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Regazzoni CJ. World health order. J Glob Health 2024; 14:03023. [PMID: 38574352 PMCID: PMC10994669 DOI: 10.7189/jogh.14.03023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024] Open
Affiliation(s)
- Carlos Javier Regazzoni
- Institute of Global Health, Faculty of Health Sciences, Kennedy University, Buenos Aires, Argentina
- Committee on Global Health and Human Security, Argentine Council on Foreign Relations, Buenos Aires, Argentina
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Townsend B, Tenni BF, Goldman S, Gleeson D. Public health advocacy strategies to influence policy agendas: lessons from a narrative review of success in trade policy. Global Health 2023; 19:60. [PMID: 37612767 PMCID: PMC10463651 DOI: 10.1186/s12992-023-00960-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 07/26/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Despite accumulating evidence of the implications of trade policy for public health, trade and health sectors continue to operate largely in silos. Numerous barriers to advancing health have been identified, including the dominance of a neoliberal paradigm, powerful private sector interests, and constraints associated with policymaking processes. Scholars and policy actors have recommended improved governance practices for trade policy, including: greater transparency and accountability; intersectoral collaboration; the use of health impact assessments; South-South networking; and mechanisms for civil society participation. These policy prescriptions have been generated from specific cases, such as the World Trade Organization's Doha Declaration on TRIPS and Public Health or specific instances of trade-related policymaking at the national level. There has not yet been a comprehensive analysis of what enables the elevation of health goals on trade policy agendas. This narrative review seeks to address this gap by collating and analysing known studies across different levels of policymaking and different health issues. RESULTS Sixty-five studies met the inclusion criteria and were included in the review. Health issues that received attention on trade policy agendas included: access to medicines, food nutrition and food security, tobacco control, non-communicable diseases, access to knowledge, and asbestos harm. This has occurred in instances of domestic and regional policymaking, and in bilateral, regional and global trade negotiations, as well as in trade disputes and challenges. We identified four enabling conditions for elevation of health in trade-related policymaking: favourable media attention; leadership by trade and health ministers; public support; and political party support. We identified six strategies successfully used by advocates to influence these conditions: using and translating multiple forms of evidence, acting in coalitions, strategic framing, leveraging exogenous factors, legal strategy, and shifting forums. CONCLUSION The analysis demonstrates that while technical evidence is important, political strategy is necessary for elevating health on trade agendas. The analysis provides lessons that can be explored in the wider commercial determinants of health where economic and health interests often collide.
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Affiliation(s)
- Belinda Townsend
- Australian Research Centre for Health Equity, School of Regulation and Global Governance, Australian National University, Canberra, Australia.
| | - Brigitte Frances Tenni
- School of Psychology and Public Health, La Trobe University, Bundoora, VIC, 3086, Australia
- Nossal Institute for Global Health, The School of Population and Global Health, The University of Melbourne, Carlton, VIC, 3010, Australia
| | - Sharni Goldman
- Australian Research Centre for Health Equity, School of Regulation and Global Governance, Australian National University, Canberra, Australia
| | - Deborah Gleeson
- School of Psychology and Public Health, La Trobe University, Bundoora, VIC, 3086, Australia
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Patay D, Schram A, Collin J, Sell S, Friel S. Authority in tobacco control in Pacific Small Island Developing States: a qualitative study of multisectoral tobacco governance in Fiji and Vanuatu. Tob Control 2022:tobaccocontrol-2022-057404. [PMID: 35882520 DOI: 10.1136/tc-2022-057404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 07/16/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Small Island Developing States (SIDS) struggle with implementing multisectoral tobacco control measures, and health sector actors often lack capacity to forge multisectoral commitment. This study aims to explore the sources and dynamics of authority that can enable multisectoral collaboration despite the divergence of policy agendas in tobacco control. METHODS We applied a qualitative, explorative case study design, with data collection and analysis guided by an analytical framework that identifies sources and dynamics of authority. Seventy interviews were conducted in Fiji and Vanuatu between 2018 and 2019. RESULTS The key features shaping multisectoral coordination for tobacco control in Fiji and Vanuatu are the expert, institutional, capacity-based and legal authority that state and non-state actors have in tobacco governance. The amount of authority actors can secure from these sources was shown to be influenced by their performance (perceived or real), the discourse around tobacco control, the existing legal tools and their strategic alliances. SIDS vulnerabilities, arising from small size, isolation and developing economies, facilitate an economic growth discourse that reduces health sector actors' authority and empowers protobacco actors to drive tobacco governance. CONCLUSIONS Our results highlight the need for terms of engagement with the tobacco industry to enable governments to implement multisectoral tobacco control measures. Expanding assistance on tobacco control among government and civil society actors and increasing messaging about the impact of economic, trade and agricultural practices on health are essential to help SIDS implement the Framework Convention on Tobacco Control.
