Protecting and promoting the rights of the 'reserve army of labour': a policy analysis of structural determinants of migrant worker health in Pakistan and Qatar.

Labour migrants who travel overseas for employment can face deep health inequities driven in large part by upstream social and structural determinants of health. We sought to study the 'labour migrant health ecosystem' between one sending country (Pakistan) and one host country (Qatar), with a focus on how the ecosystem realizes the rights of labour migrants when addressing the social and structural determinants (e.g. housing, employment law, etc.) of health. Study objectives were to (1) undertake an in-depth review of policies addressing the structural and social determinants of the health of labour migrants in both Pakistan and Qatar, analysing the extent to which these policies align with global guidance, are equity-focused and have clear accountability mechanisms in place, and (2) explore national stakeholder perspectives on priority setting for labour migrant health. We used a mixed methods approach, combining policy content analysis and interviews with stakeholders in both countries. We found a wide range of guidance from the multilateral system on addressing structural determinants of the health of labour migrants. However, policy responses in Pakistan and Qatar contained a limited number of these recommended interventions and had low implementation potential and minimal reference to gender, equity and rights. Key national stakeholders had few political incentives to act and lacked inter-country coordination mechanisms required for an effective and cohesive response to labour migrant health issues. Effectively addressing such determinants to achieve health equity for labour migrants will depend on a shift in governments' attitudes towards migrants-from a reserve army of transient, replaceable economic resources to rights-holding members of society deserving of equality, dignity and respect.

A Rapid Ethnographic Assessment of Cultural and Social Perceptions and Practices About COVID-19 in Bangladesh: What the Policy Makers and Program Planners Should Know.

Anthropological literature on health beliefs and practices related to COVID-19 is scarce, particularly in low and middle-income countries. We conducted a qualitative research on perceptions of COVID-19 among slum residents of Dhaka, Bangladesh from November 2020 through January, 2021. Methods included in-depth interviews and photo elicitation with community residents. Interviews were transcribed and analyzed thematically. Results show scientific explanations of COVID-19 conflicted with interviewees' cultural and spiritual beliefs such as: coronavirus is a disease of rich, sinful people; the virus is a curse from Allah to punish sinners. Interviewees rejected going to hospitals in favor of home remedies, and eschewed measures such as mask-wearing or social distancing instead preferring to follow local beliefs. We have highlighted a gap between community beliefs about the pandemic and science-led interventions proposed by health professionals. For public health policy to be more effective it requires a deeper understanding of and response to community perceptions.

Sex-disaggregated data matters: tracking the impact of COVID-19 on the health of women and men.

Sex and gender matter to health outcomes, but despite repeated commitments to sex-disaggregate data in health policies and programmes, a persistent and substantial absence of such data remains especially in lower-income countries. This represents a missed opportunity for monitoring and identifying gender-responsive, evidence-informed solutions to address a key driver of the pandemic. In this paper we review the availability of national sex-disaggregated surveillance data on COVID-19 and examine trends on the testing-to-outcome pathway. We further analyse the availability of data according to the economic status of the country and investigate the determinants of sex differences, including the national gender inequality status (according to a global index) in each country. Results are drawn from 18 months of global data collection from over 200 countries. We find differences in COVID-19 prevention behaviours and illness outcomes by sex, with lower uptake of vaccination and testing plus an elevated risk of severe disease and death among men. Supporting and maintaining the collection, collation, interpretation and presentation of sex-disaggregated data requires commitment and resources at subnational, national and global levels, but provides an opportunity for identifying and taking gender-responsive action on health inequities. As a first step the global health community should recognise, value and support the importance of sex-disaggregated data for identifying and tackling an inequitable pandemic.

Promoting labour migrant health equity through action on the structural determinants: A systematic review.

BACKGROUND: Labour migrants, who represent over sixty per cent of international migrants globally, frequently have poorer health status than the population of host countries. These health inequities are determined in a large part by structural drivers including political, commercial, economic, normative and social factors, including living and working conditions. Achieving health equity for migrant workers requires structural-level interventions to address these determinants. METHODS: We undertook a systematic review of peer-reviewed literature designed to answer the question "what is the evidence for the effectiveness of interventions to address the structural determinants of health for labour migrants?" using the Ovid Medline electronic database. FINDINGS: We found only two papers that evaluated structural interventions to improve the health of labour migrants. Both papers evaluated the impact of insurance - health or social. In contrast, we found 19 evaluations of more proximal, small-scale interventions focused on changing the knowledge, attitudes and behaviours of labour migrants. INTERPRETATION: Despite the rise in international migration, including for work, and evidence that labour migrants have some higher health risks, there is a paucity of research addressing the structural determinants of health inequities in labour migrants. The research community (including funders and academic institutions) needs to pay greater attention to the structural determinants of health - which generally requires working across disciplines and sectors and thinking more politically about health and health inequities. FUNDING: Wellcome Trust (208712/Z/17/Z).

