The transnational governance of global health : Norwegian and Swiss cases of national policies on global health

The objective of this thesis is to understand the relationship between national policy on global health and global health governance (GHG). To this end, the thesis examines an emergent object, national policy on global health (NPGH), from the perspective of the interdisciplinary research field of health political science. It draws on theories and concepts from policy studies to explore the processes, rules, and power relations that characterise national policy arenas in which multiple sectors interact to coordinate the global health strategy of a country’s government. Conceptualised in public policy terms, NPGH is a multisectoral action arena wherein actors from health, development, and foreign affairs sectors interact to make decisions about how to manage the government’s work on global health. The study of NPGH as a research object sheds light on three broad areas of concern for public health and health promotion policy-related research and practice, such as intersectorality, governance, and the role of social science. The thesis is presented in ten chapters, including four articles (two published and two to be submitted) and two case monographs.   The theoretical framework that informs the research questions for the thesis and orients the deductive approach used to generate and analyse the empirical material is presented in Article 1. We adapted Real-Dato’s synthesis framework from the discipline of political science to conceptualise the processes of NPGH in public policy terms. This framework establishes the analytical categories constituting NPGH action arenas, set within a multidimensional set of contexts, around which we drew internal (national) and external (global) boundaries for exploring mechanisms of policy change between NPGH and GHG.  This thesis used a retrospective qualitative multiple case study design with two in-depth case studies of NPGH in Norway and Switzerland to answer three research questions:  1) What are the elements of policy design in formally adopted NPGH documents?  2) What characterises action arenas that develop NPGH documents? and  3) How do mechanisms of policy change operate between the system of GHG and the arenas of NPGH?   Data was collected through documentary and interview methods. In 2014 and 2015, I carried out thirty-three semi-structured interviews with key informants from the countries of Switzerland (n=14) and Norway (n=19), using visual techniques (Article 2). Key informants included senior policy actors and experts from the health, development, and foreign affairs sectors as well as civil society actors and researchers. For each case study, a “Context Advisory Group” was established. These groups are an integrated feature of the research design for this thesis as methodological devices to support and validate the construction of the cases.  Article 3 presents the results of the first comparative study, which examines the two formally adopted NPGH policy documents, the Swiss Health Foreign Policy and the White Paper on Global health in foreign and development policy from Norway. We used Schneider and Ingram’s policy design framework to conduct a directed qualitative content analysis of these documents to understand the aims of these policies and the plan to achieve them. This study found that these NPGH aim to create change at the international level and plan to use instruments of health diplomacy and cooperation to modify the global health governance system.  Retrospectively reconstructing the policy arenas that produced these two documents (between 2005-2013), I found that in both cases, government actors from health and foreign affairs sectors (among others) innovated, using strategy and opportunism to build arenas for collaboration to act in and on the global health governance system. To contextualise and construct the two in-depth cases of NPGH action arenas in Norway and Switzerland, analyses were carried out in three stages:  • stage 1 to map action situations in the two national action arenas,  • stage 2 to understand the processes within each action situation, and  • stage 3 to produce a report of each action situation focusing on rules and power.  Rules institutionalised power-sharing arrangements and challenged sectoral cultures in the five situations of the Swiss arena, and they reinforced power asymmetry and sectoral territorialisation in the six situations of the Norwegian arena. The sectors responsible for initiating the NPGH action arena were different in each of the two cases: the health sector being the driver in the Swiss case, and the foreign policy sector in the Norwegian one.  Article 4 presents the results of the second comparative study, which aimed to better understand the relationship between processes for governing global health at national and international levels. Data from the two cases were analysed for the relational structures between the two (national and international) levels of processes for governing global health. We found five forms of interactions between NPGH arenas and GHG: governing bodies of intergovernmental organisations for health, governance of global public-private health partnerships, formal and informal cooperation agreements, global health hubs, and boundary-spanning transnational elites. The circulation of ideas and feedback between different overlapping policy processes within a transnational space for governing global health signifies that an NPGH arena is partly embedded in the GHG system, similarly to the way that the GHG system is partly embedded in an NPGH arena.   Overall, three main findings contributing to better understanding NPGH as a policy process at the junction of health diplomacy and global health governance stem from this thesis: the distribution of roles for sectors varies in multisectoral arenas for NPGH; policy ideas circulate in the interactions between arenas of NPGH and GHG; and GHG materialises as a systemic policy target for arenas of NPGH. As transnational policy arenas, NPGH are intersectoral policies without borders that target and interact with actors and institutions in multiple spaces spanning domestic, international, and global arenas for governing global health. This form of transnational governance of global health may bolster the insider status of some state actors in GHG and potentially create conditions for policy transfer through networking and learning mechanisms.  This thesis makes three distinct contributions. First, it contributes in two ways to knowledge on public policy: 1) empirically, it contributes to improve understanding of how the health sector engages with other sectors in intersectoral policy and governance, and 2) methodologically, it contributes to the development of research designs and qualitative methods for comparative health policy research that considers the contextualisation of policy. Second, it makes a theoretical contribution to the conceptualisation of transnational governance of global health, wherein GHG is understood a process that happens par le bas through national policy’s various transnational interactions as an alternative understanding to that as a process that happens par le haut from international institutions. Third, as a thesis anchored in an interdisciplinary research field of health political science, it offers an example of how public policy theories can be used to understand intersectoral policy related to health and global health governance, as well as an example of how the study of global health policy can be used to develop theories of public policy.

Keyphrases: Action intersectorielle, National policy on global health, Global health governance, Norway, Switzerland, Intersectoral action, Health in all policies, Policy process, Intersectoral governance, Transnational governance