Conflicts of interest: an invisible force shaping health systems and policies

Political economy analysis of health taxes (tobacco, alcohol drink and sugar-sweteened beverage): qualitative study of three provinces in Indonesia

OBJECTIVE

Efforts to implement health tax policies to control the consumption of harmful commodities and enhance public health outcomes have garnered substantial recognition globally. However, their successful adoption remains a complex endeavour. This investigates the challenges and opportunities surrounding health tax implementation, with a particular focus on subnational government in Indonesia, where the decentralisation context of health tax remains understudied.

DESIGN

Employing a qualitative methodology using a problem-driven political economy analysis approach.

SETTING

We are collecting data from a total of 12 focus group discussions (FGDs) conducted between July and September 2022 in three provinces-Lampung, Special Region of/Daerah Istimewa Yogyakarta and Bali, each chosen to represent a specific commodity: tobacco, sugar-sweetened beverages (SSBs) and alcoholic beverages-we explore the multifaceted dynamics of health tax policies.

PARTICIPANT

These FGDs involved a mean of 10 participants in each FGD, representing governmental institutions, non-governmental organisations and consumers.

RESULTS

Our findings reveal that health tax policies have the potential to contribute significantly to public health. Consumers understand tobacco's health risks, and cultural factors influence both tobacco and alcohol consumption. For SSBs, the consumers lack awareness of long-term health risks is concerning. Finally, bureaucratic complexiting and decentralised government hinder implementation for all three commodities.

CONCLUSION

Furthermore, this study underscores the importance of effective policy communication. It highlights the importance of earmarking health tax revenues for public health initiatives. It also reinforces the need to see health taxes as one intervention as part of a comprehensive public health approach including complementary non-fiscal measures like advertising restrictions and standardised packaging. Addressing these challenges is critical for realising the full potential of health tax policies.

Health and equity impacts of global consultancy firms

BACKGROUND

Concern is growing over the power, influence, and threats to health and equity from the operations of large global consultancy firms. Collectively, these firms support a neoliberal policy environment promoting business interests ahead of public health. Global consultancy firms act as commercial determinants of health, an evolving area of research over recent years. However, this research mainly focuses on specific corporations or industry sectors, especially those which produce harmful products, including ultra-processed food, alcohol, and fossil fuels. It is therefore important to expand the focus to include large global consultancy firms and place a public health and equity lens over their operations.

MAIN BODY

Global consultancy firms have wide-ranging conflicts of interest. These arise from the 'revolving door' employment strategies between their own staff and those from government and regulatory bodies. These firms also advise governments on taxation and other matters while concurrently advising corporate clients on ways to minimise taxation. They advise fossil fuel corporations while also advising governments on climate and health policies. These firms undermine the capabilities of the public sector through the outsourcing of traditional public sector roles to these private interests. Consultancy firms foster private interests through their engagement with the higher education sector, and thereby weaken the tradition of transparent management of university affairs by accountable university councils. While private consultancies cannot be blamed for all the negative consequences for health and equity caused by the problems associated with globalisation and advanced capitalism, they have played a role in amplifying them.

CONCLUSION

Addressing the negative impacts of global consultancy firms will require strengthening the public sector, enforcing greater transparency, accountability, and minimising conflicts of interest. It will also demand critical thought, counter discourses, and activism to reframe the narratives supporting neo-liberal ideas of governance that are promoted in both government and business arenas.

Explaining the concepts and examples of conflict of interest and its management in the medical laboratory system of Iran: A scoping review

The occurrence of conflict of interest (CoI) is assumed to be a big challenge facing all healthcare sectors, including the medical laboratory system (MLS). Therefore, this study aimed to explain the concepts and examples of CoI and its management within this system. This scoping review was fulfilled in 2023 in Iran. To this end, the Persian and English keywords of this study were searched on the Persian and English databases based on the Medical Subject Headings (MeSH) and the Arksey and O'Malley methodological framework. All retrieved articles were then imported into EndNote X8, and their quality was evaluated via the Mixed Methods Appraisal Tool (MMAT). In total, 104 articles, of 6875 sources extracted, published from 2000 to 2023, were recruited following the identification and screening stages. Most articles had reported the maximum number of CoI examples in the MLS in diverse nations, including Iran, particularly in terms of structural, financial, objective, and subjective issues and primary and secondary interests among policymakers and higher-ranking managers of the healthcare system. Currently, CoI in healthcare systems, including the MLS, is unavoidable, but the best strategy, in preference to removing this situation, is to manage it under potential conditions before its occurrence and conversion into corruption. In view of that, it is recommended to provide effective training programs, increase transparency at work, facilitate compliance with professional guidelines, reform organizational structures and processes in the public sector, and establish policies best suited to manage CoI in the MLS of Iran.

