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Senegal has a reputation for having one of the most effective and far-reaching nutritionservice delivery systems in Africa. Chronic malnutrition has dropped to less than 20 percent, oneof the lowest in Sub-Saharan Africa. The reduction in stunting in particular has been deemed a success in Senegal with the prevalence of child stunting one of the lowest in Sub-Saharan Africa in absolute terms (Nene 2017). This success has at least in part been attributed to broad-based government commitment to nutrition, which has grown from US$0.3 million per year in 2002 to US$5.7 million per year in 2015, increasing from approximately 0.02 percent to 0.12 percent of the national budget. Yet concerns remain regarding whether the level of government support for nutrition is sufficient and the degree to which nutrition has been as effectively "mainstreamed" across major line ministries, such as agriculture, education, water and sanitation, socialprotection and health, to support both nutrition-specific and nutrition-sensitive interventions. Moreover, the nutrition field as a whole is characterized by a myriad of actors (international donors, NGOs, and technical support agencies) whose interventions are not well coordinated, leading to duplications of effort and inefficiencies in the provision of services. A series ofexternal shocks, including food shortages stemming from drought, the global financial crisis, and the instability of prices for local foodstuffs since 2007, has revealed the continued need for additional investment in nutrition and better intersectoral coordination of activities to counter cyclical attention to nutrition and a predominant focus on food insufficiency rather than abroader focus on nutrition. To this end, the government of Senegal, through the CLM, is in the process of drafting the new PSMN to develop a reform agenda for the sector. The PSMN will lay out a framework and timeline for the development of a nutrition financing strategy that will requirespecific analysis of the sector spending and financial basis, linking it to the coverage and quality of nutrition services and assessing the contribution of different sectors and actors to the budget. As part of the Analysis & Perspective: 15 Years of Experience in the Development of Nutrition Policy in Senegal series, the World Bank commissioned this report to elaborate the specific political challenges to and opportunities for further raising the profile ofnutrition on the government's agenda and secure a sustainable effort to reduce maternal and child malnutrition. The nutrition agenda is often prone to political economy challenges when it competes for government support, as the impact of nutritional intervention is neither immediate nor tangible. Though the benefits of proper nutrition are life-long and are foundational to proper growth and development, nutrition can fall by the wayside in policymakers' inevitably shorter-termoutlook. With this in mind, the objective of this report was to identify the policy and political levers that can be used to foster government leadership and galvanize intersectoral coordination that mainstreams nutrition into government policies and programs and effectively, efficiently, and sustainably delivers nutrition interventions in Senegal.

SummaryAlthough health is generally believed to improve with higher wealth, research on HIV in sub-Saharan Africa has shown otherwise. Whereas researchers and advocates have frequently advanced poverty as a social determinant that can help to explain sub-Saharan Africa's disproportionate burden of HIV infection, recent evidence from population surveys suggests that HIV infection is higher among wealthier individuals. Furthermore, wealthier countries in Africa have experienced the fastest growing epidemics. Some researchers have theorized that inequality in wealth may be more important than absolute wealth in explaining why some countries have higher rates of infection and rapidly increasing epidemics. Studies taking a longitudinal approach have further suggested a dynamic process whereby wealth initially increases risk for HIV acquisition and later becomes protective. Prior studies, conducted exclusively at either the individual or the country level, have neither attempted to disentangle the effects of absolute and relative wealth on HIV infection nor to look simultaneously at different levels of analysis within countries at different stages in their epidemics. The current study used micro-, meso- and macro-level data from Demographic and Health Surveys (DHS) across 170 regions within sixteen countries in sub-Saharan Africa to test the hypothesis that socioeconomic inequality, adjusted for absolute wealth, is associated with greater risk of HIV infection. These analyses reveal that inequality trumps wealth: living in a region with greater inequality in wealth was significantly associated with increased individual risk of HIV infection, net of absolute wealth. The findings also reveal a paradox that supports a dynamic interpretation of epidemic trends: in wealthier regions/countries, individuals with less wealth were more likely to be infected with HIV, whereas in poorer regions/countries, individuals with more wealth were more likely to be infected with HIV. These findings add additional nuance to existing literature on the relationship between HIV and socioeconomic status.

