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

Public-Private Partnerships in Mexico: Implications of Engaging With the Food and Beverage Industry for Public Health Nutrition

BACKGROUND

In the last few years, Mexico adopted public health policies to tackle non-communicable diseases (NCDs), such as front of package nutrition labelling, food marketing restrictions to children, and a soda tax. In parallel, transnational food and beverage industries (F&BIs), their allies, and the government have agreed on public-private partnerships (PPPs) to implement policies or deliver programs. However, research has questioned the benefits of PPPs and exposed its limitations as a suitable mechanism to improve public health. This study analyses how four PPPs between the Mexican government, the F&BI, and allies are working to achieve their goals. We critically assessed the objectives, scope, reported impacts, governance principles and perceived risks and benefits for the public health agenda of these PPPs.

METHODS

This qualitative study is based on 26 interviews with key actors, and 170 publicly available documents, including 22 obtained through freedom of information (FOI) requests related to four purposively selected PPPs aiming to improve health.

RESULTS

We found that the four PPPs studied had minimal public information available on their implementation and impact. The private partners tend to dictate the design, information management, and implementation of the programs, while promoting their brands. Few independent evaluations of the PPPs exist, and none reported on their effectiveness or public health benefits. Good governance principles, such as accountability, transparency, fairness, participation, integrity, and credibility, were barely followed in each of the cases studied. Public officials did not automatically question the conflict of interest (CoI) of such arrangements. When there were COI, the potential risks these posed did not always outweigh the financial benefits of working with the F&BI and its allies.

CONCLUSION

The four PPPs studied produced minimal gains for public health while boosting credibility for the participating transnational F&BIs. It shows the lack of awareness of how these PPPs might be hindering public health gains.

Ethical Frameworks and Global Health: A Narrative Review of the "Leave No One Behind" Principle

The "Leave No One Behind" (LNOB) principle, a fundamental commitment of the United Nations' Sustainable Development Goals, emphasizes the urgent need to address and reduce global health inequalities. As global health initiatives strive to uphold this principle, they face significant ethical challenges in balancing equity, resource allocation, and diverse health priorities. This narrative review critically examines these ethical dilemmas and their implications for translating LNOB into actionable global health strategies. A comprehensive literature search was conducted using PubMed, Scopus, Web of Science, and Semantic Scholar, covering publications from January 1990 to April 2024. The review included peer-reviewed articles, gray literature, and official reports that addressed the ethical dimensions of LNOB in global health contexts. A thematic analysis was employed to identify and synthesize recurring ethical issues, dilemmas, and proposed solutions. The thematic analysis identified 4 primary ethical tensions that complicate the operationalization of LNOB: (1) Universalism versus Targeting, where the challenge lies in balancing broad health improvements with targeted interventions for the most disadvantaged; (2) Resource Scarcity versus Equity; highlighting the ethical conflicts between maximizing efficiency and ensuring fairness; (3) Top-down versus Bottom-up Approaches, reflecting the tension between externally driven initiatives and local community needs; and (4) Short-term versus Long-term Sustainability, addressing the balance between immediate health interventions and sustainable systemic changes. To navigate these ethical challenges effectively, global health strategies must adopt a nuanced, context-sensitive approach incorporating structured decision-making processes and authentic community participation. The review advocates for systemic reforms that address the root causes of health disparities, promote equitable collaboration between health practitioners and marginalized communities, and align global health interventions with ethical imperatives. Such an approach is essential to truly operationalize the LNOB principle and foster sustainable health equity.

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.

Implementation of medicines pricing policies in sub-Saharan Africa: systematic review

BACKGROUND

High medicine prices contribute to increasing cost of healthcare worldwide. Many patients with limited resources in sub-Saharan Africa (SSA) are confronted with out-of-pocket charges, constraining their access to medicines. Different medicine pricing policies are implemented to improve affordability and availability; however, evidence on the experiences of implementations of these policies in SSA settings appears limited. Therefore, to bridge this knowledge gap, we reviewed published evidence and answered the question: what are the key determinants of implementation of medicines pricing policies in SSA countries?

METHODS

We identified policies and examined implementation processes, key actors involved, contextual influences on and impact of these policies. We searched five databases and grey literature; screening was done in two stages following clear inclusion criteria. A structured template guided the data extraction, and data analysis followed thematic narrative synthesis. The review followed best practices and reported using PRISMA guidelines.

