AbstractThe Narrative Policy Framework (NPF) suggests that narratives can be employed to define and contest policy problems. Yet, few NPF studies have explicitly addressed the narrative portrayal of problem intractability. What role do narratives play in a situation of uncertainty about the causes and solutions of the problem, when strong divergences regarding the values and interests of the policy actors exist? The article anchors the NPF to the literatures on problem definition and implementation to advance two propositions about (a) how differences in the use of narrative elements can be suggestive of the degree of problem (in‐)tractability; and (b) whether other elements of tractability, namely the presence of a valid causal theory, are associated with the usage of narrative strategies. I test the propositions by analyzing media commentaries surrounding the implementation of European decisions to tackle a tree‐killing epidemic in Italy. The findings suggest that narratives can helpfully illustrate the intractability inherent in the policy debate. However, narratives can also develop independently of factors that the implementation literature understands as conducive to lowering intractability, namely knowledge accumulation. The NPF may represent a promising alternative to understand policy implementation processes.
APPROVED ; This thesis investigates state aid allocations in the European Union (EU) member states to answer two key research questions about the political management of a market economy. Today, government officials cannot be indifferent to business performance. When direct management of the economy is not feasible, the government's role is to induce business to perform well. One way to do so is through the allocation of targeted subsidies to firms. However, not all countries support domestic producers to the same extent. Thus, the first research question it seeks to answer is: why do some national governments grant more state aid than others? In Chapter 2, I argue that political actors' incentives depend on the broad configuration of domestic and international political-economic institutions and structures, which interact to shape economic outcomes. My argument hinges on the two key words of responsiveness and accountability. With the former, I want to highlight the use of subsidies as a governmental instrument for the pursuit of a policy goal such as those mentioned above, and the degree to which these goals reflect the voters' preferences. By the latter term, I mean the possibility for the voters to identify who is responsible for policy decisions and to oust officeholders whose performance they find unsatisfactory. The need for politicians to secure re-election incentivises strategic policy-makers to use policies such as subsidies that can bring large and clear net benefits to voters, thus improving their electoral fortunes. The results, expounded in Chapter 3, show that government responsiveness to societal demands is negatively affected by power-sharing arrangements, in particular the presence of coalition partners, and international commitments, such as the regulation of state aid. These results, however, become non-significant when, in Chapter 4, the analysis closes in on one key economic sector of several EU member states, the automotive industry. On the contrary, the accountability side of the story seems to be consistent across the two analyses. This leads to a further line of inquiry: how can we understand state-business relations in state aid politics in terms of responsiveness and accountability? This second question builds on the first one and expands the scope of analysis by looking not merely at the political determinants of aid allocations, but rather at the very dynamics at the heart of state aid politics, showing how state and business interact in this domain. To answer this question, I operate a dual shift of analysis, which was partially initiated with the within-sector investigation in Chapter 4. First, I shift the level of analysis from the macro-level to the meso-level by introducing the policy network approach in Chapter 5. This theoretical framework of interest intermediation based on resource exchange not only complements the macro-level account of state aid politics, but it is also better able to capture the relationship between firms and state agencies by providing a more fine-grained analysis thereof. Secondly, I also shift the methodological approach from regression-based to a mixture of comparative-historical analysis, which investigates state-business relations, and text and content analyses of parliamentary questions, which instead explore parliamentarians' incentives to support domestic producers for electoral goals. To this aim, three member states were chosen as case studies to maximise variation across the independent variables when matched: Italy, Britain and France, which are analysed in Chapters 6, 7 and 8, respectively. In the first part of each chapter, I offer a historical analysis of state-business relations concerning subsidy allocations to the automotive industry. Then, I also provide an explanation, based on the policy network approach, as to why the particular configuration of state-business relations at one time led to specific outcomes of industrial policy and aid disbursement decisions in the industry. The second part of each chapter first presents the electoral system (or systems) of each country, along with other features that are relevant to electoral politics, such as candidate selection. After that, I investigate how parliamentarians approach questions by looking at the most frequently used words, at who asked the question, and whether or not the question could be seen as the parliamentarian engaging in constituency service. Two findings of these case studies stand out. First, regardless of the political system, there is a persistent use of subsidies as a reactive policy tool, employed more as a means to maintain the status quo in the sector rather than innovate and set up an industrial agenda. This, instead, is better explained by the nature of the sectoral policy network in each country. Secondly, parliamentarians only partly follow electoral incentives when tabling questions. Part of their behaviour seems to be instead influenced by the typology of policy network within the sector, although the direction of the effect and the causal mechanism remain unclear. The case studies prove the usefulness of this double shift of analysis, which helped in at least two respects. First, it helped bridge the macro-level findings with the sectoral-level ones. Without the sectoral regression analysis, the rest of the findings would have been contradictory, leading to wrong inferences. Secondly, it showed that, unlike what the regression findings may suggest, there is no automatic translation of how electoral institutions influence legislative behaviour to lobby for subsidies. The wider implications of this study travel across several literatures. The theoretical framework offered in Chapter 2 can be applied not only to state aid allocations, but to a variety of other policies of state intervention in business politics, such as foreign direct investment, mergers & acquisitions, privatisations, tariffs, and product market regulation. Further, other sectors beyond the automotive industry can be analysed in the same way to explore in particular the political clout that multinational corporations today have over national governments. Thirdly, by uncovering some of the shortcomings of the policy network approach that come to the fore particularly when considering the globalised and Europeanised economic environment of today, this work can contribute to its future developments. Finally, this work can also set an agenda to better investigate the interlinking of policy network and electoral politics.
