Defining and conceptualising the commercial determinants of health.

Although commercial entities can contribute positively to health and society there is growing evidence that the products and practices of some commercial actors-notably the largest transnational corporations-are responsible for escalating rates of avoidable ill health, planetary damage, and social and health inequity; these problems are increasingly referred to as the commercial determinants of health. The climate emergency, the non-communicable disease epidemic, and that just four industry sectors (ie, tobacco, ultra-processed food, fossil fuel, and alcohol) already account for at least a third of global deaths illustrate the scale and huge economic cost of the problem. This paper, the first in a Series on the commercial determinants of health, explains how the shift towards market fundamentalism and increasingly powerful transnational corporations has created a pathological system in which commercial actors are increasingly enabled to cause harm and externalise the costs of doing so. Consequently, as harms to human and planetary health increase, commercial sector wealth and power increase, whereas the countervailing forces having to meet these costs (notably individuals, governments, and civil society organisations) become correspondingly impoverished and disempowered or captured by commercial interests. This power imbalance leads to policy inertia; although many policy solutions are available, they are not being implemented. Health harms are escalating, leaving health-care systems increasingly unable to cope. Governments can and must act to improve, rather than continue to threaten, the wellbeing of future generations, development, and economic growth.

Emergence of three general practitioner contracting-in models in South Africa: a qualitative multi-case study.

BACKGROUND: The general practitioner contracting initiative (GPCI) is a health systems strengthening initiative piloted in the first phase of national health insurance (NHI) implementation in South Africa as it progresses towards universal health coverage (UHC). GPCI aimed to address the shortage of doctors in the public sector by contracting-in private sector general practitioners (GPs) to render services in public primary health care clinics. This paper explores the early inception and emergence of the GPCI. It describes three models of contracting-in that emerged and interrogates key factors influencing their evolution. METHODS: This qualitative multi-case study draws on three cases. Data collection comprised document review, key informant interviews and focus group discussions with national, provincial and district managers as well as GPs (n = 68). Walt and Gilson's health policy analysis triangle and Liu's conceptual framework on contracting-out were used to explore the policy content, process, actors and contractual arrangements involved. RESULTS: Three models of contracting-in emerged, based on the type of purchaser: a centralized-purchaser model, a decentralized-purchaser model and a contracted-purchaser model. These models are funded from a single central source but have varying levels of involvement of national, provincial and district managers. Funds are channelled from purchaser to provider in slightly different ways. Contract formality differed slightly by model and was found to be influenced by context and type of purchaser. Conceptualization of the GPCI was primarily a nationally-driven process in a context of high-level political will to address inequity through NHI implementation. Emergence of the models was influenced by three main factors, flexibility in the piloting process, managerial capacity and financial management capacity. CONCLUSION: The GPCI models were iterations of the centralized-purchaser model. Emergence of the other models was strongly influenced by purchaser capacity to manage contracts, payments and recruitment processes. Findings from the decentralized-purchaser model show importance of local context, provincial capacity and experience on influencing evolution of the models. Whilst contract characteristics need to be well defined, allowing for adaptability to the local context and capacity is critical. Purchaser capacity, existing systems and institutional knowledge and experience in contracting and financial management should be considered before adopting a decentralized implementation approach.

Building a Systems Map: Applying Systems Thinking to Unhealthy Commodity Industry Influence on Public Health Policy.

BACKGROUND: Unhealthy commodity industries (UCIs) engage in political practices to influence public health policy, which poses barriers to protecting and promoting public health. Such influence exhibits characteristics of a complex system. Systems thinking would therefore appear to be a useful lens through which to study this phenomenon, potentially deepening our understanding of how UCI influence are interconnected with one another through their underlying political, economic and social structures. As such this study developed a qualitative systems map to depict the complex pathways through which UCIs influence public health policy and how they are interconnected with underlying structures. METHODS: Online participatory systems mapping workshops were conducted between November 2021 and February 2022. As a starting point for the workshops, a preliminary systems map was developed based on recent research. Twenty-three online workshops were conducted with 52 geographically diverse stakeholders representing academia, civil society, public office and global governance organisations. Analysis of workshop data in NVivo and feedback from participants resulted in a final systems map. RESULTS: The preliminary systems map consisted of 40 elements across six interdependent themes. The final systems map consisted of 64 elements across five interdependent themes, representing key pathways through which UCIs impact health policymaking: 1) direct access to public sector decision-makers; 2) creation of confusion and doubt about policy decisions; 3) corporate prioritisation of commercial profits and growth; 4) industry leveraging the legal and dispute settlement processes; and 5) industry leveraging policymaking, norms, rules, and processes. CONCLUSION: UCI influence on public health policy is highly complex, involves interlinked practices, and is not reducible to a single point within the system. Instead, pathways to UCI influence emerge from the complex interactions between disparate national and global political, economic and social structures. These pathways provide numerous avenues for UCIs to influence public health policy, which poses challenges to formulating a singular intervention or limited set of interventions capable of effectively countering such influence. Using participatory methods, we made transparent the interconnections that could help identify interventions future work.

