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Actors working in global health often portray it as an enterprise grounded in principled concerns, advanced by individuals and organizations who draw on scientific evidence to pursue health equity. This portrait is incomplete. It is also a field of power relations—a social arena in which actors claim and draw on expertise and moral authority to gain influence and pursue career, organizational and national interests. A clear understanding of how power operates in this field is necessary to ensure that it is used productively to serve the aims of health equity and improved population health. Responding to commentaries on an editorial published in this journal, I offer 3 ideas toward this end: (1) be skeptical of the global health rationality project—the effort to rescue the field from the alleged indignities of politics through the application of scientific methods; (2) analyze global health as a field of power relations, a concept developed by sociologist Pierre Bourdieu; and (3) elevate the place of input legitimacy—inclusive deliberation, fair process and transparency—to address legitimacy and knowledge deficits in this field.

I conducted case studies on the level of political priority given to maternal mortality reduction in 5 countries: Guatemala, Honduras, India, Indonesia, and Nigeria.

Does poverty bind developing countries to high levels of maternal death in childbirth? Or, as safe‐motherhood advocates claim, do public health and social policy interventions have the potential to accelerate maternal mortality transitions? Globally, almost one in 200 live births leads to the death of the mother, making maternal mortality an issue of critical international import. This article presents an analysis of the determinants of national maternal mortality levels with a view to shedding light on these questions. A cross‐national regression of 64 countries shows that wealth indicators explain only a portion of the variance in national maternal mortality levels. Other determinants, including women's educational levels and the proportion of deliveries attended by trained health personnel, are more clearly associated with national maternal mortality levels than are measures of wealth. The results offer grounds for optimism concerning the potential for global safe‐motherhood efforts to induce maternal mortality transitions.

The low priority that most low-income countries give to neonatal mortality, which now constitutes more than 40% of deaths to children younger than 5 years, is a stumbling block to the world achieving the child survival Millennium Development Goal. Bangladesh is an exception to this inattention. Between 2000 and 2011, newborn survival emerged from obscurity to relative prominence on the government's health policy agenda. Drawing on a public policy framework, we analyzed how this attention emerged. Critical factors included national advocacy, government commitment to the Millennium Development Goals, and donor resources. The emergence of policy attention involved interactions between global and national factors rather than either alone. The case offers guidance on generating priority for neglected health problems in low-income countries.

AbstractSince the 1970s many non‐governmental development organisations have moved away from top‐down modes of operation toward participatory practices that hand over decision‐making power to the poor. The bilateral development agencies of the industrialised states have been slower to follow suit, but in the 1980s and 1990s a number of such agencies also initiated participatory‐oriented reforms. Development scholars have paid little attention to reforms of the larger organisations. In this article, we analyse the efforts of the United States Agency for International Development to embrace participation in the 1990s. Internal reformers managed to change some agency procedures but had only limited success in institutionalising participatory practices. Forces internal to the agency, including rigid rules and employee incentive structures, hampered reform efforts. Also, while some developments external to the agency facilitated participation, many others, including legislative interference and shifting national policy priorities, hindered change toward participation. The case reveals how complex webs of accountability relationships make participatory‐oriented transformation a cumbersome process in large development organisations. Change towards participation can succeed, but only if reformers acknowledge and consider existing institutional constraints. Copyright © 2004 John Wiley & Sons, Ltd.

Commercial gambling is increasingly viewed as being part of the unhealthy commodities industries, in which products contribute to preventable ill-health globally. Britain has one of the world's most liberal gambling markets, meaning that the regulatory changes there have implications for developments elsewhere. A review of the British Gambling Act 2005 is underway. This has generated a range of actions by the industry, including mobilising arguments around the threat of the "black market". We critically explore industry's framing of these issues as part of their strategy to resist regulatory change during the Gambling Act review. We used a predefined review protocol to explore industry narratives about the "black market" in media reports published between 8 December 2020 and 26 May 2021. Fifty-five articles were identified and reviewed, and themes were narratively synthesised to examine industry framing of the "black market". The black market was framed in terms of economic threat and loss, and a direct connection was made between its growth and increased regulation. The articles mainly presented gambling industry perspectives uncritically, citing industry-generated evidence (n = 40). Industry narratives around the "black market" speak to economically and emotionally salient concerns: fear, safety, consumer freedom and economic growth. This dominant framing in political, mainstream and industry media may influence political and public opinion to support the current status quo: "protecting" the existing regulated market rather than "protecting" people. Debates should be reframed to consider all policy options, especially those designed to protect public health.

Proponents have promoted sexuality education as a means of empowering adolescents, yet it has been thwarted in many low and middle-income countries. Nigeria represents an exception. Despite social opposition, the government in 1999 unexpectedly approved sexuality education policy. Since then, implementation has advanced, although efficacy has differed across states. We draw on theory concerning international norm diffusion to understand Nigerian policy development.We find that a confluence of international and national norms and interests shaped policy outcomes, including concern over HIV/AIDS. A central dynamic was an alliance of domestic NGOs and international donors pressing the Nigerian government to act.We argue that theory on international norms can be applied to understand policy dynamics across a variety of health and population areas, finding value in approaches that integrate rather than juxtapose consideration of (1) international and national influences; (2) long and short-term perspectives on policy change; and (3) norms and interests.

BACKGROUND: Rheumatic heart disease (RHD) poses a high burden in low‐income countries, as well as among indigenous and other socioeconomically disadvantaged populations in high‐income countries. Despite its severity and preventability, RHD receives insufficient global attention and resources. We conducted a qualitative policy analysis to investigate the reasons for recent growth but ongoing inadequacy in global priority for addressing RHD. METHODS AND RESULTS: Drawing on social science scholarship, we conducted a thematic analysis, triangulating among peer‐reviewed literature, organizational documents, and 20 semistructured interviews with individuals involved in RHD research, clinical practice, and advocacy. The analysis indicates that RHD proponents face 3 linked challenges, all shaped by the nature of the issue. With respect to leadership and governance, the fact that RHD affects mostly poor populations in dispersed regions complicates efforts to coordinate activities among RHD proponents and to engage international organizations and donors. With respect to solution definition, the dearth of data on aspects of clinical management in low‐income settings, difficulties preventing and addressing the disease, and the fact that RHD intersects with several disease specialties have fueled proponent disagreements about how best to address the disease. With respect to positioning, a perception that RHD is largely a problem for low‐income countries and the ambiguity on its status as a noncommunicable disease have complicated efforts to convince policy makers to act. CONCLUSIONS: To augment RHD global priority, proponents will need to establish more effective governance mechanisms to facilitate collective action, manage differences surrounding solutions, and identify positionings that resonate with policy makers and funders.