Barriers and opportunities to restricting marketing of unhealthy foods and beverages to children in Nepal: a policy analysis.

BACKGROUND: Marketing of foods and non-alcoholic beverages high in saturated fats, trans-fatty acids, free sugars, or salt ("unhealthy foods") to children is contributing to increasing child obesity. However, many countries have not implemented WHO recommendations to restrict marketing of unhealthy foods to children. We sought to understand the absence of marketing restrictions and identify potential strategic actions to develop and implement such restrictions in Nepal. METHODS: Eighteen semi-structured interviews were conducted. Thematic analysis was based on Baker et al.'s 18 factor-framework for understanding what drives political commitment to nutrition, organised by five categories: Actors; Institutions; Political and societal contexts; Knowledge, evidence and framing; Capacities and resources. RESULTS: All factors in Baker et al.'s framework were reported to be acting largely as barriers to Nepal developing and implementing marketing restrictions. Six factors were identified by the highest number of respondents: the threat of private sector interference in policy-making; lack of international actor support; absence of well-designed and enacted policies and legislation; lack of political commitment to regulate; insufficient mobilisation of existing evidence to spur action and lack of national evidence to guide regulatory design; and weak implementation capacity. Opportunities for progress were identified as Nepal's ability to combat private sector interference - as previously demonstrated in tobacco control. CONCLUSIONS: This is the first study conducted in Nepal examining the lack of restrictions on marketing unhealthy foods to children. Our findings reflect the manifestation of power in the policy process. The absence of civil society and a multi-stakeholder coalition demanding change on marketing of unhealthy food to children, the threat of private sector interference in introducing marketing restrictions, the promotion of norms and narratives around modernity, consumption and the primary role of the individual in regulating diet - all have helped create a policy vacuum on marketing restrictions. We propose that stakeholders focus on five strategic actions, including: developing a multi-stakeholder coalition to put and keep marketing restrictions on the health agenda; framing the need for marketing restrictions as critical to protect child rights and government regulation as the solution; and increasing support, particularly through developing more robust global policy guidance.

COVID-19 and the gendered markets of people and products: explaining inequalities in infections and deaths.

COVID-19 has exposed and exploited existing inequalities in gender to drive inequities in health outcomes. Evidence illustrates the relationship between occupation, ethnicity and gender to increase risk of infection in some places. Higher death rates are seen among people also suffering from non-communicable diseases - e.g. heart disease and lung disease driven by exposure to harmful patterns of exposure to corporate products (tobacco, alcohol, ultra-processed foods), corporate by-products (e.g. outdoor air pollution) or gendered corporate processes (e.g. gendered occupational risk). The paper argues that institutional gender blindness in the health system means that underlying gender inequalities have not been taken into consideration in policies and programmatic responses to COVID-19.

La pandémie de COVID-19 a à la fois révélé et renforcé des inégalités de genre déjà existantes, provoquant une augmentation des inégalités dans les statistiques de santé. Les données recueillies révèlent que la combinaison de facteurs tels que l'occupation, l'ethnicité et le genre contribuent à une augmentation du risque d'infection dans certains lieux. Des taux de mortalité plus élevés ont ainsi été constatés dans des populations souffrant également de maladies non transmissibles, telles que les maladies cardiaques et pulmonaires causées par l'exposition aux effets nocifs de produits industriels (tabac, alcool, produits alimentaires ultra-transformés), de leur productions dérivées (pollution atmosphérique extérieure), ou de processus industriels genrés (risques professionnels liés au genre). Cet article démontre que le déni institutionnel des différences de genre dans le système médical a pour conséquence la non-prise en compte des inégalités de genre sous-jacentes dans la mise en place de réglementations et de programmes de réponses au COVID-19.

The social and structural determinants of sexual and reproductive health and rights in migrants and refugees: a systematic review of reviews.

