How does policy framing enable or constrain inclusion of social determinants of health and health equity on trade policy agendas?

Brexit, trade and the governance of non-communicable diseases: a research agenda

BACKGROUND

The UK's post-Brexit trade strategy has potentially important implications for population health and equity. In particular, it will impact on the structural risk factors for non-communicable diseases (NCDs), including the consumption of health-harming commodities such as tobacco, alcohol and ultra-processed food and beverages. This article catalogues recent developments in UK trade policy. It then presents a narrative review of the existing research literature on trade and health and previous, prospective studies on the health impacts of Brexit. In so doing it identifies key questions and foci for a future research agenda on the implications of UK's emerging trade regime for NCD prevention.

MAIN TEXT

We identify five key areas for future research. (1) Additional scholarship to document the health effects of key trade agreements negotiated by the UK government; (2) The implications of these agreements for policy-making to address health impacts, including the potential for legal challenges under dispute settlement mechanisms; (3) The strategic objectives being pursued by the UK government and the extent to which they support or undermine public health; (4) The process of trade policy-making, its openness to public health interests and actors and the impact of the political and ideological legacy of Brexit on outcomes; (5) The impact of the UK's post-Brexit trade policy on partner countries and blocs and their cumulative impact on the global trade regime.

CONCLUSIONS

Further research is urgently need to understand the ways in which the UK's post-Brexit trade strategy will impact on NCDs and policy responses to address these, including the openness of the trade policy architecture to health issues. The outcomes of this process will have wider systemic effects on the global trade regime with implications for health. Researchers must be cognizant of the ideological components of the policy debate which have been absent from previous analysis of Brexit, trade and health.

Public health advocacy strategies to influence policy agendas: lessons from a narrative review of success in trade policy

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.

Framing the policy debate over tobacco control legislation and tobacco taxation in South Africa

BACKGROUND

In 2018, South Africa opened public consultations on its newly proposed tobacco control bill, resulting in substantial public debate in which a range of arguments, either in favour of or against the Bill, was advanced. These were accompanied by the recurring discussions about the annual adjustments in tobacco taxation. This study uses the concept of framing to examine the public debate in South African print media on the potential effects of the legislation, as well as tobacco tax regulations, between their proponents and detractors.

METHODS

A systematic search of news articles using multiple data sources identified 132 media articles published between January 2018 and September 2019 that met the inclusion criteria.

RESULTS

Seven overarching frames were identified as characterising the media debate, with the three dominant frames being Economic, Harm reduction and vaping, and Health. The leading Economic frame consisted primarily of arguments unsupportive of tobacco control legislation. Economic arguments were promoted by tobacco industry spokespeople, trade unions, organisations of retailers, media celebrities and think tanks-several of which have been identified as front groups or third-party lobbyists for the tobacco industry.

CONCLUSION

The dominance of economic arguments opposing tobacco control legislation risks undermining tobacco control progress. Local and global tobacco control advocates should seek to build relationships with media, as well as collate and disseminate effective counterarguments to those advanced by the industry.

Enhancing global health diplomacy for non-communicable diseases: application of the global health network framework

BACKGROUND AND AIM

Understanding the characteristics of global policy actors and the political context in which they address diplomatic issues in the field of NCDs can play an important role in advancing NCD-related goals. The purpose of this study was to identify and analyze the network of global health actors in the field of NCDs in Iran.

METHODS

This study was conducted in 2020 using a qualitative methodology and framework analysis. In-depth semi-structured interviews were conducted with subject-matter experts from all levels of diplomacy, including global, regional, and national, who had managerial, administrative, and academic experience.

FINDINGS

A total of 21 interviews were conducted with individuals who met the inclusion criteria. Following the framework of the World Health Network, the findings were divided into three general areas: the features of the network and the actors; the policy environment; and the characteristics of the issue.

CONCLUSION

A successful and sustainable program to combat NCDs requires the participation of multiple actors from governments, the private sector, and civil society at international, national, and local levels. The Global Network for Prevention and Control of NCDs should enhance the effectiveness of NCDs policies by highlighting the need to simultaneously improve the internal factors of the network, including relationships among the actors; external factors, including the policy environment; and the complex nature of NCDs.

