The impact of internal characteristics on global health epistemic community effectiveness: The cases of global surgery, early childhood development, and urban health

In an increasingly globalized world, non-state transnational actors and networks are becoming more numerous and influential. These include epistemic communities-professional networks with recognized competence and policy-relevant expertise in particular issues. Studies examining epistemic community effectiveness have emphasized factors associated with the characteristics of the issues being addressed and the political environment (external factors) to the neglect of the strategies adopted and choices made by epistemic community members (internal factors). This neglect has limited understanding of epistemic communities and hampered theoretical development of the epistemic community concept. Through replicated case studies of three global health epistemic communities-addressing surgery, early childhood development, and urban health - I investigated why some epistemic communities are better able than others to place their issues on global agendas. My aim was to better explain: 1) how epistemic communities emerge and develop; 2) how an epistemic community's internal qualities interact with external characteristics in shaping its influence; and 3) what factor or set of factors has the greatest explanatory power in explaining epistemic community influence. I triangulated among several data sources, including semi-structured interviews with involved individuals, as well as peer-reviewed research, organization reports, conference notes, and grey literature, in order to piece together the modern history of global attention to each of the global health issues. I conducted 76 interviews and reviewed 746 documents, utilizing a process-tracing methodology. I drew on ideas from existing epistemic community scholarship, constructivist scholarship in the areas of global governance, networks, policy, and social movements, as well as my data from the three empirical cases to create a conceptual framework, organized by internal and external factors, for analyzing epistemic community development and effectiveness. In all three cases examined, the external factors alone - the social, economic, and historic forces or structures that are not explicitly inherent to epistemic communities - offered an incomplete explanation for the historical neglect of the issues on global agendas. Despite the fact that the three global health cases shared some common external features that explain each of these issue's historical neglect (i.e., multi-sectorality, lack of sufficient data to demonstrate solution tractability, etc.), there were differences in their trajectories of attention. Much of this was due to internal features. Specifically, the way in which each of these communities organized to pursue their collective goals (governance), their extent of agreement around the problem and how to address it (member cohesion), and how the case for the issue was made to policy and decision-makers (external positioning) were critical for understanding the variance in epistemic community effectiveness over time and across the cases. Ultimately, however, the amount of global attention that an issue received could only be explained by the interaction between these three internal factors and external factors. In all three cases, the internal and external qualities were intertwined: the epistemic communities transformed the very nature of the issue they sought to advance, which then created a new political environment, which then transformed how the epistemic communities behaved and their very nature. The characteristics of the issue and the policy environment are not determinative of epistemic community formation or effectiveness. While important, consideration of an epistemic community's agency is critical to understanding how it forms and its ultimate ability to advance its issue on global agendas. The findings point to three unique implications, which challenge and advance epistemic community theory. First, an epistemic community's member cohesion is not given, as suggested by the existing epistemic community scholarship; rather, it is a key determinant of effectiveness. Second, leadership at the individual and institutional levels - a factor not considered by existing epistemic community scholarship - is crucial to explaining variance in epistemic community effectiveness. Finally, there are multiple pathways - ones that extend beyond the presence of a shock or crisis as suggested by existing epistemic community scholarship - that lead decision-makers to turn to epistemic communities and ultimately make them powerful forces in global politics.