a human community that successfully claims the monopoly of the legitimate use of physical force within a given territory" ("What Is The Role Of The State?" 2018). Furthermore, the state is made up of a governing body that drafts and passes laws to protect its population ("What Is The Role Of The State?" 2018).
Responsible and accountable for achieving health goals and targets, nation-states are health stewards. Depending on the context and content, nation-states lead in the development of health policies, set and reinforce best practices and standards, and play a key part in the implementation process (Ricci 2009). In the subsequent pages, I will discuss the Post-Westphalian structure, in which state activity takes place, then proceed with a deep dive on the role of nation-state LMICs) in the implementation of the WHO Mental Health Gap Action Programme (mhGAP).
The Westphalian governance structure places nation-states "as the dominant pillar" in global health governance (Ricci 2009). This system requires nation-states to work closely with one another to address international issues such as infectious diseases while preserving their sovereign authority as exemplified by the International Health Regulations (IHR) (Fidler 2003; Buse, Mays, and Walt 2009). The IHR set by the World Health Organization (WHO) and agreed upon by 196 member states, had to be amended after the 2003 SARS incident (Fidler 2003; Gostin and Katz 2016).
The previously agreed upon international regime for infectious disease control crafted in the last half of the nineteenth century and the first half of the twentieth century never required nation-states to improve national sanitation and water systems despite knowledge that such improvements would decrease diseases like cholera outbreaks and their spread (Mack 2006; Fidler 2003; Buse, Mays, and Walt 2009). Such activity fell within the jurisdiction of each state and thus other sovereign states did not have the authority to intervene (Fidler 2003). The IHR focused on diseases that could cross borders due to trade and migration and its aim was to enable the development of public health capacities to detect and respond to health emergencies that could be a threat to other nations.
At the height of the SARS outbreak, China used the notion of sovereignty through the Westphalian doctrine to defend noncompliance of regulations and operating guidelines set by the WHO and the IHR which hindered the "effective implementation of international communicable disease control efforts" (Stevenson and Cooper 2009). There used to be a clear delineation between domestic and foreign affairs but due to the fast spread of ideas, trade, pollutants, and viruses, borders are now blurred, ultimately cornering states and relinquishing them of absolute power over their national borders (Stevenson and Cooper 2009). Further, the ease at which information is shared and accessed has proven difficult for sovereign states to contain information within their borders, especially in times of crisis (Stevenson and Cooper 2009).
The amended IHR now tasks nation-states with developing capacities within their borders and to be more accountable to its citizens as well as to the international community (Mack 2006). Globalization and its effects on health put an emphasis on these issues, not only urging the ratification of the IHR but also inviting other health actors to step up and pose themselves as aids to sovereign states (Mack 2006). Similarly, the varying frameworks, through which global health issues are now framed emboldened non-state actors to enter the global health landscape (Hein et al. 2007). A large majority of these actors, unlike nation-states, have more flexibility and capacity to assist nation-states in the provision of healthcare (Fidler 2003).
Depending on the nature of the non-state actor, they may have financial or political clout and find themselves able to influence health policy agendas which was once controlled mainly by sovereign states and organization made of sovereign states such as the United Nations (UN) and the WHO (Jang, McSparren, and Rashchupkina 2016). The diversity of actors and processes in global health has become unstructured, muddying the waters and making it difficult to see the value of state activity in the provision of health in global health (Stevenson and Cooper 2009). Thus, researchers like Fidler and Ricci observe a shift from a Westphalian system to a post-Westphalian structure.
Because of the shift from a Westphalian to a Post-Westphalian system, sovereign states are no longer the sole actors shaping the formal institutions in global health. This Post-Westphalian system is more complex and challenges the existing governance of global health (Fidler 2003). We can also see that this shift leads to the absence of a global state authority such that agreements linking different policy fields and securing universal compliance are difficult to reach (Hein et al. 2007). In this regard, nation-states, which hold authority and legitimacy, are able to play this political role and bridge the gap (Hein et al. 2007).
Despite the congested nature of global health governance, "structural elements of public health protection and healthcare delivery are still overwhelmingly controlled by either national governments or sub-state jurisdictions" (Stevenson and Cooper 2009). State activity is not only vital in the governance of health in the Post-Westphalian system but also in the management of health initiatives and programs (Maiga and Eaton 2014). The WHO recognizes that a single entity cannot effectively implement a health program and that collaboration and political will are important factors (Keynejad et al. 2018; Jang, McSparren, and Rashchupkina 2016).
As a result, sovereign states are still the most important actors in determining whether health is assigned a high priority, or is horribly neglected" (Stevenson and Cooper 2009). The Post-Westphalian system does not eliminate state activity but simply shifts the role of global health actors. This new governance structure makes way for a very dynamic governance system, one where the state's governments "are actively complicit" (Youde 2019).
Worldwide, inequalities exist in the health needs of persons suffering from mental, neurological and substance use (MNS). It is calculated that one-tenth of the population suffers from a type of mental illness and only one percent of global health focuses its efforts on mental health care (Keynejad et al. 2018). For example, in 2017, WHO estimated 0.71 mental healthcare providers per 100,000 persons in Burkina Faso.
