"It's very much part of this movement to undermine democracy": A qualitative study of European Union level opposition strategies against reproductive health and rights.

Despite increasing contestations of agreed global commitments on sexual and reproductive health and rights (SRHR), our understanding of strategies of opposition in global health policymaking remains limited. This article explores the opposition to SRHR at the European level focusing on the decision-making institutions of the European Union (EU). The central research questions ask i) how SRHR opposition actors seek to influence EU institutions and ii) what challenges their actions pose for health policymaking at the EU level. Our empirical focus is based on the qualitative method of framework analysis, with data collected from multiple sources, including documentary data on European Parliamentary debates, Council conclusions of the European Union, reports of nongovernmental organisations, and key informant interviews. Our study is in line with observations on globally coordinated efforts to restrict access to SRH services. This is a challenge for specific forums and countries, but as well for European Union's wider internal and external policies. We present a toolbox of strategies and actors operational at the European Union level. Our findings on opposition to SRHR indicate that it can be seen as a political tool that is part of a broader anti-democratic movement. Understanding strategies of anti-SRHR opposition is important for health policymakers as it shapes debates and the achievement of universal health coverage (UHC).

Climate change-induced shifts in the food systems and diet-related non-communicable diseases in sub-Saharan Africa: a scoping review and a conceptual framework.

OBJECTIVES: To determine the relationship between climate change, food systems and diet-related non-communicable diseases (DR-NCDs) in sub-Saharan Africa (SSA) and propose a conceptual framework for food systems in SSA. DESIGN: A scoping review. ELIGIBILITY CRITERIA: Studies included investigated the relationship between climate change and related systemic risks, food systems, DR-NCDs and its risk factors in SSA. Studies focusing on the association between climate change and DR-NCDs unrelated to food systems, such as social inequalities, were excluded. SOURCES OF EVIDENCE: A comprehensive search was conducted in ProQuest (nine databases), Google Scholar and PubMed in December 2022. CHARTING METHODS: Data extracted from studies included author, study type, country of study, climate change component, DR-NCD outcomes and risk factors, and impacts of climate change on DR-NCDs. A narrative approach was used to analyse the data. Based on the evidence gathered from SSA, we modified an existing food system conceptual framework. RESULTS: The search retrieved 19 125 studies, 10 of which were included in the review. Most studies used a cross-sectional design (n=8). Four explored the influence of temperature on liver cancer through food storage while four explored the influence of temperature and rainfall on diabetes and obesity through food production. Cross-sectional evidence suggested that temperature is associated with liver cancer and rainfall with diabetes. CONCLUSION: The review highlights the vulnerability of SSA's food systems to climate change-induced fluctuations, which in turn affect dietary patterns and DR-NCD outcomes. The evidence is scarce and concentrates mostly on the health effects of temperature through food storage. It proposes a conceptual framework to guide future research addressing climate change and DR-NCDs in SSA.

Is the EU steering national social and health policy making? A case-study on Finland's national reform.

As part of the European Semester, Finland received country-specific recommendations (CSRs) in 2013-2020 that encouraged the reform of national social and health services. These recommendations were part of efforts to balance public finances and implement public-sector structural reforms. Finland has been struggling to reform the national social and health care system since 2005. Only on 1 January 2023 did the new wellbeing services counties become liable for organizing social, health, and rescue services. Studying the CSRs for Finland enables us to understand better what genuinely occurs at the EU member state level. This data-driven case study aims to disclose the relevance of the European Semester for Finland in the pursuit of a national social and health system reform. The mixed-method approach is based on the research tradition of governance, and the study contains features of data sourcing and methodological triangulation. Empirically, the research material consists of Finland's official policy documents and anonymous semi-structured elite interviews. The study highlights that although the received CSRs on the need to restructure social and health services corresponded to Finland's views, their influence to national reform efforts was limited. The CSRs were administered according to the established formal routines, but separately from the national reform preparations. The CSRs, however, delivered implicit steering, which were considered to affect social and health policy making in various ways.