RESULTS

Of the 5595 studies identified, 31 met the inclusion criteria. The results showed thirteen pricing policies were implemented across SSA between 2003 and 2020. These were in four domains: targeted public subsides, regulatory frameworks and direct price control, generic medicine policies and purchasing policies. Main actors involved were government, wholesalers, manufacturers, retailers, professional bodies, community members and private and public health facilities. Key contextual barriers to implementation were limited awareness about policies, lack of regulatory capacity and lack of price transparency in external reference pricing process. Key facilitators were favourable policy environment on essential medicines, strong political will and international support. Evidence on effectiveness of these policies on reducing prices of, and improving access to, medicines was mixed. Reductions in prices were reported occasionally, and implementation of medicine pricing policy sometimes led to improved availability and affordability to essential medicines.

CONCLUSIONS

Implementation of medicine pricing policies in SSA shows some mixed evidence of improved availability and affordability to essential medicines. It is important to understand country-specific experiences, diversity of policy actors and contextual barriers and facilitators to policy implementation. Our study suggests three policy implications, for SSA and potentially other low-resource settings: avoiding a 'one-size-fits-all' approach, engaging both private and public sector policy actors in policy implementation and continuously monitoring implementation and effects of policies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020178166.

Public-Private Partnerships With Unhealthy Commodity Industries: Are They Undermining Real Progress in Non-communicable Disease Prevention? Comment on "Competing Frames in Global Health Governance: An Analysis of Stakeholder Influence on the Political Declaration on Non-communicable Diseases"

Public-private partnerships (PPPs) and whole-of-society approaches are increasingly common in public health promotion and non-communicable disease (NCD) prevention, despite a lack of evidence in favour of their effectiveness in improving health outcomes. While PPPs may have advantages, they also give industry actors more influence over the design and implementation of public health strategies and interventions. Partnering with unhealthy commodity industries in particular - including the alcohol and ultra-processed food and beverages industries - can pose significant risks to public health due to these industries' deep-rooted conflicts of interest. In this commentary, I reiterate Suzuki and colleagues' message about the importance of assessing and managing conflicts of interest before engaging with non-state actors through PPPs or other forms of engagement.

Thinking Politically About UN Political Declarations: A Recipe for Healthier Commitments-Free of Commercial Interests Comment on "Competing Frames in Global Health Governance: An Analysis of Stakeholder Influence on the Political Declaration on Non-communicable Diseases"

As evidence mounts that corporate actor engagement in United Nations (UN) policy-making processes leads to weaker and shallower public health commitments, greater attention is being paid to how to minimise undue interference and manage conflicts of interest (CoI). While we welcome efforts to develop normative guidance on managing such conflicts, we argue that there is the need to go further. In particular, we propose that an index be developed that would assess the health impacts of individual corporate actors, and those actors who fail to achieve a set benchmark would not have engagement privileges. We further propose the establishment of an independent panel of experts to advise on corporate actor engagement as well as on ambiguous and potentially health-harming commitments in text under negotiation in the UN. Recognising that the implementation of such measures will be contested, we recommend a number of practical steps to make their implementation more politically palatable.

"A Promise Unfulfilled": Stakeholder Influence and the 2018 UN High-Level Meeting on NCDs Comment on "Competing Frames in Global Health Governance: An Analysis of Stakeholder Influence on the Political Declaration on Non-communicable Diseases"

In recognition of the global burden of non-communicable diseases (NCDs), the past decade has seen three United Nations High-Level Meetings (UN HLMs) on NCDs. Yet progress in terms of political or financial commitments has been very slow. At the 2018 meeting, a political declaration was approved but featured language that had been watered down in terms of commitments. In "Competing Frames of Global Health Governance: An Analysis of Stakeholder Influence on the Political Declaration on Non-communicable Diseases," Suzuki et al analyze the documents that were submitted by Member States, non-governmental organizations and the private sector during the consultation period and conclude that the private sector and several high-income countries (HICs) appeared to oppose regulatory frameworks for products associated with NCDs, that wealthier countries resisted financing commitments, and that general power asymmetries affected the final document. This comment supports their findings and provides additional considerations for why the NCD response has yet to produce significant commitments.