This is a huge disservice to the global community and to Burkina Faso. Recognizing the pressing need to address and decrease the looming global burden of disease caused by MNS disorders, WHO created The Mental Health Gap Action Program (mhGAP) (World Health Organization, Mental Health Gap Action Programme, and World Health Organization 2008). The mhGAP and intervention guide are essential tools for health care workers, governmental ministries, such as the Ministries of Health and Education, as well as non-governmental organizations in the delivery of mental health care to be taken up in over 90 LMICs (Keynejad et al. 2018).
The nature of the program illustrates how state activity is critical to the successful implementation of global health initiatives in the Post-Westphalian governance structure. The WHO adds that the "successful scaling up mhGAP is the joint responsibility of governments, health professionals, civil society, ...with support from the international community" and that most of the activities outlined in the mhGAP will need to be implemented at the national level (Saxena, Funk, and Chisholm 2013).
Consequently, research has been conducted to analyze and better understand the implementation process of mhGAP in LMICs. Through surveys of mental health experts and professionals, Saraceno et al identified barriers that prevent the successful intervention of mental health services in LMICs. These include, "the prevailing public-health priority agenda and its effect on funding; the complexity of and resistance to decentralization of mental health services; challenges to implementation {sic} of mental health care in primary care settings; the low numbers and few types of workers who are trained and supervised in mental health care; and the frequent scarcity of public-health perspectives in mental health leadership" (Saraceno and Dua 2009).
These barriers are political and can be overcome with political will. Without state activity, these barriers will remain; hindering and retarding the successes of mental health targets agreed upon by the global community. Moreover, until the introduction of mhGAP, mental health was not a large part of the conversation when setting the policy agenda at the national levels in LMICs (Saxena, Funk, and Chisholm 2013). This has a hefty implication on healthcare budgets added to it being overlooked because LMICs have a small budget for health thus mental health takes a minuscule portion, less than 1% of an already small health budget (Saraceno and Dua 2009; Maiga and Eaton 2014). This is also a reflection of the prioritization, buy-in, and recognition from national governments that mental health is a huge burden of disease. Despite being agreed upon publicly, until governments vote politically and with their funds, the implementation of programs such as mhGAP will fail due to implementation barriers and the "the lack of effective public health leadership for mental health" (Saraceno and Dua 2009; Maiga and Eaton 2014).
Experts see the inclusion of mental health care in the primary health care system as a positive strategy in providing care to the affected population. Although this may be ideal, the reality is that primary health systems in LMICs are not equipped nor prepared for such an addition. Existing primary health care systems are overburdened, there is little oversight and referrals to other departments, and the unreliability of medicine undermines the development, implementation, and sustainability of mental health care (Maiga and Eaton 2014). Furthermore, as noted by Saraceno et al, the scale-up of mental health services as urged by the WHO mhGAP necessitates capacity building of mental health workers, an effective implementation plan and evaluation (Charlson et al. 2019; Saraceno et al. 2007).
Limitations in human resources contribute to this barrier, little capacity has been built to support mental health care in LMICs (Saraceno and Dua 2009). Saraceno and colleagues point out from their research yet another barrier that hinders the implementation of mental health programs, the lack of decentralization.
Reflecting on the fact that when the national government, regional districts, and local level, do not align with the vision of decentralization, it simply will not occur (Saraceno et al. 2007). Drawing from the experiences of survey participants from Pakistan and South Africa, participants echo that the "successes in reform of policy or legislation at the national level do not necessarily translate to improvements in services in provinces or districts.
Authorities at these levels of government, who were responsible for the implementation of national policy and legislation, continued to allocate insufficient resources to develop mental health services (Saraceno et al. 2007). The various governmental branches responsible for tertiary care and community health service halted the transfer of resources to local community care (Saraceno et al. 2007).
Regardless of the investment and efforts by the WHO and other non-state actors in the delivery of mental health care, without nation-states prioritizing mental health, mhGAP proves to be difficult to implement (Saraceno et al. 2007). Additionally, buy-in from all stakeholders is imperative to the success of mhGAP and without it, action will not follow suit.
Because nation-states are the arena in which global health activity takes place, the arena must be ripe for such an activity and free of "perceptions of insufficient gains from investment in mental health" (Saraceno et al. 2007). This attitude is slowly changing in the international community but can still be seen among policymakers, national governments and global health donors (Saraceno et al. 2007).
The Post-Westphalian system, although it enables key partnerships and provides strategic support, these aspects are not a surrogate for the role that nation-states must play in addressing the implementation barriers that mhGAP faces (Pinet 2003). Further studies have been carried out on LMICs participants in mhGAP to corroborate and understand the key ingredients needed for mhGAP to thrive.
Charlson et al determined that good governance is the foundation of any health system (Charlson et al.2019). In their view, good governance "comprises of accountability, responsiveness, open and transparent decision making, and community engagement" (Charlson et al. 2019). Any LMICs possessing these key features have a stronger probability of implementing mhGAP and addressing the mental health needs of their society (Charlson et al. 2019). These features cannot be acted upon without the nation-state being a part of the conversation.
