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This paper proposes an explanation concerning why some global health issues such as HIV/AIDS attract significant attention from international and national leaders, while other issues that also represent a high mortality and morbidity burden, such as pneumonia and malnutrition, remain neglected. The rise, persistence and decline of a global health issue may best be explained by the way in which its policy community--the network of individuals and organizations concerned with the problem--comes to understand and portray the issue and establishes institutions that can sustain this portrayal. This explanation emphasizes the power of ideas and challenges interpretations of issue ascendance and decline that place primary emphasis on material, objective factors such as mortality and morbidity levels and the existence of cost-effective interventions. This explanation has implications for our understanding of strategic public health communication. If ideas in the form of issue portrayals are central, strategic communication is far from a secondary public health activity: it is at the heart of what global health policy communities do.

A number of individuals and organizations have considerable influence over the selection of global health priorities and strategies. For some that influence derives from control over financial resources. For others it comes from expertise and claims to moral authority-what can be termed, respectively, epistemic and normative power. In contrast to financial power, we commonly take for granted that epistemic and normative forms of power are legitimate. I argue that we should not; rather we should investigate the origins of these forms of power, and consider under what circumstances they are justly derived.

Global health networks, webs of individuals and organizations with a shared concern for a particular condition, have proliferated over the past quarter century. They differ in their effectiveness, a factor that may help explain why resource allocations vary across health conditions and do not correspond closely with disease burden. Drawing on findings from recently concluded studies of eight global health networks-addressing alcohol harm, early childhood development (ECD), maternal mortality, neonatal mortality, pneumonia, surgically-treatable conditions, tobacco use, and tuberculosis-I identify four challenges that networks face in generating attention and resources for the conditions that concern them. The first is problem definition: generating consensus on what the problem is and how it should be addressed. The second is positioning: portraying the issue in ways that inspire external audiences to act. The third is coalition-building: forging alliances with these external actors, particularly ones outside the health sector. The fourth is governance: establishing institutions to facilitate collective action. Research indicates that global health networks that effectively tackle these challenges are more likely to garner support to address the conditions that concern them. In addition to the effectiveness of networks, I also consider their legitimacy, identifying reasons both to affirm and to question their right to exert power.

Why do some global health initiatives receive priority from international and national political leaders whereas others receive little attention? To analyse this question we propose a framework consisting of four categories: the strength of the actors involved in the initiative, the power of the ideas they use to portray the issue, the nature of the political contexts in which they operate, and characteristics of the issue itself. We apply this framework to the case of a global initiative to reduce maternal mortality, which was launched in 1987. We undertook archival research and interviewed people connected with the initiative, using a process-tracing method that is commonly employed in qualitative research. We report that despite two decades of effort the initiative remains in an early phase of development, hampered by difficulties in all these categories. However, the initiative's 20th year, 2007, presents opportunities to build political momentum. To generate political priority, advocates will need to address several challenges, including the creation of effective institutions to guide the initiative and the development of a public positioning of the issue to convince political leaders to act. We use the framework and case study to suggest areas for future research on the determinants of political priority for global health initiatives, which is a subject that has attracted much speculation but little scholarship.

Early childhood development programmes vary in coordination and quality, with inadequate and inequitable access, especially for children younger than 3 years. New estimates, based on proxy measures of stunting and poverty, indicate that 250 million children (43%) younger than 5 years in low-income and middle-income countries are at risk of not reaching their developmental potential. There is therefore an urgent need to increase multisectoral coverage of quality programming that incorporates health, nutrition, security and safety, responsive caregiving, and early learning. Equitable early childhood policies and programmes are crucial for meeting Sustainable Development Goals, and for children to develop the intellectual skills, creativity, and wellbeing required to become healthy and productive adults. In this paper, the first in a three part Series on early childhood development, we examine recent scientific progress and global commitments to early childhood development. Research, programmes, and policies have advanced substantially since 2000, with new neuroscientific evidence linking early adversity and nurturing care with brain development and function throughout the life course.

I conducted case studies on the level of political priority given to maternal mortality reduction in 5 countries: Guatemala, Honduras, India, Indonesia, and Nigeria. Among the factors that shaped political priority were international agency efforts to establish a global norm about the unacceptability of maternal death; those agencies’ provision of financial and technical resources; the degree of cohesion among national safe motherhood policy communities; the presence of national political champions to promote the cause; the deployment of credible evidence to show policymakers a problem existed; the generation of clear policy alternatives to demonstrate the problem was surmountable; and the organization of attention-generating events to create national visibility for the issue. The experiences of these 5 countries offer guidance on how political priority can be generated for other health causes in developing countries.

Global health networks-webs of individuals and organizations linked by a shared concern for a particular condition-have proliferated over the past quarter century. In a recent editorial in this journal, I presented evidence that their effectiveness in addressing four challenges-problem definition, positioning, coalitionbuilding and governance-shapes their ability to influence policy. The editorial prompted five thoughtful commentaries that reflected on these and other challenges. In this follow-up editorial, I build on the commentaries to suggest ways of advancing research on global health networks. I argue that investigators would do well to consider three social theory-influenced global governance debates pertaining to agency-the capacity of individuals and organizations to act autonomously amidst structural constraints. The three debates concern the relationship between agency and structure, the power of ideas vis-à-vis interests and material capabilities, and the level of influence of non-state actors in a global governance system that most scholars identify as state-dominated. Drawing on these debates, I argue that rather than presume global health network influence, we need to find more robust ways to investigate their effects. I argue also that rather than juxtapose agency and structure, ideas and interests and non-state and state power, it would be more productive to consider the ways in which these elements are intertwined.

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.

Despite progress, early childhood development (ECD) remains a neglected issue, particularly in resource-poor countries. We analyse the challenges and opportunities that ECD proponents face in advancing global priority for the issue. We triangulated among several data sources, including 19 semi-structured interviews with individuals involved in global ECD leadership, practice, and advocacy, as well as peer-reviewed research, organisation reports, and grey literature. We undertook a thematic analysis of the collected data, drawing on social science scholarship on collective action and a policy framework that elucidates why some global initiatives are more successful in generating political priority than others. The analysis indicates that the ECD community faces two primary challenges in advancing global political priority. The first pertains to framing: generation of internal consensus on the definition of the problem and solutions, agreement that could facilitate the discovery of a public positioning of the issue that could generate political support. The second concerns governance: building of effective institutions to achieve collective goals. However, there are multiple opportunities to advance political priority for ECD, including an increasingly favourable political environment, advances in ECD metrics, and the existence of compelling arguments for investment in ECD. To advance global priority for ECD, proponents will need to surmount the framing and governance challenges and leverage these opportunities.