Exploring the gap between refugee-background communities' needs and existing community-based physical activity programs in Australia

Physical activity programs run by local government, public health and not-for-profit sectors are a key public health strategy for improving rates of physical activity within local communities. However, these programs are underutilized. This is especially the case among members of refugee-background communities whose participation could have far-ranging and multilevel benefits. To explore how greater engagement among refugee-background communities with these programs could be fostered in Brisbane, Queensland, Australia, a qualitative study was undertaken from the perspectives of both community-based physical activity program providers and agencies involved in delivering services to refugee-background communities. This study involved a series of semi-structured interviews with a purposive sample of personnel from agencies that work with individuals and families from refugee-background communities and organizations that provide low-cost or no-cost physical activity programs and initiatives. Reflexive thematic analysis was used to interpret meaning from these data. Three themes relating to how participation in community-based physical activity programs could be improved among refugee-background communities were identified: improving cultural safety through intersectoral collaboration; confronting constraints imposed by the broader public health policy environment; and building capacity and empowering the community to diversify the sector. The findings highlight the importance of localized, deep-level intersectoral collaborations in bridging the gap between the health and social care needs of refugee-background communities and existing physical activity programs. However, a range of systems-produced barriers to the creation of such collaborations must be addressed to enable local actors to help mitigate and address the systemic exclusion of marginalized populations from participation in broader society.

How gender is socially constructed in policy making processes: a case study of the Adolescent and Youth Health Policy in South Africa

BACKGROUND

Gender equality remains an outstanding global priority, more than 25 years after the landmark Beijing Platform for Action. The disconnect between global health policy intentions and implementation is shaped by several conceptual, pragmatic and political factors, both globally and in South Africa. Actor narratives and different framings of gender and gender equality are one part of the contested nature of gender policy processes and their implementation challenges. The main aim of this paper is to foreground the range of policy actors, describe their narratives and different framings of gender, as part exploring the social construction of gender in policy processes, using the Adolescent Youth Health Policy (AYHP) as a case study.

METHODS

A case study design was undertaken, with conceptual underpinnings combined from gender studies, sociology and health policy analysis. Through purposive sampling, a range of actors were selected, including AYHP authors from government and academia, members of the AYHP Advisory Panel, youth representatives from the National Department of Health Adolescent and Youth Advisory Panel, as well as adolescent and youth health and gender policy actors, in government, academia and civil society. Qualitative data was collected via in-depth, semi-structured interviews with 30 policy actors between 2019 and 2021. Thematic data analysis was used, as well as triangulation across both respondents, and the document analysis of the AYHP.

RESULTS

Despite gender power relations and more gender-transformative approaches being discussed during the policy making process, these were not reflected in the final policy. Interviews revealed an interrelated constellation of diverse and juxtaposed actor gender narratives, ranging from framing gender as equating girls and women, gender as inclusion, gender as instrumental, gender as women's rights and empowerment and gender as power relations. Some of these narrative framings were dominant in the policy making process and were consequently included in the final policy document, unlike other narratives. The way gender is framed in policy processes is shaped by actor narratives, and these diverse and contested discursive constructions were shaped by the dynamic interactions with the South Africa context, and processes of the Adolescent Youth Health Policy. These varied actor narratives were further contextualised in terms of reflections of what is needed going forward to advance gender equality in adolescent and youth health policy and programming. This includes prioritising gender and intersectionality on the national agenda, implementing more gender-transformative programmes, as well as having the commitments and capabilities to take the work forward.

CONCLUSIONS

The constellation of actors' gender narratives reveals overlapping and contested framings of gender and what is required to advance gender equality. Understanding actor narratives in policy processes contributes to bridging the disconnect between policy commitments and reality in advancing the gender equality agenda.

A Framing Analysis of Consultation Submissions on the WHO Global Strategy to Reduce the Harmful Use of Alcohol: Values and Interests

BACKGROUND

In response to the magnitude of harms caused by alcohol, the World Health Organization (WHO) Global Strategy to Reduce the Harmful Use of Alcohol (GAS) was endorsed in 2010. We analysed submissions to the 2019 WHO consultation on the implementation of the GAS to identify how different stakeholders frame alcohol use and control; and to assess how stakeholders engage with the consultation process, with possibly harmful consequences for public health policy.