BACKGROUND: The sexual and reproductive health and rights (SRHR) of migrants and refugees present important public health challenges. Social and structural determinants affect both the general health and SRHR of migrants, but the drivers of SRHR among migrant and refugee populations remain understudied. AIMS: To identify upstream social and structural determinants of SRHR health of migrants and refugees reported in systematic reviews. METHODS: We conducted a systematic review of reviews. We studied 3 aspects of SRHR: sexually transmitted infections, sexual violence and unintended pregnancy in migrants and refugees. We used an inductive approach to synthesize emerging themes, summarized them in a narrative format and made an adapted version of Dahlgren and Whitehead's social determinants of health (SDH) model. RESULTS: We included 12 systematic reviews, of which 10 were related to sexually transmitted infections, 4 to sexual violence and 2 to unintended pregnancy. We identified 6 themes that operate at 4 different levels in an adapted version of the Dahlgren and Whitehead SDH model: economic crisis and hostile discourse on migration; limited legal entitlements, rights and administrative barriers; inadequate resources and financial constraints; poor living and working conditions; cultural and linguistic barriers; and stigma and discrimination based on migration status, gender, sex and ethnicity. CONCLUSION: This review provides evidence of how upstream social and structural determinants undermine the SRHR of refugees and migrants. Unless these are addressed in policy-making and planning, the health of migrants and refugees is at risk.

The state of diet-related NCD policies in Afghanistan, Bangladesh, Nepal, Pakistan, Tunisia and Vietnam: a comparative assessment that introduces a 'policy cube' approach.

We assessed the technical content of sugar, salt and trans-fats policies in six countries in relation to the World Health Organization 'Best Buys' guidelines for the prevention and control of non-communicable diseases (NCDs). National research teams identified policies and strategies related to promoting healthy diets and restricting unhealthy consumption, including national legislation, development plans and strategies and health sector-related policies and plans. We identified relevant text in relation to the issuing agency, overarching aims, goals, targets and timeframes, specific policy measures and actions, accountability systems, budgets, responsiveness to inequitable vulnerabilities across population groups (including gender) and human rights. We captured findings in a 'policy cube' incorporating three dimensions: policy comprehensiveness, political salience and effectiveness of means of implementation, and equity/rights. We compared diet-related NCD policies to human immunodeficiency virus policies in relation to rights, gender and health equity. All six countries have made high-level commitments to address NCDs, but dietary NCDs policies vary and tend to be underdeveloped in terms of the specificity of targets and means of achieving them. There is patchwork reference to internationally recognized, evidence-informed technical interventions and a tendency to focus on interventions that will encounter least resistance, e.g. behaviour change communication in contrast to addressing food reformulation, taxation, subsidies and promotion/marketing. Policies are frequently at the lower end of the authoritativeness spectrum and have few identified budgetary commitments or clear accountability mechanisms. Of concern is the limited recognition of equity and rights-based approaches. Healthy diet policies in these countries do not match the severity of the NCDs burden nor are they designed in such a way that government action will focus on the most critical dietary drivers and population groups at risk. We propose a series of recommendations to expand policy cubes in each of the countries by re-orienting diet-related policies so as to ensure healthy diets for all.

Soft power and global health: the sustainable development goals (SDGs) era health agendas of the G7, G20 and BRICS.

BACKGROUND: In 2017, the G20 health ministers convened for the first time to discuss global health and issued a communiqué outlining their health priorities, as the BRICS and G7 have done for years. As these political clubs hold considerable political and economic influence, their respective global health agendas may influence both global health priorities and the priorities of other countries and actors. METHODS: Given the rising salience of global health in global summitry, we analyzed the health ministerial communiqués issued by the BRICS, G7 and G20 after the SDGs were adopted in 2015. We compared the stated health priorities of the BRICS, G7 and G20 against one another and against the targets of SDG 3 on health, using a traffic light system to assess the quality of their commitments. RESULTS: With regard to the SDG 3 targets, the BRICS, G7 and G20 priorities overlapped in their focus on emergency preparedness and universal health coverage, but diverged in areas of environmental pollution, mental health, and maternal and child health. Health issues with considerable associated burdens of disease, including substance use, road traffic injuries and sexual health, were missing from the agendas of all three political clubs. In terms of SDG 3 principles and ways of working, the BRICS, G7 and G20 varied in their emphasis on human rights, equity and engagement with non-state actors, but all expressed their explicit commitment to Agenda 2030. CONCLUSIONS: The leadership of BRICS, G7 and G20 on global health is welcome. However, their relatively narrow focus on the potential impact of ill-health primarily in relation to the economy and trade may not be sufficiently comprehensive to achieve the Agenda 2030 vision of promoting health equity and leaving no-one behind. Recommendations for the BRICS, G7 and G20 based on this analysis include: 1) expanding focus to the neglected SDG 3 health targets; 2) placing greater emphasis on upstream determinants of health; 3) greater commitment to equity and leaving no-one behind; 4) adopting explicit commitments to rights-based approaches; and 5) making commitments that are of higher quality and which include time-bound quantitative targets and clear accountability mechanisms.