Complex Interventions for a Complex System? Using Systems Thinking to Explore Ways to Address Unhealthy Commodity Industry Influence on Public Health Policy.

BACKGROUND: Interventions are needed to prevent and mitigate unhealthy commodity industry (UCI) influence on public health policy. Whilst literature on interventions is emerging, current conceptualisations remain incomplete as they lack considerations of the wider systemic complexities surrounding UCI influence, which may limit intervention effectiveness. This study applies systems thinking as a theoretical lens to help identify and explore how possible interventions relate to one another in the systems in which they are embedded. Related challenges to addressing UCI influence on policy, and actions to support interventions, were also explored. METHODS: Online participatory workshops were conducted with stakeholders with expertise in UCIs. A systems map, depicting five pathways to UCI influence, and the Action Scales Model were used to help participants identify interventions and guide discussions. Codebook thematic analysis was used to analyse the data. RESULTS: Fifty-two stakeholders participated in 23 workshops. Participants identified 27 diverse, interconnected and interdependent interventions corresponding to the systems map's pathways that reduce the ability of UCIs to influence policy, e.g., reform policy financing; regulate public-private partnerships; reform science governance and funding; frame and reframe the narrative, challenge neoliberalism and GDP growth; leverage human rights; change practices on multistakeholder governance; and reform policy consultation and deliberation processes. Participants also identified four potential key challenges to interventions (i.e., difficult to implement or achieve; partially formulated; exploited or misused; requires tailoring for context), and four key actions to help support intervention delivery (i.e., coordinate and cooperate with stakeholders; invest in civil society; create a social movement; nurture leadership). CONCLUSION: A systems thinking lens revealed the theoretical interdependence between disparate and heterogenous interventions. This suggests that to be effective, interventions need to align, work collectively, and be applied to different parts of the system synchronously. Importantly, these interventions need to be supported by intermediary actions to be achieved. Urgent action is now required to strengthen healthy alliances and implement interventions.

What and how can we learn from complex global problems for antimicrobial resistance policy? A comparative study combining historical and foresight approaches.

OBJECTIVES: To (i) develop a methodology for using historical and comparative perspectives to inform policy and (ii) provide evidence for antimicrobial-resistance (AMR) policymaking by drawing on lessons from climate change and tobacco control. METHODS: Using a qualitative design, we systematically examined two other complex, large-scale policy issues-climate change and tobacco control-to identify what relevance to AMR can be learned from how these issues have evolved over time. During 2018-2020, we employed a five-stage approach to conducting an exploratory study involving a review of secondary historical analysis, identification of drivers of change, prioritisation of the identified drivers, scenario generation and elicitation of possible policy responses. We sought to disrupt more 'traditional' policy and research spaces to create an alternative where, stimulated by historical analysis, academics (including historians) and policymakers could come together to challenge norms and practices and think creatively about AMR policy design. RESULTS: An iterative process of analysis and engagement resulted in lessons for AMR policy concerning persistent evidence gaps and uncertainty, the need for cross-sector involvement and a collective effort through global governance, the demand for new interventions through more investment in research and innovation, and recognising the dynamic relationship between social change and policy to change people's attitudes and behaviours are crucial towards tackling AMR. CONCLUSION: We draw on new methodological lessons around the pragmatism of future- and policy-oriented approaches incorporating robust historical and comparative analysis. The study demonstrates proof of concept and offers a reproducible method to advance further methodology, including transferrable policies that could tackle health problems, such as AMR.

Proposed methods for evaluating efforts made by governments to prevent and mitigate corporate influence and conflicts of interest in public health policy.

Background: There is evidence that corporations try to delay, weaken, and avoid the adoption of measures that would protect and improve population health. This is particularly true and problematic for health harming industries, such as those producing ultra-processed foods, alcohol, and cigarettes. Financial conflicts of interest (COI) are also problematic in policy-making because they may compromise decision-makers' loyalty and independent judgment. Public opinion is in favor of preventing and mitigating that influence from corporations and COI on public health policy. A scoping review recently identified twenty-three mechanisms that could be adopted with that purpose and which principally cover: i) transparency and disclosure; ii) identification, monitoring, and education; iii) management; iv) prohibition of interactions with the industry and/or COI. There is, however, limited knowledge on the adoption of such mechanisms by governments. We therefore propose new methods for evaluating that progress at the country level. Methods and expected results: The proposed evaluation comprises five steps: 1) Gathering information about the national context; 2) Gathering evidence on the implementation of mechanisms by national governments; 3) Verification of step 2 by government officials and policy experts and local public health experts; 4) Identification and prioritization of actions in a workshop; 5) Supporting the translation of findings into policy actions. Conclusions: The evaluation of progress made by governments in their implementation of mechanisms for preventing and mitigating the influence of corporations and COI in public health policy could help countries systematize their efforts, benchmark their progress internationally, and give perspective on particular weaknesses, approaches, and investment gaps needed for change. We will implement and validate our methods in Ireland, as a first case-study.

