Income Inequality and Health

In this guest post, Ronald Labonté moves from describing the impact of income inequality on health to the implications of this relationship for both the Canadian and global context. He presents two sets of policy reforms necessary for acting on these contexts and illustrates the scope for Canadian engagement with both national and global policy options. Labonté holds a Canada Research Chair in Globalization and Health Equity at the Institute of Population Health, and is Professor in the Faculty of Medicine, University of Ottawa; and in the Faculty of Health Sciences, Flinders University of South Australia.

Acting to reduce health inequity: How much evidence is enough?

It is often asserted that more evidence is needed to take action on the social determinants of health. In this guest post Ted Schrecker identifies such claims as a key obstacle to achieving health equity. He argues that to overcome this obstacle, we must recognize that decisions about how much evidence is enough are irrevocably bound together with important ethical and political choices. Ted is a Professor of Global Health Policy at Durham University.

Paul Krugman: America’s Greatest Public Health Champion?

Last week the New York Times reported on a study which documents a reversing trend in life expectancy for the least educated whites in the US. The study shows that since 1990, life expectancy for white Americans without a high school diploma has fallen by five years for women and three years for men. Reading […]

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Student Spotlight: Jillian Kowalchuk

With this guest contribution, we are initiating a new series on Healthy Policies which spotlights students who are exploring issues related to the political determinants of health. This first post comes from Jillian Kowalchuk who writes about Kingdon’s three streams model in relation to the Framework Convention in Tobacco Control, which  entered into force 11 years ago, today. 

Policy Entrepreneurs and Kingdon’s three streams model for agenda setting during the formation of the Framework Convention in Tobacco Control: a student applies theory to example

Jillian Kowalchuk

DL lunch-22

The creation of the Framework Convention in Tobacco Control (FCTC) in 2003 was the World Health Organization’s (WHO) first international treaty. Prior to the FCTC, there were no global regulations to combat tobacco use. Nor was there a structure in place to support countries that wished to enact policies.

Policies are made over time and are influenced by the interactions between people who have the power, ability and resources to get things done. Termed actors in academia, they drive the policy process and may include national, international, governmental, intergovernmental and local organizations and individuals (1). Hundreds of people were involved in the creation of the FCTC. This article will focus on a handful that paved the way for the FCTC to move from idea to reality. These ‘policy entrepreneurs” are key actors that create momentum and opportunities. They start the conversation, develop connections that support and guide the process so that a policy moves to the forefront of the agenda (2-4).

The idea of the FCTC began in the 1990’s with Ruth Roemer and Allyn Taylor. Ruth Roemer was a professor in law at UCLA and a formidable leader in public health law. Allyn Taylor is a global health law consultant whose PhD thesis in the 1990’s formed the partial basis for the FCTC. By the 1990s, the tobacco epidemic was becoming recognized as a monumental public health concern in most developed countries (2). Local, state and national tobacco control policies were intermittently emerging in various nations, however global statistics of the impact of tobacco use climbed. More than 3.5 million lives were lost to tobacco in 1998 alone (3).

The FCTC follows Kingdon’s theory of how policies get onto the agenda. Kingdon’s three streams model of agenda setting is the idea that it is the alignment of politics, the problem and the policy that creates a window of opportunity for a policy to move onto the agenda. The ‘policy stream’ involves the analyses of problem, debates and resolutions that reflect dominant social values that are feasible, and publically and politically acceptable. The ‘politics stream’ is the coming together of visible and hidden participants to advocate for a solution and create movement (5). Roemer and Taylor recognized the ‘problem stream’ of the tobacco epidemic; it would require international legislative agreements between countries in order to be successful. This was reiterated by Dr. Gro Harlem Brundtland, who was elected as Director General of the World Health Organization in 1998, and stated,

“Tobacco control cannot succeed solely through the efforts of individual governments, national non-governmental organizations and media advocates. We need an international response to an international problem” (3 p6).

The application of the ‘policy stream’ began with Roemer and Taylor networking through their spheres of influence in public health and law, to lobby that a tobacco control treaty was technically feasible and increasingly publically and politically necessary for the WHO to develop, negotiate and lead (3). Dr. Gro Brundland’s declaration was the ‘politics stream’ bridging together all three streams to place tobacco control on the global health agenda.