AbstractDespite widespread acknowledgement of the dangers of selective subsidisation, government support to business remains common practice. Looking at State aid allocations in the European Union, the article explores why some countries grant more aid than others. Scholarship has failed to address this issue in a comprehensive manner, focusing either on the responsiveness of governments to voters' preferences or on the use of subsidies as a way to ensure the political survival of the incumbent. Using the lens of distributive politics, this article proposes a more comprehensive account of State aid politics that joins these two perspectives. By means of time-series cross-section regression analysis, it tests how aid allocation depends on the attainment of policy goals (namely correction of market failures), electoral pragmatism and responsibility towards international commitments. The results show that politicians are indeed electorally pragmatic, but not necessarily responsive, due to institutional constraints and international commitments.
Recent data for the global burden of disease reflect major demographic and lifestyle changes, leading to a rise in noncommunicable diseases. Most countries with high levels of tuberculosis face a large comorbidity burden from both non-communicable and communicable diseases. Traditional disease-specific approaches typically fail to recognise common features and potential synergies in integration of care, management, and control of non-communicable and communicable diseases. In resource-limited countries, the need to tackle a broader range of overlapping comorbid diseases is growing. Tuberculosis and HIV/AIDS persist as global emergencies. The lethal interaction between tuberculosis and HIV coinfection in adults, children, and pregnant women in sub-Saharan Africa exemplifies the need for well integrated approaches to disease management and control. Furthermore, links between diabetes mellitus, smoking, alcoholism, chronic lung diseases, cancer, immunosuppressive treatment, malnutrition, and tuberculosis are well recognised. Here, we focus on interactions, synergies, and challenges of integration of tuberculosis care with management strategies for non-communicable and communicable diseases without eroding the functionality of existing national programmes for tuberculosis. The need for sustained and increased funding for these initiatives is greater than ever and requires increased political and funder commitment.
Recent data for the global burden of disease reflect major demographic and lifestyle changes, leading to a rise in non-communicable diseases. Most countries with high levels of tuberculosis face a large comorbidity burden from both non-communicable and communicable diseases. Traditional disease-specific approaches typically fail to recognise common features and potential synergies in integration of care, management, and control of non-communicable and communicable diseases. In resource-limited countries, the need to tackle a broader range of overlapping comorbid diseases is growing. Tuberculosis and HIV/AIDS persist as global emergencies. The lethal interaction between tuberculosis and HIV coinfection in adults, children, and pregnant women in sub-Saharan Africa exemplifies the need for well integrated approaches to disease management and control. Furthermore, links between diabetes mellitus, smoking, alcoholism, chronic lung diseases, cancer, immunosuppressive treatment, malnutrition, and tuberculosis are well recognised. Here, we focus on interactions, synergies, and challenges of integration of tuberculosis care with management strategies for non-communicable and communicable diseases without eroding the functionality of existing national programmes for tuberculosis. The need for sustained and increased funding for these initiatives is greater than ever and requires increased political and funder commitment.