Globalization, platform work, and wellbeing-a comparative study of Uber drivers in three cities: London, Helsinki, and St Petersburg.

BACKGROUND: Globalization of platform work has become a challenge for wider social and employment relations and wellbeing of workers, yet on-location work remains governed also by local regulatory context. Understanding common challenges across countries and potential for regulatory measures is essential to enhance health and wellbeing of those who work in platform economy. Our comparative study on platform work analyzed concerns of Uber drivers in three cities with a different regulatory and policy context. METHODS: Drawing from current understanding on employment and precarity as social determinants of health we gathered comparative documentary and contextual data on regulatory environment complemented with key informant views of regulators, trade unions, and platform corporations (N = 26) to provide insight on the wider regulatory and policy environment. We used thematic semi-structured interviews to examine concerns of Uber drivers in Helsinki, St Petersburg, and London (N = 60). We then analysed the driver interviews to identify common and divergent concerns across countries. RESULTS: Our results indicate that worsening of working conditions is not inevitable and for drivers the terms of employment is a social determinant of health. Drivers compensated declining pay with longer working hours. Algorithmic surveillance as such was of less concern to drivers than power differences in relation to terms of work. CONCLUSIONS: Our results show scope for regulation of platform work especially for on-location work concerning pay, working hours, social security obligations, and practices of dismissal.

Laws, Policies, and Collective Agreements Protecting Low-wage and Digital Platform Workers During the COVID-19 Pandemic.

In the context of the COVID-19 pandemic, this commentary describes and compares shifting employment and occupational health social protections of low-wage workers, including self-employed digital platform workers. Through a focus on eight advanced economy countries, this paper identifies how employment misclassification and definitions of employees were handled in law and policy. Debates about minimum wage and occupational health and safety standards as they relate to worker well-being are considered. Finally, we discuss promising changes introduced during the COVID-19 pandemic that protect the health of low-wage and self-employed workers. Overall, we describe an ongoing "haves" and a "have not" divide, with on the one extreme, traditional job arrangements with good work-and-health social protections and, on the other extreme, low-wage and self-employed digital platform workers who are mostly left out of schemes. However, during the pandemic small and often temporary gains occurred and are discussed.

When actions do not match aspirations - comparison of the European Union policy claims against what has been negotiated for health services, trade and investment.

BACKGROUND: Obligations arising from trade and investment agreements can affect how governments can regulate and organise health systems. The European Union has made explicit statements of safeguarding policy space for health systems. We assessed to what extent health systems were safeguarded in trade negotiations using the European Union (EU) negotiation proposals for the Transatlantic Trade and Investment Partnership (TTIP) and the negotiated agreement for the EU-Canada Comprehensive Economic and Trade Agreement (CETA). METHODS: We assessed if and to what extent the European Union policy assurances were upheld in trade negotiations. Our assessment was made using three process tracing informed tests. The tests examined: i) what was covered in negotiation proposals of services and investment chapters, ii) if treatment of health services differed from treatment of another category of services (audiovisual services) with similar EU Treaty considerations, and iii) if other means of general exceptions, declarations or emphases on right to regulate could have resulted in the same outcome. RESULTS: Our analysis shows that the European Union had sought to secure policy space for publicly funded health services for services chapter, but not for investment and investment protection chapters. In comparison to audiovisual services, exceptions for health services fall short from those on audiovisual services. There is little evidence that the same outcome could have been achieved using other avenues. CONCLUSIONS: The European Union has not achieved its own assurances of protection of regulatory policy space for health services in trade negotiations. The European Union trade negotiation priorities need to change to ensure that its negotiation practices comply with its own assurances for health services and sustainable financing of health systems.

Global health without sexual and reproductive health and rights? Analysis of United Nations documents and country statements, 2014-2019.