Lacking Clarity or Strategic Ambiguity? Comment on "Competing Frames in Global Health Governance: An Analysis of Stakeholder Influence on the Political Declaration on Non-communicable Diseases"

This commentary engages with Suzuki and colleagues' analysis about the ambiguity of multi-stakeholder discourses in the United Nations (UN) Political Declaration of the 3rd High-Level Meeting of the General Assembly on the Prevention and Control of Non-Communicable Diseases (HLM-NCDs), suggesting that blurring between public and private sector in this declaration reflects broader debates about multi-stakeholder partnerships (MSPs) and public-private partnerships (PPPs) in health governance. We argue that the ambiguity between the roles and responsibilities of public and private actors involved may downplay the role (and regulation) of conflicts of interest (COI) between unhealthy commodity industries and public health. We argue that this ambiguity is not simply an artefact of the Political Declaration process, but a feature of multi-stakeholderism, which assumes that commercial actors´ interests can be aligned with the public interest. To safeguard global health governance, we recommend further empirical and conceptual research on COI and how it can be managed.

Commercial Influence on Political Declarations: The Crucial Distinction Between Consultation and Negotiation and the Need for Transparency in Lobbying Comment on "Competing Frames in Global Health Governance: An Analysis of Stakeholder Influence on the Political Declaration on Non-communicable Diseases"

Suzuki and colleagues' rare and elaborate analysis of the political processes behind the 2018 United Nations (UN) non-communicable diseases (NCD) Declaration discloses various pathways towards influencing global public health policies. Their study should be a wake-up call for further scientific political scrutiny and analysis, including clearly distinguishing between consultations such as UN multi-stakeholder hearings preceding high-level meetings and the actual negotiating and decision making process. While stakeholder positions at interactive hearings are documented and published and thus made transparent, the negotiating process among member states is not publicly known. The extent to which intergovernmental negotiations are influenced at country or regional levels by commercial interests through direct and indirect lobbying outside of public consultations should be given more attention. Lobby registers should be implemented more stringently and legislative footprints required and applied not only to legally binding but also to internationally important documents such as political declarations.

Powerful Allies and Weak Consensus: Towards a Deeper Understanding of how Health-Harming Industries Seek to Influence Global Health Governance Comment on "Competing Frames in Global Health Governance: An Analysis of Stakeholder Influence on the Political Declaration on Non-communicable Diseases"

Suzuki et al have identified commonalities in the policy positions adopted at a global forum by commercial sector actors and high-income countries (HICs), on the one hand, and non-governmental organizations (NGOs) and low- and middle-income countries (LMICs), on the other, in ways that may allow commercial sector actors to block or delay evidence-based policies through the creation of political controversy. The ability of industry actors to draw on the support of the most politically and economically powerful countries for their favoured policy agenda is an important contribution to understanding the dynamics of global health governance in the area of non-communicable diseases (NCDs) and beyond. Here we assess the relevance of this paper for the field of corporate actors' research and the potential avenues this opens up for further study. More specifically we emphasize the need for comparative, cross disciplinary research to examine the power of heath-harming industries and the relevance of these findings for decolonizing global health.

Examining Intersectoral Action as an Approach to Implementing Multistakeholder Collaborations to Achieve the Sustainable Development Goals

Objectives: The Sustainable Development Goals (SDGs) re-orient action towards improving the social and ecological determinants of health and equity. SDG 17 calls for enhanced policy and institutional coherence and strong multi-stakeholder partnerships. Intersectoral action (IA) has a promising history in public health, including health promotion and global health. Some experts see IA as crucial to the SDGs. Yet less is known about how IA is conceptualized and what promising models exist with relevance to the SDGs. We sought to investigate how IA is understood conceptually and empirically.

Methods: We conducted a narrative review of global public health and political science literatures and grey literature on the SDGs to identify theoretical models, case studies and reviews of IA research.

Results: Multiple competing conceptualizations of IA exist. Research has focused on case studies in high-income countries. More conceptual clarity, analyses of applications in LMICs, and explorations of political and institutional factors affecting IA are needed, as is attention to power dynamics between sectors.

Conclusion: IA is required to collaborate on the SDGs and address equity. New models for successful implementation merit exploration.