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Affiliation(s)
- Dori Patay
- Menzies Centre for Health Governance, School of Regulation and Global Governance, The Australian National University, Canberra, Australian Capital Territory, Australia
- Public Health Advocacy and Policy Impact team, Food Policy Division, The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Ashley Schram
- Menzies Centre for Health Governance, School of Regulation and Global Governance, The Australian National University, Canberra, Australian Capital Territory, Australia
| | - Jeff Collin
- Global Health Policy Unit, University of Edinburgh, Edinburgh, UK
| | - Susan Sell
- Menzies Centre for Health Governance, School of Regulation and Global Governance, The Australian National University, Canberra, Australian Capital Territory, Australia
| | - Sharon Friel
- Menzies Centre for Health Governance, School of Regulation and Global Governance, The Australian National University, Canberra, Australian Capital Territory, Australia
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Baum F, Townsend B, Fisher M, Browne-Yung K, Freeman T, Ziersch A, Harris P, Friel S. Creating Political Will for Action on Health Equity: Practical Lessons for Public Health Policy Actors. Int J Health Policy Manag 2022; 11:947-960. [PMID: 33327689 PMCID: PMC9808180 DOI: 10.34172/ijhpm.2020.233] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 11/14/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Despite growing evidence on the social determinants of health and health equity, political action has not been commensurate. Little is known about how political will operates to enact pro-equity policies or not. This paper examines how political will for pro-health equity policies is created through analysis of public policy in multiple sectors. METHODS Eight case studies were undertaken of Australian policies where action was either taken or proposed on health equity or where the policy seemed contrary to such action. Telephone or face-to-face interviews were conducted with 192 state and non-state participants. Analysis of the cases was done through thematic analysis and triangulated with document analysis. RESULTS Our case studies covered: trade agreements, primary healthcare (PHC), work conditions, digital access, urban planning, social welfare and Indigenous health. The extent of political will for pro-equity policies depended on the strength of path dependency, electoral concerns, political philosophy, the strength of economic and biomedical framings, whether elite interests were threatened and the success or otherwise of civil society lobbying. CONCLUSION Public health policy actors may create political will through: determining how path dependency that exacerbates health inequities can be broken, working with sympathetic political forces committed to fairness; framing policy options in a way that makes them more likely to be adopted, outlining factors to consider in challenging the interests of elites, and considering the extent to which civil society will work in favour of equitable policies. A shift in norms is required to stress equity and the right to health.