10 Pages, 1 Figure, 3 Tables. Supplementary information: http://dx.doi.org/10.1038/s41598-018-33731-1 ; Drug-resistant tuberculosis poses a persistent public health threat. The ReSeqTB platform is a collaborative, curated knowledgebase, designed to standardize and aggregate global Mycobacterium tuberculosis complex (MTBC) variant data from whole genome sequencing (WGS) with phenotypic drug susceptibility testing (DST) and clinical data. We developed a unified analysis variant pipeline (UVP) ( https://github.com/CPTR-ReSeqTB/UVP ) to identify variants and assign lineage from MTBC sequence data. Stringent thresholds and quality control measures were incorporated in this open source tool. The pipeline was validated using a well-characterized dataset of 90 diverse MTBC isolates with conventional DST and DNA Sanger sequencing data. The UVP exhibited 98.9% agreement with the variants identified using Sanger sequencing and was 100% concordant with conventional methods of assigning lineage. We analyzed 4636 publicly available MTBC isolates in the ReSeqTB platform representing all seven major MTBC lineages. The variants detected have an above 94% accuracy of predicting drug based on the accompanying DST results in the platform. The aggregation of variants over time in the platform will establish confidence-graded mutations statistically associated with phenotypic drug resistance. These tools serve as critical reference standards for future molecular diagnostic assay developers, researchers, public health agencies and clinicians working towards the control of drug-resistant tuberculosis. ; This study was supported by the Bill & Melinda Gates Foundation under grant agreement OPP1115887 to C-Path for developing the ReSeqTB drug resistance data sharing platform and under grant agreement FIND OPP1115209 to address how to score mutations in the ReSeqTB data sharing platform initiative. The South African MRC and the EDCTP support K. Dheda. I. Comas is supported by the Ministerio de Economía y Competitividad (Spanish Government) research grant SAF2016-77346-R and the European Research Council (ERC) (638553-TB-ACCELERATE). L. Chindelevitch acknowledges support by NSERC, Genome Canada, and the Sloan Foundation. Use of trade names is for identification only and does not constitute endorsement by the US Department of Health and Human Services, the US Public Health Service, or the Centers for Disease Control and Prevention. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the funding agency. ; Peer reviewed
Two decades ago, WHO declared tuberculosis a global emergency, and invested in the highly cost-effective directly observed treatment short-course programme to control the epidemic. At that time, most strains of Mycobacterium tuberculosis were susceptible to first-line tuberculosis drugs, and drug resistance was not a major issue. However, in 2013, tuberculosis remains a major public health concern worldwide, with prevalence of multidrug-resistant (MDR) tuberculosis rising. WHO estimates roughly 630 000 cases of MDR tuberculosis worldwide, with great variation in the frequency of MDR tuberculosis between countries. In the past 8 years, extensively drug-resistant (XDR) tuberculosis has emerged, and has been reported in 84 countries, heralding the possibility of virtually untreatable tuberculosis. Increased population movement, the continuing HIV pandemic, and the rise in MDR tuberculosis pose formidable challenges to the global control of tuberculosis. We provide an overview of the global burden of drug-resistant disease; discuss the social, health service, management, and control issues that fuel and sustain the epidemic; and suggest specific recommendations for important next steps. Visionary political leadership is needed to curb the rise of MDR and XDR tuberculosis worldwide, through sustained funding and the implementation of global and regional action plans.
Two decades ago, WHO declared tuberculosis a global emergency, and invested in the highly cost-effective directly observed treatment short-course programme to control the epidemic. At that time, most strains of Mycobacterium tuberculosis were susceptible to first-line tuberculosis drugs, and drug resistance was not a major issue. However, in 2013, tuberculosis remains a major public health concern worldwide, with prevalence of multidrug-resistant (MDR) tuberculosis rising. WHO estimates roughly 630 000 cases of MDR tuberculosis worldwide, with great variation in the frequency of MDR tuberculosis between countries. In the past 8 years, extensively drug-resistant (XDR) tuberculosis has emerged, and has been reported in 84 countries, heralding the possibility of virtually untreatable tuberculosis. Increased population movement, the continuing HIV pandemic, and the rise in MDR tuberculosis pose formidable challenges to the global control of tuberculosis. We provide an overview of the global burden of drug-resistant disease; discuss the social, health service, management, and control issues that fuel and sustain the epidemic; and suggest specific recommendations for important next steps. Visionary political leadership is needed to curb the rise of MDR and XDR tuberculosis worldwide, through sustained funding and the implementation of global and regional action plans.