When and why does the public support redistributive policies that seek to provide social risk protection through universal health financing? One central political dilemma in establishing systems of universal health coverage (UHC) in low- and middle-income countries is the small tax base available to contribute to pooled financing of healthcare. Middle-class workers in the formal sector (labor market insiders) may already get health coverage through the state or private insurers, leaving them little incentive to contribute to UHC that will primarily benefit indigent workers in the informal sector (labor market outsiders). Applying the insider–outsider politics framework, we explore attitudes toward UHC using recent data from Afrobarometer surveys in 36 countries in Sub-Saharan and North Africa. We find that, in spite of growing attention to universal coverage among policymakers, support from the average citizen is low, though variable, across countries. Further, in contrast with expectation, economically secure labor market insiders are more willing than labor market outsiders to pay more in taxes to finance health coverage. However, support for more tax financing of health services was dependent on trust in government and perceptions of government efficacy. Trust in the government's capacity to use tax financing effectively may be a more important determinant of support for UHC than rational self-interest.

AbstractThat policy should be evidence‐based has become a widely accepted dictum, especially in public health, where evidence‐based policy is strongly emphasized. Yet, most public health controversies arise because there is a conflict over values, which facts alone cannot resolve. Moreover, promoting population‐based health interventions requires the art of political actors to arouse public support. In discussing this tension in public health, studies often frame value conflicts as a barrier to rational decision‐making rather than viewing value considerations as an inherent part of democratic policymaking. We argue that by failing to engage value‐conflicts directly, public health professionals actually stymie evidence translation, which requires public and political buy‐in. We suggest a two‐by‐two framework that seeks to make value concerns more explicit in public health policymaking by breaking out policy controversies and alternatives along two dimensions—factual debates and value debates, creating four categories: uncontested alternatives, value debates, fact debates, and contested alternatives. We demonstrate that the policies that are most likely to be contested are those with a strong value conflict and where the evidence‐base is less solid. We also show that the framework is dynamic: fact and value conflicts are neither static nor inevitable. Rather, interested actors use both fact and value to try to push issues from contested to uncontested and vice‐versa. We conclude by demonstrating how the framework can help specify the role of both value and fact debates in public health policymaking through examples from U.S. public health policy controversies, including during the present COVID‐19 crisis.

Calorie labeling on menus became a federal law in 2010 but was not implemented until 2018, 8 years after adoption. This study reconstructs the history of the federal menu-labeling mandate using a process-tracing approach and finds that the delays in implementation resulted not from direct agency capture by the regulated industry, but rather from a system of indirect influence whereby lawmakers continue to influence policy-making even after adoption. Excessive legislative control can contribute to substantial implementation delays that undermine legislative intent. However, administrative agencies can serve as trustees to hold elected officials accountable to their own policy commitments.

Background The Joint United Nations Programme on HIV/AIDS (UNAIDS) has recently set the ambitious "90-90-90 target" of having 90% of people living with HIV (PLHIV) know their status, receive antiretroviral therapy (ART), and achieve viral suppression by 2020. This ambitious new goal is occurring in a context of global "scale-down" following nearly a decade of heightened investment in HIV prevention and treatment efforts. Arguably international goals spur action, however, setting unrealistic goals that do not take weak health systems and variations in the nature of the epidemic across countries into consideration may set them up for failure in unproductive ways that lead to a decline in confidence in global governance institutions. This study explores how policy actors tasked with implementing HIV programs navigate the competing demands placed upon them by development targets and national politics, particularly in the current context of waning international investments towards HIV. Methods To examine these questions, we interviewed 29 key informants comprising health experts in donor organizations and government employees in HIV programs in Pakistan, a country where HIV programs must compete with other issues for attention. Themes were identified inductively through an iterative process and findings were triangulated with various data sources and existing literature. Results We found both political and governance challenges to achieving the target, particularly in the context of the global HIV scale-down. Political challenges included, low and heterogeneous political commitment for HIV and a conservative legal environment that contributed towards a ban on opiate substitution therapy, creating low treatment coverage. Governance challenges includedstrained state and non-governmental organization (NGO) relations creating a hostile service delivery environment, weak bureaucratic and civil society capacity contributing to poor regulation of the health infrastructure, and resource mismanagement on both the part of the government and NGOs. Conclusion Our findings suggest that in a context of waning international attention to HIV, policy actors on the ground face a number of practical hurdles to achieving the ambitious targets set out by international agencies. Greater attention to the political and governance challenges of implementing HIV programs in low- and middle-income countries (LMICs) could help technical assistance agencies to develop more realistic implementation plans.