METHODS

All submissions from WHO Member States, international organisations, non-governmental organisations (NGOs), academic institutions and private sector entities were identified and used as data for an inductive framing analysis. This involved close reading and data familiarisation, thematic coding and identifying emergent framings. Through the analysis of texts, framing analysis can give insights into the values and interests of stakeholders. Because framing influences how issues are conceptualised and addressed, framing analysis is a useful tool to study policy-making processes.

RESULTS

We identified 161 unique submissions and seven attachments. Emerging frames were grouped according to their function: defining the problem, assigning causation, proposing solutions, or justifying and persuading. Submissions varied in terms of the framing they deployed and how this was presented, eg, how the problem was defined. Proposed policy solutions also varied. Targeted solutions emphasising individual responsibility tended to be supported by industry and some Member States. Calls for universal regulation and global mobilisation often came from NGOs and academia. Stakeholders drew on evidence and specific value systems to support the adoption of certain problem and solution ideas and to oppose competing framing.

CONCLUSION

Alcohol control is a contested policy field in which different stakeholders use framing to set the agenda and influence what policy solutions are considered legitimate. WHO should consider which interests are served by these different framings and how to weigh different stakeholders in the consultation process.

Creating Political Will for Action on Health Equity: Practical Lessons for Public Health Policy Actors

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.

Competing Frames in Global Health Governance: An Analysis of Stakeholder Influence on the Political Declaration on Non-communicable Diseases

BACKGROUND

Non-communicable diseases (NCDs) are increasingly recognized as a significant threat to health and development globally, and United Nations (UN) Member States adopted the Political Declaration of the Third High-level Meeting (HLM) on the prevention and control of NCDs in 2018. The negotiation process for the Declaration included consultations with Member States, intergovernmental organizations (IGOs), and non-state actors such as non-governmental organizations (NGOs) and the private sector. With NCD responses facing charges of inadequacy, it is important to scrutinize the governance process behind relevant high-level global decisions and commitments.

METHODS

Through a review of 159 documents submitted by stakeholders during the negotiation process, we outline a typology of policy positions advocated by various stakeholders in the development of the Declaration. We document changes in text from the draft to the final version of the Declaration to analyse the extent to which various positions and their proponents were influential.

RESULTS

NGOs and low- and middle-income countries (LMICs) generally pursued 'stricter' governance of NCD risk factors including stronger regulation of unhealthy products and improved management of conflicts of interest that arise when health-harming industries are involved in health policy-making. The private sector and high-income countries generally opposed greater restrictions on commercial factors. The pattern of changes between the draft and final Declaration indicate that advocated positions tended to be included in the Declaration if there was no clear opponent, whereas opposed positions were either not included or included with ambiguous language.

CONCLUSION

Many cost-effective policy options to address NCDs, such as taxation of health-harming products, were opposed by high-income countries and the private sector and not well-represented in the Declaration. To ensure robust political commitments and action on NCDs, multi-stakeholder governance for NCDs must consider imbalances in power and influence amongst constituents as well as biases and conflicts in positioning.

Governing ultra-processed food and alcohol industries: the presence and role of non-government organisations in Australia

OBJECTIVE

The roles of non-governmental organisations (NGOs) in regulating harmful commodity industries (HCIs) are understudied. The aim of this paper is to identify the NGOs and the roles that they play in the governance of the ultra-processed food and alcohol industries in Australia.

METHODS

We undertook an exploratory descriptive analysis of NGOs identified from an online search based on the typology we developed of type, issue area and governance function.

RESULTS

A total of 134 relevant Australian NGOs were identified: 38 work on food issues, 61 with alcohol issues and 35 are active in both. In the food domain, 90% of NGOs engage in agenda setting, 88% in capacity building, 15% in implementation and 12% in monitoring. In the alcohol domain, 92% of NGOs are active in agenda setting, 72% in capacity building, 35% in implementation and 8% in monitoring.

CONCLUSIONS

Australian NGOs are active actors in the food and alcohol governance system.

