International Influences. Policy Networks. Policy Transfer

These five models were developed based on analyses of national political systems. Increasingly, agenda-setting researchers have come to understand that policy agendas are set not by national actors and processes alone, but also by forces from outside the borders of individual nation­states.

International organizations, officials from other countries, donor agencies, and philanthropic foundations, among other transnational actors, have considerable influ­ence over domestic health priorities, particularly those of poor countries that are reliant upon external sources for health funding and technical advice. A body of research from the political science subfield of international rela­tions offers a set of concepts useful for understanding the agenda-setting power of these actors.

Policy Networks. Scholars are giving increasing attention to the role of policy networks as actors in the international system. These vary both in form and level of institutionalization. Two of the more widely researched forms are epistemic communities and transnational advocacy networks. Haas (1992) and colleagues coined the term ‘epistemic commu­nities’ to refer to groups of professionals who by virtue of their knowledge-based authority and shared beliefs about causal processes are able to influence national policies.

The community of scientists concerned about global warming is one example of an epistemic community. It has been able to influence ozone protection policy suc­cessfully. Keck and Sikkink (1998) have examined trans­national advocacy networks. These differ from epistemic communities in that their members consist of multiple organizational types, from labor unions to churches, and are linked not by expertise but by shared commitment to particular causes. In the early 1990s a transnational advo­cacy network formed for reproductive health, linking domestic women’s groups, international nongovernmental organizations, and governments across northern and southern countries.

This network was able to dominate the agenda at the United Nations’ Third International Conference on Population and Development in Cairo in 1994, mounting a significant challenge to the population control paradigm that had been ascendant for decades. The influence of this network is the major reason that reproductive health is now on the global health agenda.

Policy Transfer. While attention has been paid to the emergence and forms of these health networks, there has been less research on the means by which they influence national priorities. One concept of value on this subject is that of ‘policy transfer,’ which concerns the use of knowledge about policies or administrative arrangements in one time or place to develop such arrangements in another time or place (Dolowitz and March, 1996).

Research by Ogden et al. (2003) on the emergence of standards for the treat­ment of tuberculosis, noted above, concerns an example of an international network promoting policy transfer. Stone (1999) notes that scholars employ multiple terms to speak of the concept of policy transfer, including ‘lesson­drawing,’ ‘emulation,’ ‘external inducement,’ ‘convergence,’ and ‘diffusion.’ She identifies three modes of transfer. Policy may be transferred voluntarily if elites in one country value ideas from elsewhere and import these of their own accord.

Policies may be transferred with com­pulsion if powerful organizations such as the World Bank threaten to withhold lending to countries that do not embrace particular practices. Policies may be transferred via structural forces when policy-making elites play no active role and ideas enter national systems through pro­cesses scholars often refer to as ‘convergence.’

Constructivist theory from political science offers a useful framework for thinking about how policy transfer may occur in certain instances. Constructivism works from the premise that nation-states, like individuals, are not isolated entities. They exist within societies of other nation-states and are socialized into commonly shared norms by their encounters with international actors such as the policy networks just discussed (Finnemore, 1996).

Mainstream international relations scholars traditionally have downplayed this form of transnational influence as they have sought to understand the behavior of nation-states in the international arena by looking inside states, taking state preferences as given (Finne- more, 1996). Constructivist theorists argue that on any given policy issue, a state may not initially know what it wants but come to hold certain preferences as a result of interactions in international society with other state and nonstate actors.

For instance, a state originally may not prioritize a health cause such as polio eradication, but it may come to adopt the cause because domestic health officials learn at international gatherings that other countries are pursuing this goal and they are likely to be left behind. Thus, constructivists argue, state prefer­ences cannot be taken as given (Finnemore, 1996), but rather should be conceived of as created in the process of transnational interactions.

International organizations are critical global actors in frameworks influenced by constructivism. Organizations such as the WHO, UNICEF, the World Bank, and the

United Nations Population Fund are created by a global community of nation-states with a view to serving their jointly and individually held interests. However, these organizations may acquire the power to act as indepen­dent, autonomous agents, shaping the policy preferences of the nation-states that created them (Abbot and Snidal, 1998). Thus, UNICEF pushes nation-states to prioritize child health and UNFPA to prioritize reproductive health, even as some of the nation-states that created these organizations may object to their initiatives. Inter­national health policy networks, which link these actors with other kinds of organizations, may play similar roles in shaping national policy preferences.