Public Health Agenda Setting in a Global Context: The International Labor Organization’s Decent Work Agenda We drew on two agendasetting theories usually applied at the state or national level to assess their utility at the global level: Kingdon’s multiple streams theory and Baumgartner and Jones’s punctuated equilibrium theory. We illustrate our analysis with findings from a qualitative study of the International Labor Organization’s Decent Work Agenda. We found that both theories help explain the agendasetting mechanisms that operate in the global context, including how windows of opportunity open and what role institutions play as policy entrepreneurs. Future application of these theories could help characterize power struggles between global actors, whose voices are heard or silenced, and their impact on global policy agenda setting. (Am J Public Health. 2015;105: e58–e61. doi:10.2105/AJPH. 2014.302455)

Erica Di Ruggiero, MHSc, RD, Joanna E. Cohen, PhD, Donald C. Cole, MD, MSc, and Lisa Forman, LLB, MA, SJD

VICTOR HUGO’S ASSERTION that no one can resist “an idea whose time has come” still resonates today, but what factors contribute to making an idea timely?1(p1) Many public health issues, including tackling climate change and improving healthy working conditions, hold the potential to garner political and public attention, to mobilize organizational interests, and to surface on policy agendas. Yet these and other health issues continuously compete for legitimacy and resources in the policy process. Agenda setting has inspired much research generally but somewhat less in the public health field.2 Research has examined how such issues emerge to be considered as policies, how agendas are set and produced through the political interactions of social actors, and how attention is maintained and resources are allocated to these problems.2 If agenda setting is about shifting us toward what to think by indicating what to think about,3 what are the realworld factors, who are the relevant actors, and which factors and actors really matter? To these questions we add: what may be different about agenda-setting processes in the global context? Theories help scholars explain this contextual complexity to elucidate how and why issues get and stay on policy agendas, and theories help scholars identify the processes that drive these dynamics.4 We assessed the utility of Kingdon’s multiple streams theory and Baumgartner and Jones’s punctuated equilibrium theory for

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the study of global agenda setting,1,5 with illustrative findings from a qualitative study about the International Labor Organization’s (ILO’s) Decent Work Agenda (DWA). We analyzed selected attributes of these theories in terms of their applicability to the global policy agenda-setting context.

THE DECENT WORK AGENDA In 1999, the ILO created the DWA to encourage institutions and other actors to implement policies that support decent work.6 Work that is not decent can have negative health and social effects through unsafe and unfair working conditions.7,8 To better understand the role the DWA has played in setting the work policy agendas of two other global institutions, we engaged in two lines of inquiry. Our first line of inquiry involved 16 interviews with ILO, World Health Organization (WHO), and World Bank representatives.9 Whereas the ILO advances social justice through the promotion of labor rights, the WHO is the authority for health within the United Nations system, and the World Bank seeks to alleviate extreme poverty and promote development through financial assistance. Our second line of inquiry was a discourse analysis of 10 publicly accessible policy texts published between 1998 and 2012 to contrast health, economic, and social conceptualizations of decent work found in the work policy agendas of these institutions (E. Di Ruggiero et al., unpublished data, 2014).

AGENDA SETTING The theories of Kingdon1 and Baumgartner and Jones5 have been generally applied to understanding agenda settings in a variety of policy contexts at the country level.1,5,10,11 However, Shiffman et al.12 used the punctuated equilibrium theory to examine the ups and downs in global attention to polio, tuberculosis, and malaria control. Kingdon’s theory has been used to conceptualize how different health and social problems emerge and stay on the agenda.10,11,13 He argued that agenda setting occurs when there is a convergence of three streams: problems, policies, and politics.1,10 When the streams converge, windows of opportunity open and allow policy entrepreneurs to advance a solution to the problem. Baumgartner and Jones’s punctuated equilibrium theory characterizes the policy context as relatively stable but punctuated by periods of instability and rapid transformation.5 How an issue is defined or framed is the driving force in periods both of stability and instability that can mobilize individuals previously not interested to suddenly pay attention to an issue.5 A period of stability and inattention to an issue can be interrupted or punctuated by periods of dramatic change. Positive feedback loops are quick, with dramatic instances of diffusion and support for new political ideas replacing support for old ones. Their theory also emphasizes the role of events and precedents in explaining how policy agendas are

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changed. Events are usually limited in space and time but can have a mobilizing and destabilizing effect on what dominates policy discussions. Conversely, precedents can explain why an institution may operate in a policy arena or influence its likelihood of success.