13 Pages, 1 Figure, 4 tables. The authors' affiliations are listed in the Supplementary Appendix, available at NEJM.org. Supplementary Material, available at http://dx.doi.org/10.1056/NEJMoa1800474 ; BACKGROUND: The World Health Organization recommends drug-susceptibility testing of Mycobacterium tuberculosis complex for all patients with tuberculosis to guide treatment decisions and improve outcomes. Whether DNA sequencing can be used to accurately predict profiles of susceptibility to first-line antituberculosis drugs has not been clear. METHODS: We obtained whole-genome sequences and associated phenotypes of resistance or susceptibility to the first-line antituberculosis drugs isoniazid, rifampin, ethambutol, and pyrazinamide for isolates from 16 countries across six continents. For each isolate, mutations associated with drug resistance and drug susceptibility were identified across nine genes, and individual phenotypes were predicted unless mutations of unknown association were also present. To identify how whole-genome sequencing might direct first-line drug therapy, complete susceptibility profiles were predicted. These profiles were predicted to be susceptible to all four drugs (i.e., pansusceptible) if they were predicted to be susceptible to isoniazid and to the other drugs or if they contained mutations of unknown association in genes that affect susceptibility to the other drugs. We simulated the way in which the negative predictive value changed with the prevalence of drug resistance. RESULTS: A total of 10,209 isolates were analyzed. The largest proportion of phenotypes was predicted for rifampin (9660 [95.4%] of 10,130) and the smallest was predicted for ethambutol (8794 [89.8%] of 9794). Resistance to isoniazid, rifampin, ethambutol, and pyrazinamide was correctly predicted with 97.1%, 97.5%, 94.6%, and 91.3% sensitivity, respectively, and susceptibility to these drugs was correctly predicted with 99.0%, 98.8%, 93.6%, and 96.8% specificity. Of the 7516 isolates with complete phenotypic drug-susceptibility profiles, 5865 (78.0%) had complete genotypic predictions, among which 5250 profiles (89.5%) were correctly predicted. Among the 4037 phenotypic profiles that were predicted to be pansusceptible, 3952 (97.9%) were correctly predicted. CONCLUSIONS: Genotypic predictions of the susceptibility of M. tuberculosis to first-line drugs were found to be correlated with phenotypic susceptibility to these drugs. (Funded by the Bill and Melinda Gates Foundation and others.). ; Supported by grants from the Bill and Melinda Gates Foundation (OPP1133541, to CRyPTIC, plus separate support to Dr. Rodwell), a Wellcome Trust/Newton Fund–MRC Collaborative Award (200205/Z/15/Z, to CRyPTIC), the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC) and NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance at University of Oxford in partnership with Public Health England, the NIHR Biomedical Research Centre at Barts, the NIHR Biomedical Research Centre at Imperial, the NIHR and NHS England (to the 100,000 Genomes Project, which is managed by Genomics England, a wholly owned company of the U.K. Department of Health), the Wellcome Trust, the Medical Research Council, Public Health England, a grant from the National Science and Technology Key Program of China (2014ZX10003002), a grant from the National Basic Research program of China (2014CB744403), a grant from the Strategic Priority Research Program of the Chinese Academy of Sciences (XDB29020000), a grant from the European Commission Seventh Framework Program (FP7/2007-2013, to Borstel under grant agreement 278864 in the framework of the Patho-NGen-Trace project), the German Center for Infection Research (to Borstel), Leibniz Science Campus Evolutionary Medicine of the Lung (EvoLUNG), the Belgian Ministry of Social Affairs (to the Belgian Reference Center for Tuberculosis and Mycobacteria from Bacterial Diseases Service through a fund within the Health Insurance System), the French governmental program "Investing for the Future" (to Genoscreen), a grant from the European Commission Seventh Framework Program (FP7/2007-2013, to Genoscreen under grant agreement 278864 in the framework of the Patho-NGen-Trace project), grants from the Drug Resistant Tuberculosis Fund (R015833003, to Dr. Chaiprasert), the Faculty of Medicine, Siriraj Hospital, Mahidol University (to Dr. Chaiprasert), a grant from the Ministry of Economy and Competitiveness (MINECO), Spain (SAF2016-77346-R, to Dr. Comas), a grant from the European Research Council (638553-TB-ACCELERATE, to Dr. Comas), a grant from the BC Centre for Disease Control Foundation for Population and Public Health (to Dr. Gardy), a grant from the British Colombia Lung Association (to Dr. Gardy), grants from the Wellcome Trust and the Royal Society (101237/Z/13/Z and 102541/A/13/Z, to Drs. Wilson and Iqbal [Sir Henry Dale Fellows]), a grant from the National University of Singapore Yong Loo Lin School of Medicine Aspiration Fund (NUHSRO/2014/069/AF-New Idea/04, to Drs. Ong and Teo), a European Commission Seventh Framework Program European Genetic Network (EUROGEN) grant (201483, to Dr. Drobniewski), and the National Institute of Allergy and Infectious Diseases, National Institutes of Health (to Dr. Rodwell). Dr. T. Walker is an NIHR Academic Clinical Lecturer, and Drs. Crook, Peto, and Caulfield are NIHR Senior Investigators. No potential conflict of interest relevant to this article was reported. Disclosure forms provided by the authors are available with the full text of this article at NEJM.org. We thank Stéphanie Duthoy, Carina Hahn, Alamdar Hussain, Yannick Laurent, Mathilde Mairey, Vanessa Mohr, and Mahmood Qadir for technical assistance and George F. Gao, Director of the Chinese Center for Disease Control and Prevention, for directing the Chinese grant and sequencing program ; Peer reviewed