Drug Inspector as an antibiotic Steward: challenges and recommendations to implement national action plan of Pakistan on antimicrobial resistance

BACKGROUND

Despite significant measures, low- and middle-income countries (LMICs), including Pakistan, struggle to curtail non-prescription antibiotic sales, enforce regulations, and implement National Action Plan (NAP) against antimicrobial resistance (AMR). NAP Pakistan entails drug inspectors (DIs) to ensure prescription-based sales of antibiotics. This study seeks to understand the perspective of DIs regarding antimicrobial sales without prescription, underlying factors, and policy implementation status.

METHODS

A qualitative study employing a semi-structured interview guide using in-depth interviews with purposively selected 17 DIs was conducted. Interviews were transcribed verbatim, and data were analyzed following a thematic analysis framework utilizing MAXQDA 2022 software.

RESULTS

Five main themes emerged after data analysis: (1) drug inspector - the regulator of the antimicrobial armamentarium, (2) the policy context, (3) awareness regarding AMR, (4) barriers to combatting AMR, and (5) the way forward: strategies and recommendations.

CONCLUSION

A weak regulatory framework, low level of awareness, quackery, vested interests, and socio-economic factors augment inappropriate antibiotic utilization. Opting for better policies and strengthening the DI fraternity as outlined in NAP Pakistan is recommended. Recognizing drug inspectors as effective surveilling units and mobilizing field force against irrational antibiotic utilization is the need of the hour and requires policy reformation.

Invisibility in global health: A case for disturbing bioethical frameworks

In recent years, the global health community has increasingly reported the problem of 'invisibility': aspects of health and wellbeing, particularly amongst the world's most marginalized and impoverished people, that are systematically overlooked and ignored by people and institutions in relative positions of power. It is unclear how to realistically manage global health invisibility within bioethics and other social science disciplines and move forward. In this letter, we reflect on several case studies of invisibility experienced by people in Brazil, Malaysia, West Africa and other transnational contexts. Highlighting the complex nature of invisibility and its interconnectedness with social, political and economic issues and trends, we argue that while local and targeted interventions might provide relief and comfort locally, they will not be able to solve the underlying causes of invisibility. Building from the shared lessons of case study presentations at an Oxford-Johns Hopkins Global Infectious Disease Ethics Collaborative (GLIDE), we argue that in dealing with an intersectional issue such as invisibility, twenty-first century global health bioethics could pursue a more 'disturbing' framework, challenging the narrow comforting solutions which take as a given the sociomaterial inequalities of the status quo. We highlight that comforting and disturbing bioethical frameworks should not be considered as opposing sides, but as two approaches working in tandem in order to achieve the internationally set global health milestones of providing better health and wellbeing for everyone. Insights from sociology, anthropology, postcolonial studies, history, feminist studies and other styles of critical reasoning have long been disturbing to grand narratives of people and their conditions. To rediscover the ethos of the WHO Alma Ata Declaration-a vision of "health for all by the year 2000"-these thinking tools will be necessary aids in developing cooperation and support beyond the narrow market logic that dominates the landscape of contemporary global health.

Conflicting interests, institutional fragmentation and opportunity structures: an analysis of political institutions and the health taxes regime in Pakistan

Pakistan is the world's fifth most populous country, with large segments of its population at risk from non-communicable diseases caused by consumption of harmful products, including tobacco and sugar-sweetened beverages. Even though evidence exists that increased taxes on harmful products leads to consumption reductions as well as increased revenues, Pakistan's health taxes remain low. We seek to understand the reasons for the deficient health tax regime. Much of the existing literature emphasises industry tactics, resources and motivations. We take a different approach and instead focus on political institutions in Pakistan which could help explain deficiencies in the health taxes regime. We employed a mixed method design. We conducted: (1) a detailed analysis of media content, (2) semistructured interviews with key stakeholders (and attended relevant meetings) and (3) an analysis of primary and secondary literature, including legal and policy documents. We identify two key aspects of Pakistan's political institutions which may help explain deficiencies in health taxes. First, we identified structural issues in the design and functioning of key institutions responsible for health taxes, including with respect to federalism, intraelite conflict, interagency coordination and intra-agency fragmentation. Second, we found evidence of an entrenchment of industry interests within governmental institutions, which are characterised by weak frameworks for regulating conflicts of interest. We conclude that gaps and conflict within political institutions, owing to weak design, instability and fragmentation, create political opportunity for industry actors to influence the system to advance their interests. The findings of this research indicate towards needed interventions.