APPLYING AGENDA-SETTING THEORIES IN A GLOBAL CONTEXT Kingdon’s theory of stream convergence and the consequent opening of a policy window apply at the global level. Our research on institutional conceptualizations of decent work suggests that the three streams of problems, policies, and politics were indeed operating globally. The DWA was seen as meeting others’ institutional objectives, such as the fit between decent work and the social determinants of health and health as a human right in the case of the WHO.9 Further, Kingdon’s emphasis on problem definition and the role of defining events and institutional values applied well to our research on the DWA because we found that indecent work (the problem) was a contested notion shaped by different health, economic, and social discourses (E. Di Ruggiero et al., unpublished data, 2014), which were thought to arise through defining events (e.g., a change in the ILO’s organizational leader, the 2008---2009 economic crisis) and institutional precedents (e.g., the long-standing mandate of the ILO in promoting safe and equitable working conditions). We also found that the WHO, the ILO, and the World Bank collaborated and competed with one another for the attention of decision makers in national governments and other international institutions. Joint

collaborative structures between the WHO and ILO and endorsements by influential bodies such as the United Nations Chief Executive Board and the G20 (Group of Twenty; an international forum for the governments and central bank governors from 20 major economies) resulted from the convergence of Kingdon’s three policy streams.9 We also found that policy entrepreneurs played an important role in agenda setting, although the policy entrepreneur in this case was an institution. According to Kingdon, policy entrepreneurs navigate in the politics sphere, promote ideas, and invest time and resources that increase the chances for an idea to get on the agenda.1 Since 1999, the ILO leadership has acted as a collective policy entrepreneur and seized windows of opportunity, building on years of efforts at global, national, and subnational levels (e.g., the ILO offers technical assistance to support the implementation of decent work country programs). Several informants noted that more than 30 United Nations---affiliated agencies have successfully adopted the DWA as a result of the ILO’s policy entrepreneurial efforts. The 2008---2009 global economic crisis (an example of dramatic change) provided a momentous opportunity for the ILO to reframe decent work with a focus on jobs and to mobilize attention to unhealthy working conditions, which previously had limited agenda access. The ILO collaborated with the G20 (a decisionmaking authority) to promote policy coherence for decent work in direct response to this crisis.14 The response to the economic crisis is an example of punctuation in the equilibrium, with the G20 lending political support to promote decent work. The ILO seized

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this window of opportunity and, in so doing, elevated the agenda’s status as a credible response to the crisis.9 Although not central to our research on institutional conceptualizations of decent work, we acknowledge the significant influence of countries, private corporations, and civil society groups on what is advanced in the global policy arena.15---17 Through their informal and formal norms and social practices, powerful actors can steer or disrupt agendas and amplify or silence institutional voices. Media and civil society actors also trigger political action by building public pressure and opening policy windows for change.15

AGENDA-SETTING THEORIES NOT APPLYING AS WELL GLOBALLY Kingdon’s empirical work is derived from how agenda setting unfolds primarily in the context of the United States and from efforts to influence governmental policy agendas.1 As Stone notes, the global context is better characterized as a social and political public space of fluid, dynamic, and intermeshed relations of politics, markets, culture, and society . . . [that is] generated by globalization and shaped by the interactions of its actors,

. . . some more visible, persuasive, or powerful than are others.18(p21) We found that the complex set of macroeconomic, labor, social, and education policies that must be coordinated to promote workers’ wellbeing globally is a formidable challenge for institutions such as the ILO that are trying to position decent work in this contested policy space. The ILO’s efforts are further complicated because the institutions in question do not operate in the same multilateral system (WHO and ILO are part of the