Visionaries with power of persuasion and resources used the political, problem and policy opportunities to create the FCTC. After 3 years of negotiating, the FCTC was adopted in 2003 and came into force in 2005. Today there are 180 signatory countries to the FCTC and the latest global progress report indicates that nearly 80% of these countries have adopted or strengthened tobacco control legislation after ratifying the Convention. Using the theoretical concept of ‘policy entrepreneurs’ and Kingdon’s ‘three streams model’ not only helps us to understand how the FCTC came to be, but also illustrates how policy solutions to major health problems can be achieved.


My deepest thanks to Dr. Sue Lawrence for her contributions to the structure, revision, overall support and encouragement in pursuing publishing this assignment as a blog submission.


1. Buse, K., Mays N., Walt G, editor. Making Health Policy. 2nd ed. Berkshire: Open Unversity Press; 2005.

2. Roemer R, Taylor A, Lariviere J. Origins of the WHO framework convention on tobacco control. American Journal of Public Health. 2005. p. 936–8.

3. World Health Organization. History of the WHO Framework Convention on Tobacco Control. Geneva; 2009 p. 1–58.

4. Jha P, Chaloupka FJ, editors. Tobacco control in developing countries. New York; 2000.

5. Kingdon J (2010) Agendas, Alternatives and Public Policies, updated 2nd edition. Harlow: Longman Classics.

Author Biography:

Jillian is a recent graduate from the MSc degree in Public Health from the London School of Hygiene and Tropical Medicine (LSHTM). She also holds a Bachelor of Arts degree in Psychology from the University of Alberta.

Jillian has consulted throughout her MSc at with the private public health consultancy Be the Change Group Inc. Jillian works nationally and internationally with high-risk and vulnerable populations, in creation of campaign designs, implementation research, monitoring and evaluation,  and technical writing. Jillian volunteers on various projects, including blogging for the University of London and currently sits on the Board of Directors for Does HIV Look Like Me? International.

Jillian currently is completing a research internship at The AIDS Service Organization (TASO) in Uganda before attending her graduation in March.

To explore future collaborations and to connect please find her at:

LinkedIn: Jillian Kowalchuk 

Twitter: @kowalchuk_jill





Philip Morris v Australia: A crushing blow to Big Tobacco or a deferral of sentencing for plain packaging?

In this guest post, Ashley Schram, Ronald Labonte, and Arne Ruckert ask whether the recent decision in the legal battle between Australia and Phillip Morris is a victory for public health


The TPP’s intellectual property provisions – a blow for global health and access to medicines

In this guest post, Dr. Deborah Gleeson discusses the final negotiations of the recently agreed trade accord, the Trans-Pacific Partnership, and resulting implications for access to medicines. Deborah is a lecturer in the School of Psychology and Public Health at La Trobe University in Melbourne, Australia. Her research focuses on the impact of international trade agreements on health


Health Impact Assessment of the Trans-Pacific Partnership

In this guest post, Krycia Cowling introduces a webinar organized by Katie Hirono and Fiona Haigh, from the Centre for Health Equity Training, Research, and Evaluation, at the University of New South Wales. The webinar, presented to the APHA Trade and Health Forum, discusses the health impact assessment their team conducted on the proposed Trans-Pacific Partnership. Krycia is a doctoral student in health policy at the Johns Hopkins Bloomberg School of Public Health.


The Final Push: Canada and the Trans-Pacific Partnership (TPP) Trade Deal

In this guest post, authors Arne Ruckert, Ronald Labonté and Ashley Schram outline what’s at stake for Canada in the Trans-Pacific Partnership Trade Deal.


Health and social justice: not all good things grow on the same tree*

In this guest post, Adina Preda and Kristin Voigt respond to a Healthy Policies piece which discusses their recent article ‘The Social Determinants of Health: Why Should We Care’


A response to ‘The Social Determinants of Health: Why Should We Care?’

Philosophers Adina Preda and Kristin Voigt question policy recommendations which call for more equal distributions of social factors as a means of reducing social inequalities in health.


‘But they just can’t kill the beast’: the ongoing neoliberal plague

In this guest post, Ronald Labonté traces the history of neoliberalism through structural adjustment programs, the Great Recession and into current Austerity Agendas. Labonté examines why neoliberalism continues to dominate economic agendas and what types of policy messages are needed to combat the resulting health plagues. This post is cross-posted at Global Health Watch in support […]


Global Health Working Group Promotes Ebola Open Letter

Last week a Workshop was held at the Centre for Global Health Policy at the University of Sussex which brought together a number of scholars, primarily UK-based International Relations scholars, to discuss the current Ebola crisis and the international response to it. From this workshop arose an open letter on what the field of International […]

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