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Affiliation(s)
- Fran Baum
- Southgate Institute for Health, Society & Equity, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Belinda Townsend
- Menzies Centre for Health Policy, School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Matt Fisher
- Southgate Institute for Health, Society & Equity, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | | | - Toby Freeman
- Southgate Institute for Health, Society & Equity, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Anna Ziersch
- Southgate Institute for Health, Society & Equity, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Patrick Harris
- Menzies Centre for Health Governance, School of Regulation and Global Governance, College of Asia and the Pacific, Australian National University, Canberra, ACT, Australia
| | - Sharon Friel
- Menzies Centre for Health Policy, School of Public Health, The University of Sydney, Sydney, NSW, Australia
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Garton K, Swinburn B, Thow AM. Who influences nutrition policy space using international trade and investment agreements? A global stakeholder analysis. Global Health 2021; 17:118. [PMID: 34600556 PMCID: PMC8487514 DOI: 10.1186/s12992-021-00764-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 09/09/2021] [Indexed: 01/22/2023] Open
Abstract
Background Regulation of food environments is needed to address the global challenge of poor nutrition, yet policy inertia has been a problem. A common argument against regulation is potential conflict with binding commitments under international trade and investment agreements (TIAs). This study aimed to identify which actors and institutions, in different contexts, influence how TIAs are used to constrain policy space for improving food environments, and to describe their core beliefs, interests, resources and strategies, with the objective of informing strategic global action to preserve nutrition policy space. Methods We conducted a global stakeholder analysis applying the Advocacy Coalition Framework, based on existing academic literature and key informant interviews with international experts in trade and investment law and public health nutrition policy. Results We identified 12 types of actors who influence policy space in the food environment policy subsystem, relevant to TIAs. These actors hold various beliefs regarding the economic policy paradigm, the nature of obesity and dietary diseases as health problems, the role of government, and the role of industry in solving the health problem. We identified two primary competing coalitions: 1) a ‘public health nutrition’ coalition, which is overall supportive of and actively working to enact comprehensive food environment regulation; and 2) an ‘industry and economic growth’ focussed coalition, which places a higher priority on deregulation and is overall not supportive of comprehensive food environment regulation. The industry and economic growth coalition appears to be dominant, based on its relative power, resources and coordination. However, the public health nutrition coalition maintains influence through individual activism, collective lobbying and government pressure (e.g. by civil society), and expert knowledge generation. Conclusions Our analysis suggests that industry and economic growth-focussed coalitions are highly capable of leveraging networks, institutional structures and ideologies to their advantage, and are a formidable source of opposition acting to constrain nutrition policy space globally, including through TIAs. Opportunities for global public health nutrition coalitions to strengthen their influence in the support of nutrition policy space include strategic evidence generation and coalition-building through broader engagement and capacity-building. Supplementary Information The online version contains supplementary material available at 10.1186/s12992-021-00764-7.
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Affiliation(s)
- Kelly Garton
- School of Population Health, The University of Auckland, Auckland, New Zealand.
| | - Boyd Swinburn
- School of Population Health, The University of Auckland, Auckland, New Zealand
| | - Anne Marie Thow
- Menzies Centre for Health Policy, The University of Sydney, Sydney, NSW, Australia
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6
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Townsend B, Friel S, Schram A, Baum F, Labonté R. What Generates Attention to Health in Trade Policy-Making? Lessons From Success in Tobacco Control and Access to Medicines: A Qualitative Study of Australia and the (Comprehensive and Progressive) Trans-Pacific Partnership. Int J Health Policy Manag 2021; 10:613-624. [PMID: 32610761 PMCID: PMC9278530 DOI: 10.34172/ijhpm.2020.80] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 05/27/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Despite greater attention to the nexus between trade and investment agreements and their potential impacts on public health, less is known regarding the political and governance conditions that enable or constrain attention to health issues on government trade agendas. Drawing on interviews with key stakeholders in the Australian trade domain, this article provides novel insights from policy actors into the range of factors that can enable or constrain attention to health in trade negotiations. METHODS A qualitative case study was chosen focused on Australia's participation in the Trans-Pacific Partnership (TPP) negotiations and the domestic agenda-setting processes that shaped the government's negotiating mandate. Process tracing via document analysis of media reporting, parliamentary records and government inquiries identified key events during Australia's participation in the TPP negotiations. Semi-structured interviews were undertaken with 25 key government and non-government policy actors including Federal politicians, public servants, representatives from public interest nongovernment organisations and industry associations, and academic experts. RESULTS Interviews revealed that domestic concerns for protecting regulatory space for access to generic medicines and tobacco control emerged onto the Australian government's trade agenda. This contrasted with other health issues like alcohol control and nutrition and food systems that did not appear to receive attention. The analysis suggests sixteen key factors that shaped attention to these different health issues, including the strength of exporter interests; extent of political will of Trade and Health Ministers; framing of health issues; support within the major political parties; exogenous influencing events; public support; the strength of available evidence and the presence of existing domestic legislation and international treaties, among others. CONCLUSION These findings aid understanding of the factors that can enable or constrain attention to health issues on government trade agendas, and offer insights for potential pathways to elevate greater attention to health in future. They provide a suite of conditions that appear to shape attention to health outside the biomedical health domain for further research in the commercial determinants of health.