The rollout of mhGAP in Fiji is a good example of the important role the state played in the prioritization and implementation of health programs. Fiji and its Ministry of Health made a political decision and committed to the WHO mhGAP, further reinforcing its current national mental health program. At first, the training of health workers in mhGAP was done by WHO then taken over by Fiji's Mental Health Unit (Charlson et al. 2019).
Although this is a success story of collaboration between global health actors, the program's effectiveness relies heavily on Fiji's ability to provide necessary support in the form of medication for the treatment of patients. A survey of newly trained mhGAP health workers was conducted and "57% felt that the availability of psychotropics was unreliable in their health facility." Charlson et al uncovered that there was a shortage and inconsistent supply of medicines; "no health facility had a reliable flow of antidepressants" (Charlson et al. 2019). By being responsive during the implementation of mhGAP in its mental health unit, the provision of medicines would have been more accessible and sustainable.
Charlson et al goes on to delineate strategies that would address the challenges faced by LMICs like Fiji in implementing the mhGAP. These include routine training of health workers, integrated care systems, sensitization of the society, decentralization of health care system and "establishing information and drug supply systems" (Charlson et al. 2019). A large number of these strategies fall under Fiji's mandate.
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Overall, to deliver on the goals of mhGAP of providing "proper care, psychosocial assistance, and medication," Fiji has struggled (Charlson et al. 2019). The scale-up to train more health workers has been weak, the prioritization of the mental health department also low due to the lack of trust of high returns on investment and the provision of medicine lackadaisical, a result of the barriers that exist internally but also on an international level. Being able to make trade agreements and finance antidepressants, for example, relies on the support of the international community but also on the leadership of action taken by the nation-state (Buse, Mays, and Walt 2009).
In the case of Fiji, a strong leadership provided by national decision-makers, key priorities in creating and enabling health systems to implement evidence-based interventions are imperative to strengthening leadership and governance in the effective integration of mental health care (Charlson et al. 2019). Nation-states' inability to provide stability and continuity of medication, for example, hinders the success of global health initiatives like mhGAP, further highlighting the fact that other global health actors, in this case WHO, can participate as much as they are able, but, at the end of the day, state involvement and leadership are crucial to the sustainability of these efforts and the success of the health initiative. As evidenced by how the implementation process unfolded in Fiji, state activity is vital for the realization of the WHO mhGAP.
Critics may argue that the findings by Charlson et al, reinforce the fact that nation-states are no longer able to fulfill their role in the provision of health within their borders and that the involvement of other actors is necessary. This may be true in the short term but "ultimately the solution is to strengthen systems," an activity that turns to state actors for support (Maiga and Eaton 2014). The Post-Westphalian systems allow for states to focus their efforts on activities such as decentralization and the incorporation and delivery of mental health services in primary care facilities while non-state actors support and collaborate in these efforts by advocating for mental health to rise in priority on the policy agenda.
States remain key players in global health governance. The spread of ideas, pathogens, and the rise in efficient migration has led the way for globalization. It created a window of opportunity for non-state global health actors to flock to the arena in hopes of picking up where nation-states lag. We see a shift from the Westphalian governance system, where states were left to their own devices to dictate and secure health within their borders, in the name of globalization, to a Post-Westphalian system (Jang, McSparren, and Rashchupkina 2016).
Despite the global health arena being crowded with health actors, state activity remains imperative if global health initiatives are to be successful (Gostin and Friedman 2014). The WHO further reinforce this notion by acknowledging that government ministries are vital for health activity (World Health Organization, Mental Health Gap Action Programme, and the World Health Organization 2008). Moreover, WHO emphasizes that each "government needs to take responsibility for the planning and implementation of their strategic plan" (World Health Organization, Mental Health Gap Action Programme, and World Health Organization 2008).
Using the WHO mhGAP as a case study to further discuss the importance of state activity being vital to the success of global health, I highlighted the notion put forth by Charlson et al, that good governance is the backbone of any health systems (Charlson et al. 2019). Nation-states play a dual role by being accountable to the international community but also to their constituents at home who give them authority and legitimacy. Additionally, in the case of the WHO mhgap, states agreed to the initiative on an international platform and committed to deliver mental health services to their citizens (Saraceno et al. 2007).
The WHO mhGAP heavily relies on the corporation and buy-in of states in prioritizing mental health in setting their health policy agendas. Highlighted through the evaluation of Fiji's implementation of mhGAP are the lack of good governance and political will, thus the proper implementation of this program has been poor. Regardless of the issue, states are central to global health because they are in the "arena in which global health is played out" (Harman 2012). States remain sovereign bodies and, consequently, play a key role in health activities within their borders, from the design phase to implementation and evaluation stages of health programs, governing health activities on the ground. Nation-states remain constant while "donor programmes come and go" and nation-states "however flawed, have the staying power that far exceeds that of most global philanthropic actors" (Mahajan 2018). States are here to stay as key players in global health governance and are vital to the success of global health.
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