United Nations system, whereas the World Bank is not). Gradual development coupled with the chaotic nature of policymaking made it more difficult to ascertain when convergence of the three streams and agenda setting truly occurred.9 This determination was further complicated at the global level by the many global actors that could influence agendas and the lack of explicit legal authority to implement an agenda through the enactment of legislation or laws. The moderating role of values in agenda setting is somewhat emphasized in both theories. Schwartz described values as conceptions of the desirable that guide the way social actors (e.g., organizational leaders, policymakers, individual persons) select actions, evaluate people and events, and explain their actions and evaluations.19(p24-- 25)

The transsituational nature of values makes them applicable in any context.20 Results from our research confirmed the important role of values in shaping global policy discourses (E. Di Ruggiero et al., unpublished data, 2014).9 Kingdon would certainly argue that multiple policies are expressed as different solutions compete during agenda setting.1 Whereas at national and state levels governments can implement policies that directly affect their citizens, at the global level, global institutions can only set policy directions. These, then, need to be translated into policies or legislation at national and subnational levels. The iterative policy process at multiple levels can lead to the introduction of competing notions of decent work that reflect different values. We found evidence of competing discourses in our textual analysis (E. Di Ruggiero et al., unpublished data, 2014). Health equity, economic and market-based

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framings, and personal responsibility for decent work were each shaped by different claims, values, and ideologies (E. Di Ruggiero et al., unpublished data, 2014). The mandates of these three institutions and the dominance of a disciplinary orientation within each may partially explain these differences. Although the World Bank’s actions are primarily defined by economic thinking, the WHO is more influenced by a public health lens and the ILO by a labor rights lens. Our analyses showed traces of resistance to decent work language, in part because it was ILO terminology and was perceived to conflict with market-based solutions to promoting jobs (E. Di Ruggiero et al., unpublished data, 2014).9 Although issue definition can explain agenda access and provoke the punctuated equilibrium cycle, there are also challenges with unduly emphasizing this attribute. From our study of the DWA, the agenda and issue (decent work) were difficult to disentangle (some key informants conflated one with the other despite attempts to make the distinction). Although not necessarily surprising, it can matter if the policy solution (i.e., what is being advanced in the name of the DWA) is not consistent with what decent work is because it can reinforce gender and health inequities or promote economic solutions to workers’ health (E. Di Ruggiero et al., unpublished data, 2014). Framing workers’ health in economic terms can affect how notions of decent work and the DWA are interpreted and applied. In one of the WHO reports we analyzed, health is framed as a “prerequisite for productivity and economic development,” and workers are framed as “the major contributors to economic and social development” calling for

attention to “high-risk sectors of economic activity.”21 We also examined how, through the agenda, the ILO attempted to normalize what constitutes decent work; however, we acknowledge the powerful influence of financial agencies such as the International Monetary Fund and World Trade Organization, who produce competing dominant discourses about neoliberal solutions to work and health.20

RESEARCH AND POLICY IMPLICATIONS FOR GLOBAL AGENDA SETTING A better understanding of how these theories apply to global agenda setting should interest public health actors. Although these global processes are the subject of increasing attention, actual “accounts of globalized policy processes—distinct from national processes—are few and far between.”18(p3) We must analyze policy agenda setting in global sociocultural and political contexts over time (e.g., social norms, global organizational values and practices). This type of analysis is critical to explaining when and how windows of opportunity open and allow policy entrepreneurs to increase the legitimacy of and resources for a public health issue. Although our study focused on the role of institutions as policy entrepreneurs, a fundamental ambiguity can exist between the institutions themselves and the individuals who lead them. Individual policy entrepreneurs can operate inside and outside institutional structures as part of complex policy subsystems (i.e., policy communities and networks, advocacy coalitions).22 They can move from one institution to another and act as boundary spanners who broker relationships and help navigate different institutional

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cultures.23 Further research is needed to tease out the relative contributions of policy entrepreneurs operating at individual, institutional, or system levels and ascertain which levels matter most in the global context. Advancing knowledge of why and how some public health issues gain more legitimacy and resources at the global level has implications for practice. Public health professionals must become more sophisticated policy entrepreneurs by understanding the power asymmetry between corporations, national governments, global institutions, and public and private consortia to protect the public’s health. The Commission on Global Governance for Health’s diagnosis of the dysfunctions in global governance points to promising avenues for system change.17 They call for independently monitoring the global power asymmetry, challenging social norms that constrain sectors from addressing health inequities, strengthening the use of human rights instruments for health, and having cross-sectoral and transparent policy dialogue among state and nonstate actors in decisions affecting public health.17 These global efforts must join with country-level campaigns led by civil society, communities, and citizens that collectively present a social alternative to powerful financial forces. As stated by Labonté, Crises—economic or ecological— present moments of elasticity in prevailing power hierarchies, but movements must be prepared to enter the political space this creates with a coherent set of social options, from the policy particulars to the normative grand vision.20(p2159)