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Affiliation(s)
- Belinda Townsend
- School of Regulation and Global Governance, College of Asia and the Pacific, Australian National University, Canberra, ACT, Australia
| | - Sharon Friel
- School of Regulation and Global Governance, College of Asia and the Pacific, Australian National University, Canberra, ACT, Australia
| | - Ashley Schram
- School of Regulation and Global Governance, College of Asia and the Pacific, Australian National University, Canberra, ACT, Australia
| | - Fran Baum
- Southgate Institute for Health, Society and Equity, Department of Public Health, Flinders University, Adelaide, SA, Australia
| | - Ronald Labonté
- Institute of Population Health, University of Ottawa, Ottawa, ON, Canada
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Milsom P, Smith R, Baker P, Walls H. Corporate power and the international trade regime preventing progressive policy action on non-communicable diseases: a realist review. Health Policy Plan 2021; 36:493-508. [PMID: 33276385 PMCID: PMC8128013 DOI: 10.1093/heapol/czaa148] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2020] [Indexed: 12/21/2022] Open
Abstract
Transnational tobacco, alcohol and ultra-processed food corporations use the international trade regime to prevent policy action on non-communicable diseases (NCDs); i.e. to promote policy 'non-decisions'. Understanding policy non-decisions can be assisted by identifying power operating in relevant decision-making spaces, but trade and health research rarely explicitly engages with theories of power. This realist review aimed to synthesize evidence of different forms and mechanisms of power active in trade and health decision-making spaces to understand better why NCD policy non-decisions persist and the implications for future transformative action. We iteratively developed power-based theories explaining how transnational health-harmful commodity corporations (THCCs) utilize the international trade regime to encourage NCD policy non-decisions. To support theory development, we also developed a conceptual framework for analysing power in public health policymaking. We searched six databases and relevant grey literature and extracted, synthesized and mapped the evidence against the proposed theories. One hundred and four studies were included. Findings were presented for three key forms of power. Evidence indicates THCCs attempt to exercise instrumental power by extensive lobbying often via privileged access to trade and health decision-making spaces. When their legitimacy declines, THCCs have attempted to shift decision-making to more favourable international trade legal venues. THCCs benefit from structural power through the institutionalization of their involvement in health and trade agenda-setting processes. In terms of discursive power, THCCs effectively frame trade and health issues in ways that echo and amplify dominant neoliberal ideas. These processes may further entrench the individualization of NCDs, restrict conceivable policy solutions and perpetuate policymaking norms that privilege economic/trade interests over health. This review identifies different forms and mechanisms of power active in trade and health policy spaces that enable THCCs to prevent progressive action on NCDs. It also points to potential strategies for challenging these power dynamics and relations.
