2019 Global Health Policy Forum Keynote Address: The indispensable role of political will in enabling global medical product donation programs
The following is a transcript of the welcome remarks shared by Rabin Martin CEO Jeff Sturchio at the 2019 Global Health Policy Forum, held at the Grand Hotel Kempinski in Geneva, Switzerland…
We had a fascinating discussion yesterday afternoon about what needs to be done to transform our thinking about how to “design resilient and sustainable health systems that draw on all available expertise and resources to improve health for all.” Our discussion was framed in the context of the Sustainable Development Goals and the promise of Universal Health Coverage. We spoke about the critical perspective of viewing the challenges we face collectively through a community lens, asking how our programs would look different – and how might their objectives change – if we asked beneficiaries what they want and need. And we focused on the question of how will we know when we’ve arrived at our goals if we don’t have robust measuring and evaluation mechanisms in place to provide evidence that the investments yield results consistent with our strategic targets? At the end of the day, we want to know that the work we do – across a broad spectrum of industry, government and civil society partnerships and in a wide range of areas, including medical donations, disaster response, humanitarian assistance and health system strengthening – makes a difference in the lives of the people we set out to help.
This morning, I’d like to add to the complexity of our conversation by addressing an issue critical to the work that PQMD and its members do, namely, the question of political will. What is it? Why should we care about it? And how can we generate more of it to help us in our work to surmount barriers to creating better access to health for the billions of people in need around the globe?
Why political will?
First, let me pose some related questions: Why it is that some issues capture the public’s attention and attract significant support and resources, while others languish? Nearly sixty years ago, Rachel Carson’s Silent Spring helped to catalyze the environmental movement, leading to the creation of the EPA, and Earth Day, which captured the attention of a wide cross-section of American society, It went global in short order, with repercussions we’re still feeling today. Tobacco control efforts expanded rapidly nearly twenty years ago with the introduction of the Framework Convention for Tobacco Control and the MPOWER approach and became a global movement that changed societies around the world. The HIV/AIDS epidemic mobilized a similarly broad basis of support that led to unprecedented levels of investment to combat that disease globally. On the other hand, many of us would subscribe to the idea that health is a human right – yet every day, leaders in dozens of countries ignore systematic discrimination against the poor and marginalized populations who do not enjoy access to the products and services that would enable them to enjoy health as a human right.
An underlying reason for these differences is the fact that health and healthcare are fundamentally about political choices. Those with the power and the money to insist on their priorities over other choices find the support and the resources needed to address their concerns. Communities may have different priorities – but without the opportunity to make their voices heard, their health and the health of their loved ones may suffer due to the lens of collective action – together with the money and medicines needed to improve population health – being focused elsewhere. The importance of this political perspective is clear from Tedros’s remarks to the World Health Assembly a year ago, when he said:
“I know from my own experience in politics that with buy-in from the highest levels, anything is possible. Without it, progress is difficult. That is why I have made a priority of engaging with leaders all over the world, to advocate for political action on health.” 
The choices made by political leaders have multiple explanations, but I would argue that the relative neglect of certain global health issues comes down to a lack of imagination and leadership, a failure to think creatively about more inclusive solutions, and and to make investments better informed by the reality of life on the ground. It’s not that we lack knowledge of what to do, or lack the resources to donate medicines or program know-how or other relevant expertise in global health. But there does seem to be a vacuum in leadership in government, in industry, and yes, even in civil society, about how to move beyond barriers to put new ways of working into practice that will bring us closer to realizing the vision of “health for all” that ostensibly animates global discourse today. In other words, we lack the political will to carry through on our aspirations as a global community.
I’ll come back to this assertion later in my remarks and offer some recommendations for how to achieve different results (as E.J. Ashbourne suggested yesterday, we don’t want to be like Einstein’s crazy friend, doing things over and over and expecting a different result!) But first let me be more precise: what exactly is political will?
Defining political will
Linn Hammergren, a political scientist, has observed that political will “is the slipperiest concept in the policy lexicon. It is the sina qua non of policy success, which is never defined except by its absence. It thus becomes the explanation for every policy failure despite the fact that so many programs are undertaken where it certainly does not
seem present.”  There is a large social science literature devoted to the question of figuring out what political will is, and how much is enough. At the risk of taking a wonkish turn, bear with me while I elaborate on how to think more analytically about political will. (I do this with some trepidation: first, at the risk of exemplifying the old saying that the problem with most academic social science is that it is one long exercise in belaboring the obvious; and second, since many of you are already masters at generating and mobilizing political will.)