IMPLICATIONS FOR PUBLIC HEALTH

There are many opportunities for NGOs to regulate HCI practices, building on their relative strengths in agenda setting and capacity building, and expanding their activities in monitoring and implementation. A more detailed examination is needed of strategies that can be used by NGOs to be effective regulators in the governance system.

OUP accepted manuscript

Context

Policy-specific actions to improve food environments will support healthy population diets.

Objective

To identify cited barriers and facilitators to food environment policy (FEP) processes reported in the literature, exploring these according to the nature of the policy (voluntary or mandatory) and country development status.

Data sources

A systematic search was conducted of 10 academic and 7 grey-literature databases, national websites, and manual searches of publication references.

Data extraction

Data on government-led FEPs, barriers, and facilitators from key informants were collected.

Data synthesis

The constant-comparison approach generated core themes for barriers and facilitators. The appraisal tool developed by Hawker et al. was adopted to determine the quality of qualitative and quantitative studies.

Results

A total of 142 eligible studies were identified. Industry resistance or disincentive was the most cited barrier in policy development. Technical challenges were most frequently a barrier for policy implementation. Frequently cited facilitators included resource availability or maximization, strategies in policy process, and stakeholder partnership or support.

Conclusions

The findings from this study will strategically inform health-reform stakeholders about key elements of public health policy processes. More evidence is required from countries with human development indices ranging from low to high and on voluntary policies.

Systematic Review Registration

PROSPERO registration no. CRD42018115034.

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

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.

Corporate power and the international trade regime preventing progressive policy action on non-communicable diseases: a realist review

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.

Defending access to medicines in regional trade agreements: lessons from the Regional Comprehensive Economic Partnership - a qualitative study of policy actors' views

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.

Identifying Policy Best-Practices to Support the Contribution of Aquatic Foods to Food and Nutrition Security

The relationship between aquatic foods and food nutrition and security is increasingly recognised in policy and practice, yet many governance instruments do not acknowledge or support this important connection. The most effective policy approaches to support the link between these sectors, or 'best practices' are currently unknown. We reviewed relevant governance instruments from multiple countries to identify how these instruments linked fisheries, aquaculture and food security and nutrition, including the policy framing and evidence of political commitment. Of the documents connecting the sectors (65%), the majority did so in the context of developing the fisheries/aquaculture sector to increase aquatic food availability and/or access (51%), followed by developing the fisheries/aquaculture sector as a livelihoods approach to indirectly improve food security (33%), for example, through income generation. Sectoral links established in the context of nutrition-sensitive approaches to fisheries and aquaculture were less common (5%). Almost one third (29%) of instruments supported the connection between aquatic foods and food security and nutrition across three or more different contexts relevant to food security or food systems, while 12% indicated a very high level of commitment. We recommend some key attributes for future policy development to help build coherence between sectors and to help frame coherent food system-based policies.

How food companies use social media to influence policy debates: a framework of Australian ultra-processed food industry Twitter data

OBJECTIVE

To understand if, and how, Australian ultra-processed food industry actors use Twitter to influence food and health policy debates and produce a conceptual framework to describe such influence.

DESIGN

Twitter data of prominent industry actors were defined through purposive sampling and inductively coded to investigate possible influence on food and health policy debates. These are described using descriptive statistics and coded extracts.

SETTING

Australia.

PARTICIPANTS

Twitter accounts of nine prominent ultra-processed food industry actors, including major trade associations.

RESULTS

Ultra-processed food industry actors actively used Twitter to influence food and health policy debates. Seven overarching strategies were identified: co-opting public health narratives; opposing regulation; supporting voluntary, co- or self-regulation; engaging policy processes and decision-makers; linking regulatory environments to the need for ongoing profitability; affecting public perceptions and value judgements; and using ignorance claims to distort policy narratives. Each lobbying strategy is underpinned with tactics described throughout and captured in a framework.

CONCLUSIONS

The current study creates a framework to monitor how food industry actors can use social media to influence food and health policy debates. As such, social media appears to be not only an important commercial determinant of health for brand marketing, but also an extension of lobbying practices to reshape public perceptions of corporate conduct and policy-making.

Power and the people's health

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.

Framing action to reduce health inequalities: what is argued for through use of the 'upstream-downstream' metaphor?