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Affiliation(s)
- Penelope Milsom
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, Kings Cross, London WC1H 9SH, UK
| | - Richard Smith
- College of Medicine and Health, University of Exeter, Magdalen Road, Exeter, EX1 2LU, UK
| | - Phillip Baker
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, 221 Burwood Highway, Burwood, Melbourne, Victoria 3125 Australia
| | - Helen Walls
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, Kings Cross, London WC1H 9SH, UK
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Townsend B. Defending access to medicines in regional trade agreements: lessons from the Regional Comprehensive Economic Partnership - a qualitative study of policy actors' views. Global Health 2021; 17:78. [PMID: 34238347 PMCID: PMC8264472 DOI: 10.1186/s12992-021-00721-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 06/08/2021] [Indexed: 11/23/2022] Open
Abstract
Background The Regional Economic Partnership Agreement (RCEP) is a mega regional trade agreement signed by fifteen countries on 15 November 2020 after 8 years of negotiation. Signatories include the ten members of the Association of South East Asian Nations (ASEAN) plus China, New Zealand, Japan, South Korea and Australia. India was a negotiating party until it withdrew from the negotiations in November 2019. The RCEP negotiations were initially framed as focused on the needs of low income countries. Public health concerns emerged however when draft negotiating chapters were leaked online, revealing pressures on countries to agree to intellectual property and investment measures that could exacerbate issues of access to medicines and seeds, and protecting regulatory space for public health. A concerted Asia Pacific civil society campaign emerged in response to these concerns, and in 2019, media and government reporting suggested that several of these measures had been taken off the table, which was subsequently confirmed in the release of the signed text in November 2020. Results This paper examines civil society and health actors’ views of the conditions that successfully contributed to the removal of these measures in RCEP, with a focus on intellectual property and access to medicines. Drawing on twenty semi-structured qualitative interviews with civil society, government and legal and health experts from nine countries participating in the RCEP negotiations, the paper reports a matrix of ten conditions related to actor power, ideas, political context and specific health issues that appeared to support prioritisation of some public health concerns in the RCEP negotiations. Conclusions Conditions identified included strong low and middle income country leadership; strong civil society mobilisation, increased technical capacity of civil society and low and middle income negotiators; supportive public health norms; processes that somewhat opened up the negotiations to hear public health views; the use of evidence; domestic support for health issues; and supportive international public health legislation. Lessons from the RCEP can inform prioritisation of public health in future trade agreement negotiations.
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Affiliation(s)
- Belinda Townsend
- Menzies Centre for Health Governance, School of Regulation and Global Governance, Australian National University, Canberra, Australia.
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Friel S, Townsend B, Fisher M, Harris P, Freeman T, Baum F. Power and the people's health. Soc Sci Med 2021; 282:114173. [PMID: 34192622 DOI: 10.1016/j.socscimed.2021.114173] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 02/28/2021] [Accepted: 06/20/2021] [Indexed: 10/21/2022]
Abstract
Public policy plays a central role in creating and distributing resources and conditions of daily life that matter for health equity. Policy agendas have tended to focus on health care delivery and individualised interventions. Asking why there is a lack of policy action on structural drivers of health inequities raises questions about power inequities in policy systems that maintain the status quo. In this paper we investigate the power dynamics shaping public policy and implications for health equity. Using a Health Equity Power Framework (HEPF), we examined data from 158 qualitative interviews with government, industry and civil society actors across seven policy case studies covering areas of macroeconomics, employment, social protection, welfare reform, health care, infrastructure and land use planning. The influence of structures of capitalism, neoliberalism, sexism, colonisation, racism and biomedicalism were widely evident, manifested through the ideologies, behaviours and discourses of state, market, and civil actors and the institutional spaces they occupied. Structurally less powerful public interest actors made creative use of existing or new institutional spaces, and used network, discursive and moral power to influence policy, with some success in moderating inequities in structural and institutional forms of power. Our hope is that the methodological advancement and empirical data presented here helps to illuminate how public interest actors can navigate structural power inequities in the policy system in order to disrupt the status quo and advance a comprehensive policy agenda on the social determinants of health equity. However, this analysis highlights the unrealistic expectation of turning health inequities around in a short time given the long-term embedded power dynamics and inequities within policy systems under late capitalism. Achieving health equity is a power-saturated long game.
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Affiliation(s)
- Sharon Friel
- Menzies Centre for Health Governance, School of Regulation and Global Governance, Australian National University, Fellows Road, Canberra ACT, 2601, Australia.
| | - Belinda Townsend
- Menzies Centre for Health Governance, School of Regulation and Global Governance, Australian National University, Fellows Road, Canberra ACT, 2601, Australia.
| | - Matthew Fisher
- Southgate Institute for Society, Equity and Health, Flinders University, GPO Box 2100, Adelaide, SA, 5001, Australia.
| | - Patrick Harris
- Centre for Health Equity Training, Research & Evaluation, Australia Research Centre for Primary Health Care & Equity, University of New South Wales, Liverpool, NSW, 1871, Australia.
| | - Toby Freeman
- Southgate Institute for Society, Equity and Health, Flinders University, GPO Box 2100, Adelaide, SA, 5001, Australia.
| | - Fran Baum
- Southgate Institute for Society, Equity and Health, Flinders University, GPO Box 2100, Adelaide, SA, 5001, Australia.