Derick Brinkerhoff of RTI International has developed an operational definition based on a series of observable and measurable components that I think Is useful for our purposes this morning. He defines “political will” as “the commitment of actors to undertake actions to achieve a set of objectives and to sustain the costs of those actions over time.”  That seems straightforward – but can we make it more relevant for understanding how to apply this concept to our collective work on medical product donations in the context of disaster response, humanitarian relief and health system strengthening?
Brinkerhoff goes on to specify a set of dimensions for disaggregating the concept of political will:
- Government initiative. Political will is suspect when the push for change comes totally from external actors. Some degree of initiative from country decision-makers must exist in order to talk meaningfully of political will.
- Choice of policy/programme based on technically sound, balanced consideration and analysis of options, anticipated outcomes, and cost/benefits. When country actors choose policies and actions based on their own evidence-based assessments of the likely benefits to be obtained, the alternatives and options, and the costs to be incurred, then one can credibly speak of independently derived preferences and willingness to act.
- Mobilisation of stakeholders. This component concerns the extent to which government actors consult with, engage, and mobilise stakeholders. Do decision-makers reach out to members of civil society and the private sector to advocate for the changes envisioned? Are legislators involved? Are there ongoing efforts to build constituencies in favour of desired policies and programmes?
- Public commitment and allocation of resources. To the extent that country decision-makers reveal their policy preferences publicly and assign resources to achieve those announced policy and programme goals, these actions contribute to a positive assessment of political will.
- Accountability. A mechanism for accountability signals serious intent to address the issue.
- Continuity of effort. Achieving the goal requires resources and effort over the long-term. One-shot or episodic efforts signal weak and/or wavering political will.
- Learning and adaptation. Political will is demonstrated when country actors establish a process for tracking progress, and actively manage implementation by adapting to emerging circumstances. Learning can also apply to country policymakers observing policies, practices, and programmes from other countries and selectively adapting them for their own use.
Now we seem to be getting somewhere. Brinkerhoff points out that his concept can be summarized by noting that creating political will requires commitment, capacity and context – three summary dimensions of his framework – and a process to identify stakeholders, assess their views of problems and solutions, align understanding of which solutions to apply, and then build firm commitments and mutual accountability for outcomes. By applying this model to the issue in question, we can move from “political won’t” to “political will.” 
Building political will and competing for share of voice
This brings me back to a question I posed at the outset: why do some issues get traction and support, while others – equally important for their constituencies – fail to build momentum and resources? Here I’d like to offer one other point of view, from Jeremy Shiffman and colleagues. Shiffman (now at American University) has conducted a comparative study of a range of global health agendas and networks (e.g., polio eradication, maternal mortality, neonatal survival, tobacco use, alcohol harms, TB, pneumonia) and explained their success or lack of success at gaining political priority via a pragmatic model that analyzes: the power of ideas used to portray the issue, the nature of the political context in which they operate and the different interests and institutions at play, the characteristics of the issue itself (i.e., are solutions available? feasible?), and, finally, the strength and capabilities of the actors championing the idea.
Shiffman’s analysis also points to the critical roles of problem definition, the framing of the network’s core issue to inspire others to action; the need for effective coalition-building; and governance (or creating a set of institutions and collaborative processes to advocate for and act effectively to address the problem). 
Now we’ve come directly to the issues facing PQMD. How can we mobilize allies and resources to move medical product donations up the political agenda to encourage more partners to work with us, both globally, nationally and locally to solve problems and reach more people to improve population health? PQMD is exactly the kind of institution that Shiffman had in mind – and together you have been working on the problem definition, framing, coalition-building and advocacy that will continue to build the political will necessary to mobilize the additional resources and partners required to achieve impact at even greater scale.
Implications of this model of how to create political will for PQMD’s policy and advocacy agenda
Let me conclude with three recommendations for how PQMD can continue to build its effectiveness and impact by applying these concepts of political will to the collective work that you’re doing:
- Remember that we’re engaged in deeply political processes. As David Held, Ilona Kickbusch and their colleagues have pointed out in a recent paper in Global Policy, the centrality of health to economics and security interests has placed health high on the political agenda in recent years – think of the UN Security Council, UN General Assembly, G7 and G20 responses to issues like HIV/AIDS, Ebola, antimicrobial resistance, TB and universal health coverage. But it’s precisely because of the broad resonance and importance of these and similar issues (like those on PQMD’s agenda), that it’s too important to leave this work to the politicians alone.