This article analyzes the growing chasm between international power and state responsibility in health rights, proposing an international legal framework for collective rights -- rights that can reform international institutions and empower developing states to realize the determinants of health structured by global forces. With longstanding recognition that many developing state governments cannot realize the health of their peoples without international cooperation, scholars have increasingly sought to codify international obligations under the purview of an evolving human right to health, applying this rights-based approach as a foundational framework for reducing global health inequalities through foreign assistance. Yet the inherent limitations of the individual human rights framework stymie the right to health in impacting the global institutions that are most crucial for realizing underlying determinants of health through the strengthening of primary health care systems. Whereas the right to health has been advanced as an individual right to be realized by a state duty-bearer, the authors find that this limited, atomized right has proven insufficient to create accountability for international obligations in global health policy, enabling the deterioration of primary health care systems that lack the ability to address an expanding set of public health claims. For rights scholars to advance disease protection and health promotion through national primary health care systems -- creating the international legal obligations necessary to spur development supportive of the public's health -- the authors conclude that scholars must look beyond the individual right to health to create collective international legal obligations commensurate with a public health-centered approach to primary health care. Through the development and implementation of these collective health rights, states can address interconnected determinants of health within and across countries, obligating the international community to scale-up primary health care systems in the developing world and thereby reduce public health inequities through global health governance. Adapted from the source document.

This article analyzes the growing chasm between international power and state responsibility in health rights, proposing an international legal framework for collective rights -- rights that can reform international institutions and empower developing states to realize the determinants of health structured by global forces. With longstanding recognition that many developing state governments cannot realize the health of their peoples without international cooperation, scholars have increasingly sought to codify international obligations under the purview of an evolving human right to health, applying this rights-based approach as a foundational framework for reducing global health inequalities through foreign assistance. Yet the inherent limitations of the individual human rights framework stymie the right to health in impacting the global institutions that are most crucial for realizing underlying determinants of health through the strengthening of primary health care systems. Whereas the right to health has been advanced as an individual right to be realized by a state duty-bearer, the authors find that this limited, atomized right has proven insufficient to create accountability for international obligations in global health policy, enabling the deterioration of primary health care systems that lack the ability to address an expanding set of public health claims. For rights scholars to advance disease protection and health promotion through national primary health care systems -- creating the international legal obligations necessary to spur development supportive of the public's health -- the authors conclude that scholars must look beyond the individual right to health to create collective international legal obligations commensurate with a public health-centered approach to primary health care. Through the development and implementation of these collective health rights, states can address interconnected determinants of health within and across countries, obligating the international community to scale-up primary health care systems in the developing world and thereby reduce public health inequities through global health governance. Adapted from the source document.

Although there exists widespread recognition that the shared benefits of economic development can improve health, health advocates rarely appreciate the connections between the right to health and the right to development. The collective right to development, transcending the right to health's focus on the individual, offers public health actors an opportunity to work through development discourses to obligate and empower states to allocate public goods for the public's health. This article concludes that health scholars and advocates could employ the right to development to ensure that development policies guide states in realizing the highest attainable standard of health, fulfilling underlying determinants of health through the strengthening of national public health systems.