Research must be linked to these social change efforts. Our results point to the need to continually test and refine such

theories as applied to different policy contexts. At the global level, this includes characterizing the nature of interactions and power relations among global actors; the control and power exercised by global financial actors, whose voices and values are privileged and heard; and the impact of these actors’ influence on setting and shaping global agendas. Research on global processes including the power relations that affect health and health equity is consonant with our recommendations.24,25 As public health professionals, we must learn from our history to better understand the fate of the many public health issues competing for political action. We must examine why these issues rise to and fall off the policy agenda, and join with other sectors to create alternatives and riskbenefit processes that safeguard the public’s health and promote health equity.4,20,26 These tasks are urgent. They matter for global public health, and their time has more than come. j

About the Authors Erica Di Ruggiero, Donald C. Cole, and Lisa Forman are with the Dalla Lana School of Public Health, University of Toronto, Ontario, Canada. Joanna E. Cohen is with the Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Correspondence should be sent to Erica Di Ruggiero, 155 College St., Health Sciences Building, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario M5T3M7, Canada (e-mail: [email protected] Reprints can be ordered at by clicking the “Reprints” link. This article was accepted November 5, 2014.

Contributors E. Di Ruggiero conceptualized the study, conducted key informant interviews and discourse analysis of policy texts, led the interpretation and analysis of data, and wrote first drafts of the article. J. E. Cohen and D. C. Cole contributed to the study design. J. E. Cohen, D. C. Cole, and

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L. Forman contributed to the interpretation of results and critical revisions of the article. All authors approved the final article.

Acknowledgments The authors gratefully acknowledge the key informants for their time, Taylor Basso for his assistance with the transcription of key informant interview data, and Domna Kapetanos for her help with the formatting of references. They would like to also thank the editor and reviewers for very helpful comments on an earlier version of the article.

Human Participant Protection The Health Sciences Research Ethics Board at the University of Toronto granted approval for the study.

References 1. Kingdon JW. Agendas, Alternatives, and Public Policies. 2nd ed. Boston, MA: Longman; 2011. 2. Shiffman J. Agenda setting in public health policy. In: Heggenhougen HK, ed. International Encyclopedia of Public Health. Vol. 1. San Diego, CA: Academic Press; 2008:55---61. 3. Entman RM. How the media affect what people think: an information processing approach. J Polit. 1989;51(2): 347---370. 4. Pralle SB. Agenda-setting and climate change. Env Polit. 2009;18(5):781---799.

5. Baumgartner FR, Jones BD. Agendas and Instability in American Politics. Chicago, IL: University of Chicago Press; 1993. 6. International Labour Organization. Decent work agenda 2014. Available at: decent-work-agenda/lang---de/index.htm. Accessed April 14, 2014. 7. Benach J, Muntaner C, Santana V. Employment conditions and health inequalities: final report to the WHO Commission on Social Determinants of Health. 2007. Available at: social_determinants/resources/articles/ emconet_who_report.pdf. Accessed April 14, 2014. 8. Heymann J, Earle A. Raising the Global Floor: Dismantling the Myth That We Can’t Afford Good Working Conditions for Everyone. Stanford, CA: Stanford University Press; 2009. 9. Di Ruggiero E, Cohen JE, Cole DC. The politics of agenda setting at the global level: key informant interviews regarding the International Labour Organization Decent Work Agenda. Global Health. 2014;10:56. 10. Mannheimer LN, Gulis G, Lehto J. Introducing health impact assessment: an analysis of political and administrative intersectoral working methods. Eur J Public Health. 2007;17(5):526---531. 11. Odom-Forren J, Hahn EJ. Mandatory reporting of health care-associated infections: Kingdon’s multiple streams approach. Policy Polit Nurs Pract. 2006;7(1):64---72.