- Leadership is required at all levels to raise the profile of global health issues we care about – and not only governments exercise that political leadership. We all have a role to play – whether multilaterals, NGOs and CSOs, foundations, academic experts, or industry – in building trust, activating and mobilizing networks of actors to support change, creating inclusive partnerships and alliances (including beyond the health sector) to expand the scale of our impact, and to build the political momentum for sustained action – all of this amid a wide range of priorities competing for mind share and scarce resources. Brinkerhoff’s and Shiffman’s models show us how to build the political will and recruit the allies and champions we need to make change happen.
- Finally, PQMD is already well-positioned and has an impressive track record at convening, coordinating and collaborating among a diverse set of multisectoral technical, resource, policy and implementing partners on the core work of medical product donations in support of disaster response, humanitarian assistance and health systems strengthening. I’d like to suggest that the next stage in PQMD’s work should be to embrace the political dimension of your work in the spirit of Brinkerhoff and Shiffman and create a social movement in support of medical product donations.
The power of this approach is suggested by the kind of norm changes we’ve seen on a global level in recent years from the efforts of the tobacco control movement – as a result of their concerted efforts, global social norms around tobacco use have been transformed, with concomitant positive impacts on public health. This movement enlisted a wide range of allies and champions, operated globally on the basis of a shared evidence base about the harms of tobacco use, and implemented a set of evidence-based tools that underscored the value of the interventions suggested.
Governments took initiative, supported by a community of experts and program managers, as well as an army of citizens committed to the recommended changes. Together these coordinated actions created the political will that led to legislation, new resources and continuous efforts on a global basis that have effected a revolutionary change in global attitudes about tobacco use. 
My final point is that political will is socially constructed, and that the methods used in the successful cases I’ve mentioned are available to the PQMD community to expand and deepen the commitment among your members and partners to build a similarly robust and sustainable movement to transform the ways in which medical product donations are deployed in disaster relief and in response to humanitarian emergencies. I hope you find the perspectives I’ve offered useful as you continue to work at mobilizing the necessary political will. Together as leaders of the PQMD movement, working hand-in-hand with affected communities, you’ll be able to do even more in the right contexts to build the commitment and capacity to transform what’s possible in product donations. Imagine the enhanced impact you’ll have on the lives of millions. I’m eager to see what lies ahead!
 For perspectives on the environmental movement, the tobacco control movement, and the global response to the HIV/AIDS pandemic as social movements, see Dunlap, R.E. and Mertig, A.G. eds., American Environmentalism: The US Environmental Movement, 1970-1990 (London: Routledge, 2013); Wipfli, Heather, The Global War on Tobacco: Mapping the World’s First Public Health Treaty (Baltimore, Maryland: Johns Hopkins University Press, 2015); Wipfli, Heather, and Jonathan M. Samet, “One hundred years in the making: the global tobacco epidemic.” Annual review of public health 37 (2016): 149 -166; Kapstein, Ethan B., and Joshua W. Busby, “Making markets for merit goods: the political economy of antiretrovirals,” Global Policy 1, no. 1 (2010): 75-90; and Kapstein, Ethan B., and Joshua W. Busby, AIDS Drugs for All: Social Movements and Market Transformations (New York: Cambridge University Press, 2013).
 Dr. Tedros Adhanom Ghebreyesus, Director-General, WHO, Address at 71st World Health Assembly, Geneva, Switzerland, 21 May 2018. https://www.who.int/dg/speeches/detail/opening-of-the-seventy-first-world-health-assembly
 Hammergren, Linn, Political Will, Constituency Building and Public Support in Rule of Law Programs, PN-ACD-023 (Center for Democracy and Governance, U. S. Agency for International Development, 1998), 12.
 Brinkerhoff, Derick W. “Unpacking the concept of political will to confront corruption,” Anti-Corruption Resource Centre, U4 Brief 2010:1 (Bergen, Norway: Chr. Michelsen Institute, May 2010), https://brage.bibsys.no/xmlui/bitstream/handle/11250/2474682/Unpacking%20the%20concept%20of%20political%20will%20to%20confront%20corruption?sequence=1&isAllowed=y . See also Post, Lori Ann, Amber NW Raile, and Eric D. Raile, “Defining political will,” Politics & Policy 38, no. 4 (2010): 653-676; Raile, Amber NW, Eric D Raile, and Lori A. Post, “Analysis and action: the political will and public will approach,” Action Research, (May 2018), doi:10.1177/1476750318772662; and Part II of Odugbemi, Si, and Thomas Jacobson, eds., Governance Reform Under Real World Conditions: Citizens, Stakeholders, and Voice (Washington, DC: The World Bank, 2008).