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Came H, Matheson A, Kidd J. Smashing the patriarchy to address gender health inequities: Past, present and future perspectives from Aotearoa (New Zealand). Glob Public Health 2021; 17:1540-1550. [PMID: 34097588 DOI: 10.1080/17441692.2021.1937272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The second wave feminist dream of smashing the patriarchy remains a task yet to be completed on a complex to do list. Women, particularly able-bodied cis-gendered white women however do enjoy the privilege of living longer than men. But our longer lives take place within patriarchal-capitalist systems where many women's social and cultural rights continue to be compromised. How do we ensure that all women can exercise our right to health and wellbeing? In this paper, the authors examine, critique, review and re-vision the dynamics of power and patriarchy over three distinct time periods - 1999, 2019 and 2039. We look to the past to track progress; we look to the present to see what we have achieved and look to the future for what might be. This conceptual paper is informed by the authors' expert knowledge, a review of the literature and the novel use of speculative ethnography. The authors conclude that patriarchy remains not only a negative determinant of women's health that needs to be smashed, but is also a threat to all people and to planetary health.
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Affiliation(s)
- Heather Came
- Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Anna Matheson
- School of Health, Victoria University, Melbourne, Australia
| | - Jacquie Kidd
- Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand
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11
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Barlow P, Thow AM. Neoliberal discourse, actor power, and the politics of nutrition policy: A qualitative analysis of informal challenges to nutrition labelling regulations at the World Trade Organization, 2007-2019. Soc Sci Med 2021; 273:113761. [PMID: 33621752 DOI: 10.1016/j.socscimed.2021.113761] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 01/22/2021] [Accepted: 02/05/2021] [Indexed: 01/28/2023]
Abstract
Unhealthy diets are increasing contributors to poor health and mortality in low- and middle-income countries (LMICs). Government interventions targeting the structural drivers of unhealthy diets are needed to prevent these illnesses, including nutrition labelling regulations that create healthier food environments. Yet, implementation remains slow and uneven. One explanation for slow implementation highlights the role of politics, including powerful ideological discourse and its strategic deployment by economically powerful actors. In this article, we advance research on the politics of nutrition policies by analysing political discourse on nutrition labelling regulations within an influential and under-studied global institution: the World Trade Organization (WTO). We identified WTO Technical Barriers to Trade (TBT) Committee meeting minutes with reference to nutrition labelling policies proposed by Thailand, Chile, Indonesia, Peru, Ecuador, Bolivia, and Uruguay (2007-2019; n = 47). We analysed the frames, narratives, and normative claims that feature in inter-country discourse within TBT meetings and examined how actors mobilize ideological and material sources of power via these statements. We find that informal government challenges to nutrition labelling proposals within the Committee featured a narrative that individualized the causes of and solutions to poor diet, downplayed harms from industrialised food products, and framed state regulation as harmful and unjust. These non-technical claims mobilised neoliberal ideology and rhetoric to contest the normative legitimacy of members' proposals and to de-socialize and de-politicize poor diets. Furthermore, high-income countries (HICs) re-framed policy goals to focus on individual determinants of poor nutrition whilst calling for their preferred policies to be adopted. Patterns of discourse within TBT meetings also had striking similarities with arguments raised by multi-national food corporations elsewhere. Our findings suggest that non-technical and ideological arguments raised during TBT meetings serve as inconspicuous tools through which nutrition labelling policies in LMICs are undermined by HICs, industry, and the powerful ideology of neoliberalism.