INTRODUCTION: The initial International Conference on Population and Development in 1994 contains the first reference to sexual and reproductive health and reproductive rights (SRHR). It has been considered agreed language on SRHR in future United Nations (UN) documents. However, opposition to SRHR in global forums has increased, including in conjunction with an increase in religious, far-right populist politics. This study provides an empirical analysis of UN documents to discover whether opposition to SRHR has resulted in changes in the language on SRHR between and what these changes are. METHODS: This is a qualitative policy analysis in which 14 UN resolutions, 6 outcome documents from the Commission on the Status of Women (CSW) and 522 country and group statements and 5 outcome reports from the Commission on Population and Development were collected from the organisations websites from 2014 to 2019. Framework analysis was used. The text from documents was charted and indexed and themes developed from these. RESULTS: The results demonstrated a disappearance of the language on abortion in the CSW outcome documents from 2017 and a change in the language on comprehensive sexuality education in the CSW as well as the UN General Assembly resolutions from 2018. This change included a removal of 'sexuality' to an increased emphasis on the role of families. Furthermore, documents showed an inability of some states to accept any mention of sexual and reproductive health at all, expanding from the usual contestations over abortion. CONCLUSION: Our findings suggest that the global shift in politics and anti-SRHR actors at UN negotiations and conferences have removed previously agreed on language on SRHR from future UN resolutions and outcome documents. This is a concern for the global realisation of SRHR.

COVID-19 pandemic in Finland - Preliminary analysis on health system response and economic consequences.

OBJECTIVES: The objective of this study was to describe and analyze the impact of the coronavirus disease COVID-19 on health policy, social- and health system, and economic and financing system to prevent, treat, contain and monitor the virus in Finland. METHODS: This study provides early outcomes of health policy measures, social- and health system capacity as well as economic challenges in COVID-19 pandemic in Finland. This paper is based available documents and reports of different ministries and social, health and economic authorities collected online. This was complemented by other relevant pandemic data from Finland. RESULTS: The impact of COVID-19 pandemic on the Finnish society has been unpredictable although it has not been as extensive and massive than in many other countries. As the situation evolved the Government took strict measures to stop the spread of the virus (e.g. Emergency Powers Act). Available information shows that the economic consequences will be drastic also in Finland, albeit perhaps less dramatic than in large industrial economies. CONCLUSIONS: Finland has transferred gradually to a "hybrid strategy", referring to a move from extensive restrictive measures to enhanced management of the epidemic. However, health system must be prepared for prospective setback. It is possible, that COVID-19 pandemic has accelerated the development of digital health services and telemedicine in Finnish healthcare system.

Finland: Health System Review.

This analysis of the Finnish health system reviews developments in its organization and governance, financing, provision of services, health reforms and health system performance. Finland is a welfare state witha high standard of social and living conditions and a low poverty rate. Its health system has a highly decentralized administration, multiple funding sources, and three provision channels for statutory services in first-contact care: the municipal system, the national health insurance system, and occupational health care. The core health system is organized by the municipalities (i.e. local authorities) which are responsible for financing primary and specialized care. Health financing arrangements are fragmented, with municipalities, the health insurance system, employers and households all contributing substantial shares. The health system performs relatively well, as health services are fairly effective, but accessibility may be an issue due to long waiting times and relatively high levels of cost sharing. For over a decade, there has been broad agreement on the need to reform the Finnish health system, but reaching a feasible policy consensus has been challenging.

Policy space for health and trade and investment agreements.

New trade agreements affect how governments can regulate for health both within health systems and in addressing health protection, promotion and social determinants of health in other policies. It is essential that those responsible for health understand the impacts of these trade negotiations and agreements on policy space for health at a national and local level. While we know more about implications from negotiations concerning intellectual property rights and trade in goods, this paper provides a screening checklist for less-discussed areas of domestic regulation, services, investment and government procurement. As implications are likely to differ on the basis of the organization and structures of national health systems and policy priorities, the emphasis is on finding out key provisions as well as on how exemptions and exclusions can be used to ensure policy space for health.

"Trade creep" and implications of the Transatlantic Trade and Investment Partnership Agreement for the United Kingdom National Health Service.