Policies on doctors' declaration of interests in medical organisations: a thematic analysis

OBJECTIVES

There has been growing concern about doctors' conflicts of interests (COIs) but it is unclear what processes and tools exist to enable the consistent declaration and management of such interests. This study mapped existing policies across a variety of organisations and settings to better understand the degree of variation and identify opportunities for improvement.

DESIGN

Thematic analysis.

SETTING

We studied the COI policies of 31 UK and international organisations which set or influence professional standards or engage doctors in healthcare commissioning and provision settings.

PARTICIPANTS

31 UK and international organisations.

MAIN OUTCOME MEASURES

Organisational policy similarities and differences.

RESULTS

Most policies (29/31) referred to the need for individuals to apply judgement when deciding whether an interest is a conflict, with just over half (18/31) advocating a low threshold. Policies differed on the perception of frequency of COI, the timings of declarations, the type of interests that needed to be declared, and how COI and policy breaches should be managed. Just 14/31 policies stated a duty to report concerns in relation to COI. Only 18/31 policies advised COI would be published, while three stated that any disclosures would remain confidential.

CONCLUSIONS

The analysis of organisational policies revealed wide variation in what interests should be declared, when and how. This variation suggests that the current system may not be adequate to maintain a high level of professional integrity in all settings and that there is a need for better standardisation that reduces the risk of errors while addressing the needs of doctors, organisations and the public.

Incentivisation practices and their influence on physicians' prescriptions: A qualitative analysis of practice and policy in Pakistan

Focus on profit-generating enterprise in healthcare can create conflicts of interest that adversely impact prescribing and pricing of medicines. Although a global challenge, addressing the impacts on quality of care is particularly difficult in countries where the pharmaceutical industry and physician lobby is strong relative to regulatory institutions. Our study characterises the range of incentives exchanged between the pharmaceutical industry and physicians, and investigates the differences between incentivisation practices and policies in Pakistan. In this mixed methods study, we first thematically analysed semi-structured interviews with 28 purposively selected for-profit primary-care physicians and 13 medical sales representatives from pharmaceutical companies working across Pakistan's largest city, Karachi. We then conducted a content analysis of policies on ethical practice issued by two regulatory bodies responsible in Pakistan, and the World Health Organization. This enabled a systematic comparison of incentivisation practices with what is considered 'prohibitive' or 'permissive' in policy. Our findings demonstrate that incentivisation of physicians to meet pharmaceutical sales targets is the norm, and that both parties play in the symbiotic physician-pharma incentivisation dynamics. Further, we were able to categorise the types of incentive exchanged into one of five categories: financial, material, professional or educational, social or recreational, and familial. Our comparison of incentivisation practices with policies revealed three reasons for such widespread incentivisation linked to sales targets: first, some clear policies were being ignored by physicians; second, there are ambiguous or contradictory policies with respect to specific incentive types; and third, numerous incentive types are unaddressed by existing policies, such as pharmaceutical companies paying for private clinic renovations. There is a need for policies to be clarified and updated, and to build buy-in for policy enforcement from pharmaceutical companies and physicians, such that transgressions on target-driven prescribing are seen to be unethical.

Youth engagement in research and policy: The CO-CREATE framework to optimize power balance and mitigate risks of conflicts of interest

Including youth in the co-creation of policies that affect them has proven to be particularly impactful in public health. Using youth participatory action research methods, the CO-CREATE project engages European youth 16-18 years old in the co-creation of obesity prevention policies. To discuss the feasibility and implications of the policy, youth are invited to engage in an intergenerational dialogue. Given the youth-adult dynamic and policy discussion, conflicts of interests (COIs) can arise and impact the quality of the dialogue. COI frameworks are a tool that can help identify, mitigate, and address COIs. This paper presents a novel framework to mitigate COIs in intergenerational policy dialogues, with a focus on power imbalance. Following a series of youth consultations, interviews, and examination of existing frameworks, our findings suggest that safe, participatory, and empowering dialogues can take place if appropriate measures are integrated into all phases of a dialogue. The selection of stakeholders, use of accessible language, and youth moderation are all factors that can impact COI risks. Measures that promote mutual empowerment, such as equal representation of youth and adults, were deemed important. This framework provides a roadmap to ensure that youth participation in the formulation of policies is safe and empowering.

