The global health agenda is ill-defined as an analytical construct, complicating attempts by scholars and proponents to measure and make valid claims concerning the status of high-profile and neglected problems alike. Studies seeking to assess and explain differences in the agenda status of global health problems often turn to the allocation of rhetorical, policy and programmatic attention and more tangible indicators, such as human, budgetary and technical resources, to measure the agenda without clearly defining what the agenda refers to or developing methods that can be scaled up beyond the case studies that dominate this body of scholarship. Studies that assess international donor priorities by analyzing data from large aid databases form an important exception [1,2,3]; however, aid priorities form only a partial representation of the global health agenda. We develop and explore the potential of an arenas model to form a foundation for addressing these conceptual and measurement challenges. We leverage the emergent novel coronavirus (COVID-19) pandemic, a focusing event that provides an opportunity to investigate quick and substantial shifts (punctuation) in agendas [4,5,6].
We present the groundwork underpinning a collaborative effort to investigate trends in global health agenda setting under the rubric of the Global Health Agendas Project.Footnote 1 We draw on public policy scholarship, including seminal work by Kingdon  and Baumgartner and Jones , an arenas model from sociology  and analyses of agenda setting in global health , to develop an analytical model that posits the global health agenda is formed in national and transnational arenas that overlap and interact with each other. We identify several arenas in which global health agenda setting occurs and discuss indicators that may be used to advance systematic approaches to measurement. We then apply the model to illustrate how the status of established (HIV/AIDS), emergent (diabetes) and rising (Alzheimer’s disease) issues might be measured, compared and change in light of a pandemic shock (COVID-19). We analyze the status of these global health issues in 2019 relative to their status in the year following China’s report to the World Health Organization (WHO) of a cluster of viral pneumonia cases on December 31, 2019.
Coronavirus priority indicators rose precipitously in all five arenas in 2020, reflecting the kind of punctuation often caused by focusing events or shocks [4,5,6] The magnitude of change varied somewhat by arena, with the most pronounced shift in the global news media arena. Priority indicators for the other conditions showed decreases of up to 21% and increases of up to 41% between 2019 and 2020, with increases in the pharmaceutical industry, media and scientific research arenas suggesting that the global health agenda expanded in some arenas in 2020—COVID-19 did not consistently displace priority for HIV/AIDS, diabetes or Alzheimer’s disease, though it might have for other issues. The study suggests that the conceptual model and measurement approach hold promise to advance knowledge useful to scholars and those working for accountability and justice on global health problems that disproportionately impact marginalized communities.
Using an arenas model to conceptualize and measure the global health agenda
Global health includes state and non-state actors [9,10,11,12]. Kingdon  provides a definition of the agenda that applies to national settings: “… the list of subjects or problems to which governmental officials, and people outside of government closely associated with those officials, are paying some serious attention at any given time.” Global health scholars and proponents use indicators of serious attention in national settings, including pledges of support, policy change, budget commitments and intervention coverage by governments and other nationally engaged actors (such as donors and United Nations agencies), to assess and make claims concerning the global health agenda status of issues ranging from diarrheal diseases to undernutrition [13,14,15,16,17,18]. Assessments of the global health agenda rely in part on the extent to which problems gain traction in sovereign settings and in part on the extent to which they gain traction in arenas that transcend national boundaries.
Our analytical approach is informed by a model from sociology [4, 6, 8, 14, 19,20,21,22,23]. The public arenas model posits that agendas develop in collectivities of institutions not limited to governments or narrowly defined policy communities through processes of issue definition and competition for their limited resources; as such, only a limited number of issues can be on the agenda in a given arena at any time . Drawing on Kingdon  and Hilgartner and Bosk , we thus conceive the global health agenda as consisting of those subjects or problems to which collectivities of actors operating nationally and globally are paying serious attention at different points in time. We assume that national and transnational arenas interact and may overlap.
Hilgartner and Bosk  point to social action groups, research communities, religious organizations, news and entertainment media, professional societies and branches of government as public arenas in which social problems are defined and compete for resources. Global health agenda setting arenas are comprised of collectivities of institutions that allocate and from which proponents seek attention and resources. Urgent calls to action on oral and other chronic diseases, maternal and neonatal survival, malaria, diarrheal diseases and a range of infections show that proponents often make demands in arenas comprised of political leaders, governments, multilateral institutions, the international aid community, professional groups, civil society, researchers, commercial industries (e.g. pharmaceutical and medical suppliers, food and beverage manufacturers), and groups in interdependent sectors (e.g. water and sanitation, education, trade), among others [24,25,26,27,28,29]. Mass media is also recognized as an important arena for global health agenda setting, with headlines shaping public awareness and policymaker decisions .
In their calls to action, proponents often implore actors in various agenda setting arenas to invest resources in: recognizing and engaging global health problems; providing leadership and coordination; advancing disease surveillance, prevention and control; developing and executing plans, policies and programs; allocating financial, technical and human resources; setting goals and supporting robust systems for monitoring and accountability; building health system capacity; conducting research that is relevant to low- and middle-income countries; making medicines and technologies widely accessible; and protecting patients and consumers [24,25,26,27,28,29]. Global health agenda setting scholars often turn to a patchwork of measurement approaches that use more and less reliable and comparable indicators such as these to assess the agenda status of health problems nationally and globally [13, 14, 18, 31,32,33]. A public arenas model offers advantage in part by narrowing the unit of analysis to arenas in which global health agenda setting occurs and for which reliable and comparable indicators are available if underutilized.