BACKGROUND

Public health insights struggle to compete with dominant ideas which frame health inequalities as a problem of individual behaviour. There is consequently a need to critically reflect upon and question the effectiveness of different strategies for framing and communicating key insights. Taking the example of the 'upstream-downstream' metaphor, this literature review contributes to a necessary first step by asking what exactly is being argued for through its use.

METHODS

An iterative search strategy was used to identify peer-reviewed articles which could contribute to the review question. A discourse analysis framework informed data extraction and synthesis of 24 articles. Articles were subsequently categorized into groups which reflected the different uses of the metaphor identified.

RESULTS

All authors used the metaphor to promote a particular causal understanding of health inequalities, leading some to recommend policies and programmes, and others to focus on implementation processes. This seemingly simple metaphor has evolved beyond differentiating 'upstream' from 'downstream' determinants, to communicate an ambitious politically engaged agenda for change.

CONCLUSIONS

The metaphor is not without its critics and in light of the complexity of the arguments encapsulated in its use, work is needed to establish if it can, and does, resonate as intended with wider audiences.

Planting seeds of change: reconceptualizing what people eat as eating practices and patterns

Language focused on individual dietary behaviors, or alternatively, lifestyle choices or decisions, suggests that what people eat and drink is primarily a choice that comes down to free will. Referring to and intervening upon food consumption as though it were a freely chosen behavior has an inherently logical appeal due to its simplicity and easily defined targets of intervention. However, despite decades of behavioral interventions, population-level patterns of food consumption remain suboptimal. This debate paper interrogates the manner in which language frames how problems related to poor diet quality are understood and addressed within society. We argue that referring to food consumption as a behavior conveys the idea that it is primarily a freely chosen act that can be ameliorated through imploring and educating individuals to make better selections. Leveraging practice theory, we subsequently propose that using the alternative language of eating practices and patterns better conveys the socially situated nature of food consumption. This language may therefore point to novel avenues for intervention beyond educating and motivating individuals to eat more healthfully, to instead focus on creating supportive contexts that enable sustained positive dietary change. Clearly, shifting discourse will not on its own transform the science and practice of nutrition. Nevertheless, the seeds of change may lie in aligning our terminology, and thus, our framing, with desired solutions.

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

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.

Framing global discourses on non-communicable diseases: a scoping review

Background

The choices that policymakers make are shaped by how their problems are framed. At last, non-communicable diseases (NCDs) have risen high on the global policy agenda, but there are many disputed issues. First, what are they? Their name refers not to what they are but what they are not. Second, where do their boundaries lie? What diseases are included? Third, should we view their causes as mainly biomedical, behavioural, or social, or a combination? Our failure to resolve these issues has been invoked as a reason for our limited progress in developing and implementing effective remedies. In this scoping review, we ask “What is known from the existing literature about how NCDs are framed in the global policy discourses?” We answer it by reviewing the frames employed in policy and academic discourses.

Methods

We searched nine electronic databases for articles published since inception to 31 May 2019. We also reviewed websites of eight international organisations to identify global NCDs policies. We extracted data and synthesised findings to identify key thematic frames.

Results

We included 36 articles and nine policy documents on global NCDs policies. We identified five discursive domains that have been used and where there are differing perspectives. These are: “Expanding the NCDs frame to include mental health and air pollution”; “NCDs and their determinants”; “A rights-based approach to NCDs”; “Approaches to achieving policy coherence in NCDs globally”; and “NCDs as part of Sustainable Socio-economic Development”. We further identified 12 frames within the five discursive domains.

Conclusions

This scoping review identifies issues that remain unresolved and points to a need for alignment of perspectives among global health policy actors, as well as synergies with those working on mental health, maternal health, and child health. The current COVID-19 pandemic warrants greater consideration of its impact on global NCDs policies. Future global strategies for NCDs need to consider explicitly how NCDs are framed in a changing global health discourse and ensure adequate alignment with implementation and global health issues. There is a need for global strategies to recognise the pertinent role of actors in shaping policy discourses.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05958-0.