Socioecological factors linked with pharmaceutical incentive-driven prescribing in Pakistan

Pharmaceutical marketing through financial incentivisation to general practitioners (GPs) is a poorly studied health system problem in Pakistan. Pharmaceutical incentivisation is seen to be distorting GPs prescribing behaviour that can compromise the health and well-being of patients. We draw on a conceptual framework outlined in the ecological system theory to identify multiple factors linked with pharmaceutical incentivisation to GPs in Pakistan. We conducted qualitative interviews with 28 policy actors to seek their views on the health system dynamics, how they sustain pharmaceutical incentivisation and their effect on the quality of care. Our analysis revealed four interlinked factors operating at different levels and how they collectively contribute to pharmaceutical incentivisation. In addition to influences such as the increasing family needs and peers' financial success, sometimes GPs may naturally be inclined to maximise incomes by engaging in pharmaceutical incentivisation. On other hand, the pharmaceutical market dynamics that involve that competition underpinned by a profit-maximisation mindset enable pharmaceutical companies to meet GPs' desires/needs in return for prescribing their products. Inadequate monitoring and health regulations may further permit the pharmaceutical industry and GPs to sustain the incentive-driven relationship. Our findings have important implications for potential health reforms such as introducing regulatory controls, and appropriate monitoring and regulation of the private health sector, required to address pharmaceutical incentivisation to GPs.

What the policy and stewardship landscape of a national health research system looks like in a developing country like Iran: a qualitative study

BACKGROUND

The health research system (HRS) is an important national priority that requires a systematic and functional approach. Evaluating the HRS of Iran as a developing country and identifying its challenges reveals the stewardship-related role in how the whole system is operating well. This study aims to assess the HRS in terms of stewardship functions and highlight the enhancement points.

METHODS

This study was carried out between March 2020 and April 2021 using a systematic review and meta-synthesis of evidence to examine the Iranian HRS stewardship challenges and interview 32 stakeholders, using a critical case sampling and snowballing approach which included both semi-structured and in-depth interviews. The interviewees were selected based on criteria covering policy-makers, managers, research bodies and nongovernmental organizations (NGOs) in health research-related fields like higher education, research, technology, innovation and science. All data were analysed using content analysis to determine eight main groups of findings under three levels: macro, meso, and micro.

RESULTS

Analysis of the findings identified eight main themes. The most critical challenges were the lack of an integrated leadership model and a shared vision among different HRS stakeholders. Their scope and activities were often contradictory, and their role was not clarified in a predetermined big picture. The other challenges were legislation, priority-setting, monitoring and evaluation, networking, and using evidence as a decision support base.

CONCLUSIONS

Stewardship functions are not appropriately performed and are considered the root causes of many other HRS challenges in Iran. Formulating a clear shared vision and a work scope for HRS actors is critical, along with integrating all efforts towards a unified strategy that assists in addressing many challenges of HRS, including developing strategic plans and future-oriented and systematic research, and evaluating performance. Policy-makers and senior managers need to embrace and use evidence, and effective networking and communication mechanisms among stakeholders need to be enhanced. An effective HRS can be achieved by redesigning the processes, regulations and rules to promote transparency and accountability within a well-organized and systematic framework.

Navigating credibility of online information during COVID-19: using mnemonics to empower the public to spot red flags in health information online

Misinformation creates challenges for the general public in differentiating truth from fiction in web-based content. During the COVID-19 pandemic, this issue has been amplified due to high volumes of news and changing information. Evidence on misinformation largely focuses on understanding the psychology of misinformation and debunking strategies but neglects to explore critical thinking education for the general public. This viewpoint outlines the science of misinformation and the current resources available to the public. This paper describes the development and theoretical underpinnings of a mnemonic (Conflict of Interest, References, Author, Buzzwords, Scope of Practice [CRABS]) for identifying misinformation in web-based health content. Leveraging evidence-based educational strategies may be a promising approach for empowering the public with the confidence needed to differentiate truth from fiction in an infodemic.

The public health playbook: ideas for challenging the corporate playbook

Many commercial actors use a range of coordinated and sophisticated strategies to protect business interests-their corporate playbook-but many of these strategies come at the expense of public health. To counter this corporate playbook and advance health and wellbeing, public health actors need to develop, refine, and modernise their own set of strategies, to create a public health playbook. In this Viewpoint, we seek to consolidate thinking around how public health can counter and proactively minimise powerful commercial influences. We propose an initial eight strategies for this public health playbook: expand public health training and coalitions, increase public sector resources, link with and learn from social movements to foster collective solidarity, protect public health advocates from industry threats, develop and implement rigorous conflict of interest safeguards, monitor and expose corporate activities, debunk corporate arguments, and leverage diverse commercial interests. This set of strategies seeks to amplify inherent assets of the public health community and create opportunities to explicitly counter the corporate playbook. These strategies are not exhaustive, and our aim is to provoke further discussion on and exploration of this topic. TRANSLATION: For the Spanish translation of this paper see Supplementary Materials section.

