Fifty shades of partnerships: a governance typology for public private engagement in the nutrition sector.

BACKGROUND: Multistakeholder collaboration has emerged as a dominant approach for engaging and mobilising non-state actors; notably embedded in the paradigm of the UN Sustainable Development Goals. Yet, considerable ambiguity and contestation surrounds the appropriate terms of public private engagement (PPE) with industry actors. MAIN BODY: This paper seeks to conceptualise different forms of engagement with the food industry in tackling diet-related noncommunicable disease, within the context of power asymmetries across engaged stakeholders. It does so by introducing the Governance Typology for Public Private Engagement in the Nutrition Sector, a typology for government-led engagement with food industry actors across three domains: (i) the form of industry and civil society actor engagement (i.e., rules of exercising institutional power), based on the degree of participation in formal decision-making as well as participation at different stages in the policy cycle; (ii) the type of industry actors being engaged (i.e., pre-existing power attributes), based on function, size, and product portfolios for profit; and (iii) the substantive policy focus of engagement. CONCLUSIONS: The Governance Typology for Public Private Engagement in the Nutrition Sector seeks to inform national level nutrition policy makers on good engagement practice with food industry actors and complements existing risk assessment tools. This typology has the potential to inform decision-making on public sector engagement with other industries that profit from products detrimental to human and planetary health.

Incorporating a gender lens into nutrition and health-related policies in Fiji: analysis of policies and stakeholder perspectives.

BACKGROUND: Gender equality, zero hunger and healthy lives and well-being for all, are three of the Sustainable Development Goals (SDGs) that underpin Fiji's National Development Plan. Work towards each of these goals contributes to the reduction of non-communicable diseases (NCDs). There are gender differences in NCD burden in Fiji. It is, however, unclear whether a gender lens could be more effectively included in nutrition and health-related policies. METHODS: This study consisted of three components: (i) a policy content analysis of gender inclusion in nutrition and health-related policies (n = 11); (ii) policy analysis using the WHO Gender Analysis tool to identify opportunities for strengthening future policy; and (iii) informant interviews (n = 18), to understand perceptions of the prospects for gender considerations in future policies. RESULTS: Gender equality was a goal in seven policies (64%); however, most focused on women of reproductive age. One of the policies was ranked as gender responsive. Main themes from key informant interviews were: 1) a needs-based approach for the focus on specific population groups in policies; 2) gender-related roles and responsibilities around nutrition and health; 3) what is considered "equitable" when it comes to gender, nutrition, and health; 4) current considerations of gender in policies and ideas for further gender inclusion; and 5) barriers and enablers to the inclusion of gender considerations in policies. Informants acknowledged gender differences in the burden of nutrition-related NCDs, yet most did not identify a need for stronger inclusion of gender considerations within policies. CONCLUSIONS: There is considerable scope for greater inclusion of gender in nutrition and health-related policies in Fiji. This could be done by: 1) framing gender considerations in ways that are actionable and inclusive of a range of gender identities; 2) undertaking advocacy through actor networks to highlight the need for gender-responsive nutrition and health-related policies for key stakeholder groups; 3) ensuring that data collected to monitor policy implementation is disaggregated by sex and genders; and 4) promoting equitable participation in nutrition related issues in communities and governance processes. Action on these four areas are likely critical enablers to more gender equitable NCD reduction in Fiji.

Implementing effective salt reduction programs and policies in low- and middle-income countries: learning from retrospective policy analysis in Argentina, Mongolia, South Africa and Vietnam.

OBJECTIVE: To understand the factors influencing the implementation of salt reduction interventions in low- and middle-income countries (LMIC). DESIGN: Retrospective policy analysis based on desk reviews of existing reports and semi-structured stakeholder interviews in four countries, using Walt and Gilson's 'Health Policy Triangle' to assess the role of context, content, process and actors on the implementation of salt policy. SETTING: Argentina, Mongolia, South Africa and Vietnam. PARTICIPANTS: Representatives from government, non-government, health, research and food industry organisations with the potential to influence salt reduction programmes. RESULTS: Global targets and regional consultations were viewed as important drivers of salt reduction interventions in Mongolia and Vietnam in contrast to local research and advocacy, and support from international experts, in Argentina and South Africa. All countries had population-level targets and written strategies with multiple interventions to reduce salt consumption. Engaging industry to reduce salt in foods was a priority in all countries: Mongolia and Vietnam were establishing voluntary programs, while Argentina and South Africa opted for legislation on salt levels in foods. Ministries of Health, the WHO and researchers were identified as critical players in all countries. Lack of funding and technical capacity/support, absence of reliable local data and changes in leadership were identified as barriers to effective implementation. No country had a comprehensive approach to surveillance or regulation for labelling, and mixed views were expressed about the potential benefits of low sodium salts. CONCLUSIONS: Effective scale-up of salt reduction programs in LMIC requires: (1) reliable local data about the main sources of salt; (2) collaborative multi-sectoral implementation; (3) stronger government leadership and regulatory processes and (4) adequate resources for implementation and monitoring.

Defining Priorities for Action and Research on the Commercial Determinants of Health: A Conceptual Review.