Gender equality and gender norms: framing the opportunities for health.

The Sustainable Development Goals offer the global health community a strategic opportunity to promote human rights, advance gender equality, and achieve health for all. The inability of the health sector to accelerate progress on a range of health outcomes brings into sharp focus the substantial impact of gender inequalities and restrictive gender norms on health risks and behaviours. In this paper, the fifth in a Series on gender equality, norms, and health, we draw on evidence to dispel three myths on gender and health and describe persistent barriers to progress. We propose an agenda for action to reduce gender inequality and shift gender norms for improved health outcomes, calling on leaders in national governments, global health institutions, civil society organisations, academic settings, and the corporate sector to focus on health outcomes and engage actors across sectors to achieve them; reform the workplace and workforce to be more gender-equitable; fill gaps in data and eliminate gender bias in research; fund civil-society actors and social movements; and strengthen accountability mechanisms.

Gender, health and the 2030 agenda for sustainable development.

Gender refers to the social relationships between males and females in terms of their roles, behaviours, activities, attributes and opportunities, and which are based on different levels of power. Gender interacts with, but is distinct from, the binary categories of biological sex. In this paper we consider how gender interacts with the 2030 agenda for sustainable development, including sustainable development goal (SDG) 3 and its targets for health and well-being, and the impact on health equity. We propose a conceptual framework for understanding the interactions between gender (SDG 5) and health (SDG 3) and 13 other SDGs, which influence health outcomes. We explore the empirical evidence for these interactions in relation to three domains of gender and health: gender as a social determinant of health; gender as a driver of health behaviours; and the gendered response of health systems. The paper highlights the complex relationship between health and gender, and how these domains interact with the broad 2030 agenda. Across all three domains (social determinants, health behaviours and health system), we find evidence of the links between gender, health and other SDGs. For example, education (SDG 4) has a measurable impact on health outcomes of women and children, while decent work (SDG 8) affects the rates of occupation-related morbidity and mortality, for both men and women. We propose concerted and collaborative actions across the interlinked SDGs to deliver health equity, health and well-being for all, as well as to enhance gender equality and women's empowerment. These proposals are summarized in an agenda for action.

Le genre fait référence aux relations sociales entre les hommes et les femmes pour ce qui est de leurs rôles, comportements, activités, attributs et opportunités, qui reposent sur différents niveaux de pouvoir. Le genre interagit avec les catégories binaires du sexe biologique mais diffère de celles-ci. Dans cet article, nous nous intéressons aux interactions entre le genre et le Programme de développement durable à l'horizon 2030, notamment l'objectif de développement durable (ODD) 3 et ses cibles en matière de santé et de bien-être, ainsi qu'à son impact sur l'équité dans le domaine de la santé. Nous proposons un cadre conceptuel pour comprendre les interactions entre le genre (ODD 5) et la santé (ODD 3) ainsi que 13 autres ODD qui influencent la santé. Nous examinons les données empiriques afin de relever ces interactions dans trois domaines du genre et de la santé: le genre comme déterminant social de la santé; le genre comme facteur de comportements liés à la santé; et la réponse sexospécifique des systèmes de santé. Cet article souligne la relation complexe entre la santé et le genre, et la manière dont ces trois domaines interagissent avec le Programme 2030 dans son ensemble. Dans ces trois domaines (déterminants sociaux, comportements liés à la santé et systèmes de santé), les données révèlent les liens entre le genre, la santé et d'autres ODD. L'éducation (ODD 4), par exemple, a un impact mesurable sur la santé des femmes et des enfants, tandis qu'un travail décent (ODD 8) affecte le taux de morbidité et de mortalité pour cause professionnelle, aussi bien chez les hommes que chez les femmes. Nous proposons des actions collaboratives et concertées vis-à-vis de ces ODD interdépendants afin d'assurer l'équité en matière de santé ainsi que la santé et le bien-être pour tous, et de renforcer l'égalité des genres et l'autonomisation des femmes. Ces propositions sont résumées dans un programme d'action.