 This section is adapted largely verbatim from Brinckerhoff (note 4), pp. 2-3 – the only change was to substitute “accountability” for “application of credible sanctions.”
 Malena, Carmen, ed., From Political Won’t to Political Will: Building Support for Participatory Governance (Sterling, VA: Kumarian Press, 2009).
 Shiffman, Jeremy, “A social explanation for the rise and fall of global health issues”, Bulletin of the World Health Organization 87 (2009): 608-613; Shiffman, Jeremy, Kathryn Quissell, Hans Peter Schmitz, David L. Pelletier, Stephanie L. Smith, David Berlan, Uwe Gneiting et al. “A framework on the emergence and effectiveness of global health networks,” Health policy and planning 31, Supplement 1 (2015): i3 – i16; and Shiffman, Jeremy, Hans Peter Schmitz, David Berlan, Stephanie L. Smith, Kathryn Quissell, Uwe Gneiting, and David Pelletier. “The emergence and effectiveness of global health networks: findings and future research,” Health Policy and Planning 31, Supplement 1 (2016): i110 – i123.
 Shiffman, J., “Four challenges that global health networks face,” International journal of health policy and management, 6, no. 4 (2017): 183 – 189. See also Benford, Robert D., and David A. Snow, “Framing processes and social movements: An overview and assessment,” Annual review of sociology 26, no. 1 (2000): 611-639.
 Held, David, Ilona Kickbusch, Kyle McNally, Dario Piselli, and Michaela Told, “Gridlock, innovation and resilience in global health governance.” Global Policy (February 2019), https://doi.org/10.1111/1758-5899.12654
 There is a large literature on the organization, mobilization and evolution of social movements. I’ve found the following helpful: Benford and Snow (note 8); Van Dyke, Nella, and Holly J. McCammon, Strategic Alliances: Coalition Building and Social Movements (Minneapolis: University of Minnesota Press, 2010); Goodwin, Jeff, and James M. Jasper, eds. The Social Movements Reader: Cases and Concepts (New York: John Wiley & Sons, 2014); Della Porta, Donatella, and Mario Diani, eds., The Oxford Handbook of Social Movements (Oxford: Oxford University Press, 2015); Kapstein and Busby (note 1); Kapstein, Ethan B., and Joshua William Busby, “Social movements and market transformations: Lessons from HIV/AIDS and climate change,” International Studies Quarterly 60, no. 2 (2016): 317-329; Wang, Dan, Alessandro Piazza, and Sarah A. Soule, “Boundary-spanning in social movements: antecedents and outcomes.” Annual Review of Sociology 44 (2018): 167-187; Crutchfield, Leslie, How Change Happens: Why Some Social Movements Succeed While Others Don’t (New York: John Wiley & Sons, 2018); Almeida, Paul, Social Movements: The Structure of Collective Mobilization (Berkeley: University of California Press, 2019); and Tilly, Charles. Social Movements, 1768-2004 (London: Routledge, 2019).
 On the tobacco control movement, in addition to Wipfli and Samet (note 1) and Wiplfi (note 1), see Wipfli, Heather L. and Samet, J., “Framing progress in global tobacco control to inform action on noncommunicable diseases,” Health Affairs, 34, no. 9 (2015): 1480-1488; Yach, Derek, “How can progress on global tobacco control inform progress on NCDs?” Global heart 11, no. 4 (2016): 399-402; Gneiting, Uwe, and Hans Peter Schmitz, “Comparing global alcohol and tobacco control efforts: Network formation and evolution in international health governance,” Health Policy and Planning 31, Supplement 1 (2016): i98 – i109; and Reubi, David, and Virginia Berridge, “The internationalisation of tobacco control, 1950–2010,” Medical history 60, no. 4 (2016): 453-472. Connie Hoe and colleagues have provided a fascinating case study of building political will for tobacco control in Turkey, using a “multiple streams” framework that complements the models discussed above: Hoe, Connie, Daniela C. Rodriguez, Yeşim Üzümcüoğlu, and Adnan A. Hyder,”“Quitting like a Turk:” How political priority developed for tobacco control in Turkey,” Social Science & Medicine 165 (2016): 36 – 45; and Hoe, Connie, Daniela C. Rodriguez, Yeşim Üzümcüoğlu, and Adnan A. Hyder, “Understanding political priority development for public health issues in Turkey: lessons from tobacco control and road safety,” Health research policy and systems 17, no. 1 (2019): 13.