How conflicts of interest hinder effective regulation of healthcare: an analysis of antimicrobial use regulation in Cambodia, Indonesia and Pakistan

Background

There has been insufficient attention to a fundamental force shaping healthcare policies—conflicts of interest (COI). We investigated COI, which results in the professional judgement of a policymaker or healthcare provider being compromised by a secondary interest, in relation to antimicrobial use, thereby illuminating challenges to the regulation of medicines use more broadly. Our objectives were to characterise connections between three groups—policymakers, healthcare providers and pharmaceutical companies—that can create COI, and elucidate the impacts of COI on stages of the policy process.

Methods

Using an interpretive approach, we systematically analysed qualitative data from 136 in-depth interviews and five focus group discussions in three Asian countries with dominant private healthcare sectors: Cambodia, Indonesia and Pakistan.

Findings

We characterised four types of connections that were pervasive between the three groups: financial, political, social and familial. These connections created strong COI that could impact all stages of the policy process by: preventing issues related to medicines sales from featuring prominently on the agenda; influencing policy formulation towards softer regulatory measures; determining resource availability for, and opposition to, policy implementation; and shaping how accurately the success of contested policies is reported.

Interpretation

Our multicountry study fills a gap in empirical evidence on how COI can impede effective policies to improve the quality of healthcare. It shows that COI can be pervasive, rather than sporadic, in influencing regulation of medicine use, and highlights that, in addition to financial connections, other types of connections should be examined as important drivers of COI.

Transparency of COVID-19-Related Research in Dental Journals

Objective

We aimed to assess the adherence to transparency practices (data availability, code availability, statements of protocol registration and conflicts of interest and funding disclosures) and FAIRness (Findable, Accessible, Interoperable, and Reusable) of shared data from open access COVID-19-related articles published in dental journals available from the Europe PubMed Central (PMC) database.

Methods

We searched and exported all COVID-19-related open-access articles from PubMed-indexed dental journals available in the Europe PMC database in 2020 and 2021. We detected transparency indicators with a validated and automated tool developed to extract the indicators from the downloaded articles. Basic journal- and article-related information was retrieved from the PMC database. Then, from those which had shared data, we assessed their accordance with FAIR data principles using the F-UJI online tool (f-uji.net).

Results

Of 650 available articles published in 59 dental journals, 74% provided conflicts of interest disclosure and 40% funding disclosure and 4% were preregistered. One study shared raw data (0.15%) and no study shared code. Transparent practices were more common in articles published in journals with higher impact factors, and in 2020 than in 2021. Adherence to the FAIR principles in the only paper that shared data was moderate.

Conclusion

While the majority of the papers had a COI disclosure, the prevalence of the other transparency practices was far from the acceptable level. A much stronger commitment to open science practices, particularly to preregistration, data and code sharing, is needed from all stakeholders.

Trust and responsibility in food systems transformation. Engaging with Big Food: marriage or mirage?

Concentration of power among transnational 'Big Food' companies has contributed to food systems that are unsustainable, unhealthy and inequitable for people and planet. Given these commercial determinants of health, if 'food systems transformation' is to be authentic-more than a passing narrative-then leveraging Big Food is paramount. To this end, researchers, practitioners and policy-makers are increasingly encouraged to engage with these powerful entities. However, given the conflicts of interest at stake, engagement relies on trust and transparency, that all stakeholders take responsibility for their actions and demonstrate commitment to do no harm. Given Big Food's track record in influencing policy, shifting costs and responsibility for their harms-and while profit primarily drives business decision making-we question whether it is logical to expect trust.This analysis explores concepts of responsibility and trust in relation to food systems transformation involving public-private partnerships. Through short cautionary case studies-looking at the United Nations Food Systems Summit, and Big Food's plastic burden-it argues that unless such companies take responsibility for their cross-cutting effects and earn authentic trust through demonstrably doing no harm, their participation in evidence generation and policy processes should be limited to responding to information requests and adhering to regulation. Any involvement in research agenda-setting or formulating policy solutions introduces conflicts of interest, legitimises corporate irresponsibility and jeopardises scientific integrity. Big Food has dynamism and power to address food system problems, but while it contributes to so many of these problems it should follow-not formulate-transformational evidence, policies and regulations.