El género hace referencia a las relaciones sociales entre hombres y mujeres en términos de roles, comportamientos, actividades, atributos y oportunidades, y se basan en diferentes niveles de poder. El género interactúa con, pero es distinto de, las categorías binarias del sexo biológico. En este documento, consideramos cómo el género interactúa con la agenda 2030 para el desarrollo sostenible, incluidos los Objetivos de Desarrollo Sostenible (ODS) 3 y sus objetivos para la salud y el bienestar, y el impacto en la equidad en salud. Proponemos un marco conceptual para comprender las interacciones entre género (ODS 5) y salud (ODS 3) y otros 13 ODS, que influyen en los resultados de salud. Exploramos la evidencia empírica de estas interacciones en relación con tres dominios de género y salud: el género como determinante social de la salud; el género como conductor de conductas de salud; y la respuesta de género de los sistemas de salud. El documento destaca la compleja relación entre salud y género, y cómo estos dominios interactúan con la amplia agenda de 2030. A través de los tres dominios (determinantes sociales, comportamientos de salud y sistema de salud), encontramos evidencia de los vínculos entre género, salud y otros ODS. Por ejemplo, la educación (ODS 4) tiene un impacto cuantificable en los resultados de salud de mujeres y niños, mientras que el trabajo decente (ODS 8) afecta las tasas de morbilidad y mortalidad relacionadas con la ocupación, tanto para hombres como para mujeres. Proponemos acciones coordinadas y colaborativas entre los ODS interconectados para generar equidad en salud, salud y bienestar para todos, así como para mejorar la igualdad de género y el empoderamiento de las mujeres. Estas propuestas se resumen en una agenda de acción.

Healthy people and healthy profits? Elaborating a conceptual framework for governing the commercial determinants of non-communicable diseases and identifying options for reducing risk exposure.

BACKGROUND: Non-communicable diseases (NCDs) represent a significant threat to human health and well-being, and carry significant implications for economic development and health care and other costs for governments and business, families and individuals. Risks for many of the major NCDs are associated with the production, marketing and consumption of commercially produced food and drink, particularly those containing sugar, salt and transfats (in ultra-processed products), alcohol and tobacco. The problems inherent in primary prevention of NCDs have received relatively little attention from international organizations, national governments and civil society, especially when compared to the attention paid to secondary and tertiary prevention regimes (i.e. those focused on provision of medical treatment and long-term clinical management). This may in part reflect that until recently the NCDs have not been deemed a priority on the overall global health agenda. Low political priority may also be due in part to the complexity inherent in implementing feasible and acceptable interventions, such as increased taxation or regulation of access, particularly given the need to coordinate action beyond the health sector. More fundamentally, governing determinants of risk frequently brings public health into conflict with the interests of profit-driven food, beverage, alcohol and tobacco industries. MATERIALS: We use a conceptual framework to review three models of governance of NCD risk: self-regulation by industry; hybrid models of public-private engagement; and public sector regulation. We analyse the challenges inherent in each model, and review what is known (or not) about their impact on NCD outcomes. CONCLUSION: While piecemeal efforts have been established, we argue that mechanisms to control the commercial determinants of NCDs are inadequate and efforts at remedial action too limited. Our paper sets out an agenda to strengthen each of the three governance models. We identify reforms that will be needed to the global health architecture to govern NCD risks, including to strengthen its ability to consolidate the collective power of diverse stakeholders, its authority to develop and enforce clear measures to address risks, as well as establish monitoring and rights-based accountability systems across all actors to drive measurable, equitable and sustainable progress in reducing the global burden of NCDs.

Gender blind? An analysis of global public-private partnerships for health.

BACKGROUND: The Global Public Private Partnerships for Health (GPPPH) constitute an increasingly central part of the global health architecture and carry both financial and normative power. Gender is an important determinant of health status, influencing differences in exposure to health determinants, health behaviours, and the response of the health system. We identified 18 GPPPH - defined as global institutions with a formal governance mechanism which includes both public and private for-profit sector actors - and conducted a gender analysis of each. RESULTS: Gender was poorly mainstreamed through the institutional functioning of the partnerships. Half of these partnerships had no mention of gender in their overall institutional strategy and only three partnerships had a specific gender strategy. Fifteen governing bodies had more men than women - up to a ratio of 5:1. Very few partnerships reported sex-disaggregated data in their annual reports or coverage/impact results. The majority of partnerships focused their work on maternal and child health and infectious and communicable diseases - none addressed non-communicable diseases (NCDs) directly, despite the strong role that gender plays in determining risk for the major NCD burdens. CONCLUSIONS: We propose two areas of action in response to these findings. First, GPPPH need to become serious in how they "do" gender; it needs to be mainstreamed through the regular activities, deliverables and systems of accountability. Second, the entire global health community needs to pay greater attention to tackling the major burden of NCDs, including addressing the gendered nature of risk. Given the inherent conflicts of interest in tackling the determinants of many NCDs, it is debatable whether the emergent GPPPH model will be an appropriate one for addressing NCDs.