The ambitious and comprehensive Transatlantic Trade and Investment Partnership Agreement (TTIP/TAFTA) agreement between the European Union and United States is now being negotiated and may have far-reaching consequences for health services. The agreement extends to government procurement, investment, and further regulatory cooperation. In this article, we focus on the United Kingdom National Health Service and how these negotiations can limit policy space to change policies and to regulate in relation to health services, pharmaceuticals, medical devices, and health industries. The negotiation of TTIP/TAFTA has the potential to "harmonize" more corporate-friendly regulation, resulting in higher costs and loss of policy space, an example of "trade creep" that potentially compromises health equity, public health, and safety concerns across the Atlantic.

Undermining patient and public engagement and limiting its impact: the consequences of the Health and Social Care Act 2012 on collective patient and public involvement.

Patient and public involvement has been at the heart of UK health policy for more than two decades. This commitment to putting patients at the heart of the British National Health Service (NHS) has become a central principle helping to ensure equity, patient safety and effectiveness in the health system. The recent Health and Social Care Act 2012 is the most significant reform of the NHS since its foundation in 1948. More radically, this legislation undermines the principle of patient and public involvement, public accountability and returns the power for prioritisation of health services to an unaccountable medical elite. This legislation marks a sea-change in the approach to patient and public involvement in the UK and signals a shift in the commitment of the UK government to patient-centred care.

Commercial influence and global nongovernmental public action in health and pharmaceutical policies.

Nongovernmental public action has been effective in influencing global agenda-setting in health and pharmaceutical policies, yet its record in influencing solutions to the problems identified has been notably more limited. While trade policies have been particularly resistant to change, more substantial changes are observable in global health policies and global health governance. However, some of the directions of change may not be conducive to the democratic accountability of global health governance, to the wise use of public resources, to health systems development, or to longer-term access to health care within developing countries. The authors argue that observed changes in global health policies can be understood as accommodating to corporate concerns and priorities. Furthermore, the changing global context and the commercialization of global public action itself pose sharp challenges to the exercise of influence by global nongovernmental public actors. Nongovernmental organizations not only face a major challenge in terms of the imbalance in power and resources between themselves and corporate interest groups when seeking to influence policymaking; they also face the problem of corporate influence on public action itself.

The state of Health in All policies (HiAP) in the European Union: potential and pitfalls.

Health in All Policies (HiAP) was formally legitimated as a European Union (EU) approach in 2006. It resulted from more long-term efforts to enhance action on considering health and health policy implications of other policies, as well as recognition that European-level policies affect health systems and scope for health-related regulation at national level. However, implementation of HiAP has remained a challenge. European-level efforts to use health impact assessment to benefit public health and health systems have not become strengthened by the new procedures. And, as a result of the Lisbon Treaty, European-level policy-making is expected to become more important in shaping national policies. HiAP has at European level remained mostly as rhetoric, but legitimate health arguments and provides policy space for health articulation within EU policy-making. HiAP is a broader approach than health impact assessment and at European level requires consideration of mechanisms that recognise the nature of European policy-making, as well as extending from administrative tools to increased transparency, accountability and scope for health and health policy-related arguments within political decision-making in the EU.

The impact of economic globalisation on health.

The analysis of the impact of economic globalisation on health depends on how it is defined and should consider how it shapes both health and health policies. I first discuss the ways in which economic globalisation can and has been defined and then why it is important to analyse its impact both in terms of health and health policies. I then explore the ways in which economic globalisation influences health and health policies and how this relates to equity, social justice, and the role of values and social rights in societies. Finally, I argue that the process of economic globalisation provides a common challenge for all health systems across the globe and requires a broader debate on values, accountability, and policy approaches.

The future of European health policies.

The role of the European Union in health policies is changing. The European social model is under threat due to shifts in E.U. policies on liberalization of service provision, limited public budgets, a focus on the health sector as a productive sector in the context of broader European policies and the Lisbon strategy, and changes in the context of the new Constitutional Treaty. These changes are evident in a new reflection paper on European health strategy and its focus. E.U. health policies are at a critical juncture. The danger is that the current processes will lead European health policies and the health systems of member states more in the direction of U.S. health policies and the commercialization of health systems than toward improvement of the current situation.