In recent years, the concept of commercial determinants of health (CDoH) has attracted scholarly, public policy, and activist interest. To date, however, this new attention has failed to yield a clear and consistent definition, well-defined metrics for quantifying its impact, or coherent directions for research and intervention. By tracing the origins of this concept over 2 centuries of interactions between market forces and public health action and research, we propose an expanded framework and definition of CDoH. This conceptualization enables public health professionals and researchers to more fully realize the potential of the CDoH concept to yield insights that can be used to improve global and national health and reduce the stark health inequities within and between nations. It also widens the utility of CDoH from its main current use to study noncommunicable diseases to other health conditions such as infectious diseases, mental health conditions, injuries, and exposure to environmental threats. We suggest specific actions that public health professionals can take to transform the burgeoning interest in CDoH into meaningful improvements in health. (Am J Public Health. 2021;111(12):2202-2211. https://doi.org/10.2105/AJPH.2021.306491).

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.

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.

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, 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.

Integrating cardiovascular diseases, hypertension, and diabetes with HIV services: a systematic review.

Non-communicable diseases (NCDs), including cardiovascular diseases (CVD), hypertension and diabetes together with HIV infection are among the major public health concerns worldwide. Health services for HIV and NCDs require health systems that provide for people's chronic care needs, which present an opportunity to coordinate efforts and create synergies between programs to benefit people living with HIV and/or AIDS and NCDs. This review included studies that reported service integration for HIV and/or AIDS with coronary heart diseases, chronic CVD, cerebrovascular diseases (stroke), hypertension or diabetes. We searched multiple databases from inception until October 2015. Articles were screened independently by two reviewers and assessed for risk of bias. 11,057 records were identified with 7,616 after duplicate removal. After screening titles and abstracts, 14 papers addressing 17 distinct interventions met the inclusion criteria. We categorized integration models by diseases (HIV with diabetes, HIV with hypertension and diabetes, HIV with CVD and finally HIV with hypertension and CVD and diabetes). Models also looked at integration from micro (patient focused integration) to macro (system level integrations). Most reported integration of hypertension and diabetes with HIV and AIDS services and described multidisciplinary collaboration, shared protocols, and incorporating screening activities into community campaigns. Integration took place exclusively at the meso-level, with no micro- or macro-level integrations described. Most were descriptive studies, with one cohort study reporting evaluative outcomes. Several innovative initiatives were identified and studies showed that CVD and HIV service integration is feasible. Integration should build on existing protocols and use the community as a locus for advocacy and health services, while promoting multidisciplinary teams, including greater involvement of pharmacists. There is a need for robust and well-designed studies at all levels - particularly macro-level studies, research looking at long-term outcomes of integration, and research in a more diverse range of countries.

Monitoring HIV-Related Laws and Policies: Lessons for AIDS and Global Health in Agenda 2030.

The National Commitments and Policy Instrument (NCPI) has been used to monitor AIDS-related laws and policies for over 10 years. What can be learnt from this process? Analyses draw on NCPI questionnaires, NCPI responses, the UNAIDS Law Database, survey data and responses to a 2014 survey on the NCPI. The NCPI provides the first and only systematic data on country self-reported national HIV laws and policies. High NCPI reporting rates and survey responses suggest the majority of countries consider the process relevant. Combined civil society and government engagement and reporting is integral to the NCPI. NCPI experience demonstrates its importance in describing the political and legal environment for the HIV response, for programmatic reviews and to stimulate dialogue among stakeholders, but there is a need for updating and in some instances to complement results with more objective quantitative data. We identify five areas that need to be updated in the next iteration of the NCPI and argue that the NCPI approach is relevant to participatory monitoring of targets in the health and other goals of the UN 2030 Agenda for Sustainable Development.

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.

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.

Building from the HIV Response toward Universal Health Coverage.

Jonathan Jay and colleagues draw lessons from the the global HIV response that could help guide the universal health coverage movement.

Civil society: the catalyst for ensuring health in the age of sustainable development.

Sustainable Development Goal Three is rightly ambitious, but achieving it will require doing global health differently. Among other things, progressive civil society organisations will need to be recognised and supported as vital partners in achieving the necessary transformations. We argue, using illustrative examples, that a robust civil society can fulfill eight essential global health functions. These include producing compelling moral arguments for action, building coalitions beyond the health sector, introducing novel policy alternatives, enhancing the legitimacy of global health initiatives and institutions, strengthening systems for health, enhancing accountability systems, mitigating the commercial determinants of health and ensuring rights-based approaches. Given that civil society activism has catalyzed tremendous progress in global health, there is a need to invest in and support it as a global public good to ensure that the 2030 Agenda for Sustainable Development can be realised.

Health in the sustainable development goals: ready for a paradigm shift?

The Millennium Development Goals (MDGs) galvanized attention, resources and accountability on a small number of health concerns of low- and middle-income countries with unprecedented results. The international community is presently developing a set of Sustainable Development Goals as the successor framework to the MDGs. This review examines the evidence base for the current health-related proposals in relation to disease burden and the technical and political feasibility of interventions to achieve the targets. In contrast to the MDGs, the proposed health agenda aspires to be universally applicable to all countries and is appropriately broad in encompassing both communicable and non-communicable diseases as well as emerging burdens from, among other things, road traffic accidents and pollution.We argue that success in realizing the agenda requires a paradigm shift in the way we address global health to surmount five challenges: 1) ensuring leadership for intersectoral coherence and coordination on the structural (including social, economic, political and legal) drivers of health; 2) shifting the focus from treatment to prevention through locally-led, politically-smart approaches to a far broader agenda; 3) identifying effective means to tackle the commercial determinants of ill-health; 4) further integrating rights-based approaches; and 5) enhancing civic engagement and ensuring accountability. We are concerned that neither the international community nor the global health community truly appreciates the extent of the shift required to implement this health agenda which is a critical determinant of sustainable development.