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Affiliation(s)
- P Barlow
- Department of Health Policy, London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, United Kingdom.
| | - A M Thow
- Menzies Centre for Health Policy, School of Public Health, Charles Perkins Centre (D17), The University of Sydney, NSW, 2006 Australia
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12
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Townsend B, Friel S, Freeman T, Schram A, Strazdins L, Labonte R, Mackean T, Baum F. Advancing a health equity agenda across multiple policy domains: a qualitative policy analysis of social, trade and welfare policy. BMJ Open 2020; 10:e040180. [PMID: 33158831 PMCID: PMC7651713 DOI: 10.1136/bmjopen-2020-040180] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE While there is urgent need for policymaking that prioritises health equity, successful strategies for advancing such an agenda across multiple policy sectors are not well known. This study aims to address this gap by identifying successful strategies to advance a health equity agenda across multiple policy domains. DESIGN We conducted in-depth qualitative case studies in three important social determinants of health equity in Australia: employment and social policy (Paid Parental Leave); macroeconomics and trade policy (the Trans Pacific Partnership agreement); and welfare reform (the Northern Territory Emergency Response). The analysis triangulated multiple data sources included 71 semistructured interviews, document analysis and drew on political science theories related to interests, ideas and institutions. RESULTS Within and across case studies we observed three key strategies used by policy actors to advance a health equity agenda, with differing levels of success. The first was the use of multiple policy frames to appeal to a wide range of actors beyond health. The second was the formation of broad coalitions beyond the health sector, in particular networking with non-traditional policy allies. The third was the use of strategic forum shopping by policy actors to move the debate into more popular policy forums that were not health focused. CONCLUSIONS This analysis provides nuanced strategies for agenda-setting for health equity and points to the need for multiple persuasive issue frames, coalitions with unusual bedfellows, and shopping around for supportive institutions outside the traditional health domain. Use of these nuanced strategies could generate greater ideational, actor and institutional support for prioritising health equity and thus could lead to improved health outcomes.
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Affiliation(s)
- Belinda Townsend
- Menzies Centre for Health Governance, School of Regulation and Global Governance, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Sharon Friel
- Menzies Centre for Health Governance, School of Regulation and Global Governance, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Toby Freeman
- Southgate Institute of Health, Society and Equity, Flinders University, Adelaide, South Australia, Australia
| | - Ashley Schram
- Menzies Centre for Health Governance, School of Regulation and Global Governance, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Lyndall Strazdins
- National Centre for Epidemiology and Research School of Population Health, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Ronald Labonte
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Tamara Mackean
- Aboriginal and Torres Strait Islander Health, Flinders University, Adelaide, South Australia, Australia
| | - Fran Baum
- Southgate Institute of Health, Society and Equity, Flinders University, Adelaide, South Australia, Australia
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Matheson A. Health Inequality as a Large-Scale Outcome of Complex Social Systems: Lessons for Action on the Sustainable Development Goals. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E2684. [PMID: 32295177 PMCID: PMC7215954 DOI: 10.3390/ijerph17082684] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 03/30/2020] [Accepted: 04/09/2020] [Indexed: 11/26/2022]
Abstract
Action on the Sustainable Development Goals (SDGs) needs to become real and impactful, taking a "whole systems" perspective on levers for systems change. This article reviews what we have learned over the past century about the large-scale outcome of health inequality, and what we know about the behaviour of complex social systems. This combined knowledge provides lessons on the nature of inequality and what effective action on our big goals, like the SDGs, might look like. It argues that economic theories and positivist social theories which have dominated the last 150 years have largely excluded the nature of human connections to each other, and the environment. This exclusion of intimacy has legitimatised arguments that only value-free economic processes matter for macro human systems, and only abstract measurement constitutes valuable social science. Theories of complex systems provide an alternative perspective. One where health inequality is viewed as emergent, and causes are systemic and compounding. Action therefore needs to be intensely local, with power relationships key to transformation. This requires conscious and difficult intervention on the intolerable accumulation of resources; improved reciprocity between social groups; and reversal of system flows, which at present ebb away from the local and those already disadvantaged.
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Affiliation(s)
- Anna Matheson
- School of Health, Te Herenga Waka, Victoria University of Wellington, Wellington 6140, New Zealand;
- Te Pūnaha Matatini, Centre for Complex Systems, Auckland 1142, New Zealand
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