Beyond the Chair: Public Health and Governmental Measures to Tackle Sugar

Limiting free sugars to <5% of energy intake is a World Health Organization evidence-based recommendation to protect oral health throughout the life course. Achieving this requires a concerted approach with upstream interventions, including legislation underpinning community interventions and health promotion. Global production and trade are the main drivers of sugars consumption, which can be addressed only through prioritization of health impacts in agricultural and trade agreements, including pricing and subsidies. Increasing evidence demonstrates the benefit, including dental benefits, of taxes on sugar-sweetened beverages, a major source of sugars—with taxes based on sugars content being favored due to the dual impact in incentivizing consumers to buy less and encouraging producers to use less through product reformulation. A benefit of product reformulation is that the potential impact on sugars intake occurs independent of consumer behavior change, making the benefits more equitable across social groups. Evidence from meta-analysis indicates that sugars reformulation and portion size reduction could lower energy intake by more than 10% and 16%, respectively. Sophisticated and targeted digital marketing of products high in sugars is another key driver of sugars intake. With the exception of children’s television broadcasting, marketing of products high in sugars is largely unregulated, and increased awareness of modern marketing strategies and more stringent regulation are urgently needed. To ensure a commercial level playing field, mandatory approaches are required. Midstream actions include creating healthier food environments in neighborhoods, community settings (schools, sports centers, hospitals), and workplaces. Only through coalition among authorities responsible for planning and health will “obesogenic and cariogenic” environments be replaced with those that make healthy choices the easiest choice. It is recognized that providing nutrition health education alone is insufficient to achieve necessary sugars reduction; however, education has a key role to play in changing social norms and creating drive for change.

An exposé of the realpolitik of trade negotiations: implications for population nutrition

OBJECTIVE

To explore the formal and informal ways in which different actors involved in shaping trade agreements pursue their interests and understand the interactions with nutrition, in order to improve coherence between trade and nutrition policy goals.

DESIGN

The paper draws on empirical evidence from Australian key informant interviews that explore the underlying political dimensions of trade agreements that act as barriers or facilitators to getting nutrition objectives on trade agendas.

SETTING

Countries experiencing greater availability and access to diets full of energy-dense and nutrient-poor foods through increased imports, greater foreign direct investment and increasing constraints on national health policy space as a result of trade agreements.

PARTICIPANTS

Interviews took place with Australian government officials, industry, public-interest non-government organizations and academics.

RESULTS

The analysis reveals the formal and informal mechanisms and structures that different policy actors use both inside and outside trade negotiations to pursue their interests. The analysis also identifies the discourses used by the different actors, as they attempt to influence trade agreements in ways that support or undermine nutrition-related goals.

CONCLUSIONS

Moving forward requires policy makers, researchers and health advocates to use various strategies including: reframing the role of trade agreements to include health outcomes; reforming the process to allow greater access and voice to health arguments and stakeholders; establishing cross-government partners through accountable committees; and building circles of consensus and coalitions of sympathetic public-interest actors.

How do actors with asymmetrical power assert authority in policy agenda-setting? A study of authority claims by health actors in trade policy

How health advocates and industry actors attempt to assert their authority as a strategy of influence in policymaking remains underexplored in the health governance literature. Greater exploration of the kinds of authority sources used by health actors vis-à-vis market actors and the role ideational factors may play in shaping access to these sources provides insight into advocates' efforts to exert influence in policy forums. Using the trade domain in Australia as a case study of the way in which the commercial determinants of health operate, we examined the different ways in which health, public interest and market actors assert their authority. Drawing on a political science typology of authority, we analysed 87 submissions to the Australian government during the Trans-Pacific Partnership negotiations. We identify four types of authority claims; institutional authority, derived from holding a position of influence within another established institution; legal authority through appeals to legal agreements and precedents; networked authority through cross-referencing between actors, and expert authority through use of evidence. Combining these claims with a framing analysis, we found that these bases of authority were invoked differently by actors who shared the dominant neoliberal ideology in contrast to those actors that shared a public interest discourse. In particular, market actors were much less likely to rely on external sources of authority, while health and public interest actors were more likely to appeal to networked and expert authority. We argue that actors who share strong ideational alignment with the dominant policy discourse appear less reliant on other sources of authority. Implications of this analysis include the need for greater attention to the different strategies and ideas used by industry and public health organisations in trade policy agenda-setting for health, which ultimately enable or constrain the advancement of health on government agendas.