12. Shiffman J, Beer T, Wu Y. The emergence of global disease control priorities. Health Policy Plan. 2002; 17(3):225---234. 13. Sardell A, Johnson K. The politics of EPSDT policy in the 1990s: policy entrepreneurs, political streams, and children’s health benefits. Milbank Q. 1998;76(2):175---205. 14. International Labour Organization. ILO Century Project. 2014. Available at: index.htm. Accessed April 14, 2014. 15. Ottersen OP, Dasgupta J, Blouin C. The political origins of health inequity: prospects for change. Lancet. 2014; 383(9917):630---667. 16. Labonté R, Schrecker T, Packer C, Runnels V, eds. Globalization and Health: Pathways, Evidence and Policy. New York: Routledge; 2009. 17. Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. 2008. Available at: determinants/thecommission/finalreport/ en. Accessed April 14, 2014. 18. Stone D. Global public policy, transnational policy communities, and their networks. Policy Stud J. 2008;36 (1):19---38.

20. Labonté R. Health activism in a globalising era: lessons past for efforts future. Lancet. 2013;381(9884):2158---2159. 21. World Health Organization. Workers’ health: global plan of action. 2007. Available at: occupational_health/WHO_health_ assembly_en_web.pdf. Accessed April 14, 2014. 22. Fafard P. Evidence and healthy public policy: insights from health and political sciences. 2008. Available at: http://www. Accessed April 14, 2014. 23. Long JC, Cunningham FC, Braithwaite J. Bridges, brokers and boundary spanners in collaborative networks: a systematic review. BMC Health Serv Res. 2013;13:158. 24. Janes CR, Corbett KK. Anthropology and global health. Annu Rev Anthropol. 2009;38:167---183. 25. Östlin P, Schrecker T, Sadana R, et al. Priorities for research on equity and health: towards an equity-focused health research agenda. PLoS Med. 2011;8(11): e1001115. 26. Galea G, McKee M. Public---private partnerships with large corporations: setting the ground rules for better health. Health Policy. 2014;115 (2---3):138---140.

19. Schwartz SH. A theory of cultural values and some implications for work. Applied Psychol Int Rev. 1999;48(1): 23---47.

Reducing Sugary Drink Consumption: New York City’s Approach Studies have linked the consumption of sugary drinks to weight gain, obesity, and type 2 diabetes. Since 2006, New York City has taken several actions to reduce consumption. Nutrition standards limited sugary drinks served by city agencies. Mass media campaigns educated New Yorkers on the added sugars in sugary drinks and their health impact. Policy proposals included an excise tax, a restriction on use of Supplemental Nutrition

Assistance Program benefits, and a cap on sugary drink portion sizes in food service establishments. These initiatives were accompanied by a 35% decrease in the number of New York City adults consuming one or more sugary drinks a day and a 27% decrease in public high school students doing so from 2007 to 2013. (Am J Public Health. 2015;105:e61–e64. doi:10. 2105/AJPH.2014.302497)

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Susan M. Kansagra, MD, MBA, Maura O. Kennelly, MPH, Cathy A. Nonas, MS, RD, Christine J. Curtis, MBA, Gretchen Van Wye, PhD, MA, Andrew Goodman, MD, MPH, and Thomas A. Farley, MD, MPH

FROM 1977 TO THE EARLY 2000s, Americans dramatically increased their consumption of sugary drinks, including carbonated beverages, fruit drinks, sports and energy drinks, and other drinks with added sugars.1 A nationally representative survey conducted in 2009 to 2010 found that sugary drinks contributed approximately 150 calories a day to the diet of both adults and

youths, with some subgroups consuming far more; for example, adolescent boys consumed a mean of 278 calories per day, and men aged 20 to 39 years consumed a mean of 258 calories per day.2 Numerous studies have linked the intake of sugary drinks, the largest single source of added sugars in the diet, with weight gain, obesity, type 2 diabetes, and heart disease.3---8

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Public health agenda setting in a global context: the International Labor Organization's decent work agenda.

We drew on two agenda-setting theories usually applied at the state or national level to assess their utility at the global level: Kingdon's multiple ...
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