Advances that have been made in measuring priorities in the international aid arena by analyzing financial data from the WHO Global Health Expenditure Database, Institute for Health Metrics and Evaluation  and the OECD’s Creditor Reporting System Database  suggest that taking arenas as the central unit of analysis offers advantages. Actors comprising different arenas offer and are asked to prioritize problems by allocating fairly distinctive forms of attention and resources, pointing to indicators that may be used to measure the status of issues in various arenas. For instance, actors comprising the international aid arena offer and are asked to provide development assistance for health, the news media column space and industry arenas research, development and product supply.
Several arenas and indicators that are closely associated with them may be analyzed separately and collectively to gain a more nuanced understanding of which problems are on the global health agenda at any given time, and to identify leading, lagging and irrelevant arenas—which may vary by the type of global health issue. For instance, emergent infectious disease outbreaks may commonly attract headlines in the news media arena. Meanwhile, the status of nonclinical issues like road traffic injuries and health system management may persistently lag in the pharmaceutical industry arena, reflecting limited need and relevance.
We use a set of five arenas that extend beyond national boundaries (i.e., transnational arenas), including international aid, news media, pharmaceutical industry, scientific research and civil society to illustrate the utility of an arenas model for global health agenda setting and a measurement approach that employs reliable and comparable indicators. We focus on transnational arenas for global health agenda setting because approaches to conceptualizing and measuring the status of issues in them is underdeveloped compared to national arenas. Scholarship informing the set of preliminary arenas and potential indicators is discussed in the paragraphs that follow, with those indicators incorporated into our exploratory study highlighted in Table 1.
International aid arena
Development assistance for health (DAH), which has grown substantially since 1990 and reached $41 billion in 2019 , is a common status indicator in the international aid arena [1,2,3]. Analyses show that HIV/AIDS, which accounted for nearly a quarter of DAH in 2019, surged ahead in the competition for financial resource allocations in the international aid arena over the past two decades , displacing aid to malaria and the broader health sector in the mid-2000s . DAH has also been used as an indicator of donor priority for maternal and child survival relative to newborn survival [37, 38].
The status of global health problems in commercial industrial arenas is often crucial, shaping access to preventive and therapeutic drugs, medical equipment and technologies, and environmental risks. For instance, though the status of HIV/AIDS has since risen, doubts that a market for antiretroviral drugs existed in low-income countries suppressed investment in the pharmaceutical industry arena in the 1990s and early 2000s . In addition, research shows that diseases prevalent in low-income countries compete with those prevalent in high-income countries for clinical drug trial investments in the pharmaceutical industry arena, with cancer treatments leading the pack between 2006 and 2011 . Trends in industry-funded registered clinical drug trials may thereby form an important indicator of status in the pharmaceutical industry arena. The relevance of other industry arenas and indicators should also be considered. For instance, the hygiene product industry arena plays into the status of menstrual hygiene management as a global public health issue . So do the transnational tobacco and alcohol industry arenas for non-communicable diseases .
Scientific research arena
Global health problems are defined and compete for resources among collectivities of scientific researchers and institutions that generate evidence of their nature, severity and tractability, with implications for other arenas. For instance, growing evidence of the toll and tractability of maternal and neonatal mortality resulting from prioritization among researchers helped these issues gain traction in national and aid arenas . Bibliographic trends in medical and public health journals, which have been used to track priority for diarrheal diseases and maternal health interventions among researchers and funders, comprise an important indicator of priority in the scientific research arena [13, 43]. Data on dissertations, sponsored research and non-industry funded clinical drug trials might be used as indicators of emergent and current research attention that is not well captured by recent bibliographic trends due to the time it takes to conduct and publish research [13, 40].
News media arena
News media, including television news, magazines, newspapers and radio, are among Hilgartner and Bosk’s  original arenas, with column inches and minutes of air time serving as index measures. Publishing trends indicate that news media privilege certain health issues and portrayals, informing public and elite policy decisions on such issues as diabetes , childhood obesity , and reproductive health . Publishing trends have also been used to show that the status of Global Fund diseases, including HIV/AIDS, tuberculosis and malaria, is much higher than lower funded and higher burden childhood pneumonia, diarrhea and measles in the news media arena .
Civil society arena
Referring to “the broad spectrum of voluntary associations that are entirely or largely independent of government and that are not primarily motivated by commercial concerns” , civil society has grown in prominence and centrality over the past few decades due to its expanding role in generating international support for such critical public health issues as HIV/AIDS, reproductive health and tobacco control [49,50,51]. Surveys of members of The World Federation for Mental Health and European Public Health Alliance have been used to assess priorities in the segments of the civil society arenas concerned with these issues [52, 53]. And widespread community mobilization has been cited as an indicator of priority for children affected by HIV/AIDS . These measurement approaches are not viable for this study, which seeks to capture shifts in the global health agenda during a quickly evolving emergent disease pandemic. We settled on an imperfect solution, observing indicators of civil society mobilization on our issues via a purposeful sample of nonstate organizations’ websites.
To summarize, we propose that global health agenda setting occurs in several interacting national and transnational arenas. A contribution of an arenas model for global health agenda setting is the potential use of a measurement approach that involves the systematic observation and analysis of several reliable and comparable, if preliminary, indicators of priority within distinctive arenas. The model and measurement approach have strong potential to enhance support for inferences about a fragmented global health agenda. The measurement approach is likely to benefit from complementary case study research, which may be better suited to uncovering indicators that are difficult to assess using quantitative methods (e.g., emergent disease threats being discussed among isolated clusters of specialists), the nuances of programmatic attention to established versus emergent health conditions, and causal mechanisms that underly punctuations and stability [4, 19, 55]. Steps should also be taken to ensure that the overall measurement strategy avoids crowding out other forms of knowledge that are not readily quantifiable .