Identifying misleading corporate narratives: The application of linguistic and qualitative methods to commercial determinants of health research.

Narratives are key to the way corporations represent themselves to the outside world, are important to the development of shared understandings and ultimately determine whether and how corporations are able to influence societal norms and participate in policy debates. A leaked corporate affairs strategy document, from the world's largest transnational tobacco company, Philip Morris International (PMI), suggests a company concerned about credibility; it highlights "normalization" as a key strategic priority until at least 2024. This suggests that the PMI are seeking to rehabilitate their image and alter perceptions of their business. We designed a mixed-methods analysis of corporately authored content, combining quantitative querying of large bodies of text (Corpus Linguistics) with inductive coding of key themes to critically examine PMI's corporate language and how these themes might impact public health debates. We systematically analysed a sample of PMI's corporate communications (n = 170), comparing investor-facing (investor reports, slides and presentations as well as annual reports) and public-facing (YouTube content and Webpage content) communications covering a period of eight years (2012-2019). Our analysis identifies how PMI's misleading external communication contradicts its core business focus and may threaten public health. In public-facing communications, PMI stress their commitment to transformation and change, while in investor-facing communications, they focus on cigarettes and reiterate the strength of their existing cigarette brand portfolios. This suggests that webpage and YouTube content provide a means through which PMI attempt to neutralise negative public perception of tobacco-product related harms and to present themselves as advocates of "better" consumer choice and even public health. The recurrence of transformation, sustainability, and science, as well as the co-option of united-nations terminology in their external-facing communications may serve to legitimise their involvement in policy arenas from which they currently excluded. We present a novel method through which corporate narratives can be monitored and critically assessed.

Recruiting the "Heavy-Using Loyalists of Tomorrow": An Analysis of the Aims, Effects and Mechanisms of Alcohol Advertising, Based on Advertising Industry Evaluations.

Restricting alcohol advertising and marketing is a cost-effective intervention for reducing alcohol harms. However, the alcohol industry maintains that advertising does not affect consumption, claiming that its purpose is to help consumers choose brands, it is not aimed at young people, it only promotes "responsible consumption", and any relationships with consumption are not causal. We reviewed 39 case studies (1981-2016) published by the advertising industry, which evaluate the effects of alcohol advertising campaigns. We used these to examine these industry claims. 30/39 (77%) of the case studies mentioned increasing/maintaining market share as an objective, or used this to assess the effectiveness of advertising campaigns. Most (25/39, 64%) found that campaigns increased consumption-related outcomes. Some campaigns targeted women, and heavy drinkers (e.g., Stella Artois lager, Famous Grouse whisky). Campaigns often (13/39, 33%) targeted younger drinkers. These data show that advertising does influence market share. Other effects reported in the case studies include changing the consumer profile towards: younger drinkers, women, new/lapsed drinkers, and heavy drinkers. They also present evidence of a causal relationship between advertising and consumption. In conclusion, this analysis, based on industry data, presents significant new evidence on (i) the effects of alcohol advertising on consumption-related outcomes, and (ii) the mechanisms by which it achieves those effects.

Unpacking policy formulation and industry influence: the case of the draft control of marketing of alcoholic beverages bill in South Africa.

Alcohol is a major contributor to the Non-Communicable Disease burden in South Africa. In 2000, 7.1% of all deaths and 7% of total disability-adjusted life years were ascribed to alcohol-related harm in the country. Regulations proposed to restrict alcohol advertising in South Africa present an evidence-based upstream intervention. Research on policy formulation in low- and middle-income countries is limited. This study aims to describe and explore the policy formulation process of the 2013 draft Control of Marketing of Alcoholic Beverages Bill in South Africa between March 2011 and May 2017. Recognising the centrality of affected actors in policy-making processes, the study focused on the alcohol industry as a central actor affected by the policy, to understand how they-together with other actors-may influence the policy formulation process. A qualitative case study approach was used, involving a stakeholder mapping, 10 in-depth interviews, and review of approximately 240 documents. A policy formulation conceptual framework was successfully applied as a lens to describe a complex policy formulation process. Key factors shaping policy formulation included: (1) competing and shared values-different stakeholders promote conflicting ideals for policymaking; (2) inter-department jostling-different government departments seek to protect their own functions, hindering policy development; (3) stakeholder consultation in democratic policymaking-policy formulation requires consultations even with those opposed to regulation and (4) battle for evidence-evidence is used strategically by all parties to shape perceptions and leverage positions. This research (1) contributes to building an integrated body of knowledge on policy formulation in low- and middle-income countries; (2) shows that achieving policy coherence across government departments poses a major challenge to achieving effective health policy formulation and (3) shows that networks of actors with commercial and financial interests use diverse strategies to influence policy formulation processes to avoid regulation.