Developing a protocol on antimicrobial resistance through WHO's pandemic treaty will protect lives in future pandemics.

Addressing antimicrobial resistance (AMR) through the pandemic treaty is a crucial aspect of pandemic prevention, preparedness, and response. At the moment, AMR-related provisions in the draft text do not go far enough and will likely lead countries to commit to the status-quo of AMR action. We suggest that the protocol mechanism of the treaty proposed under Article 31 offers an opportunity to develop a subsidiary agreement (or protocol) to further codify the specific obligations and enforcement mechanisms necessary to meet the treaty's AMR provisions. We also highlight experiences with previous treaty implementation that relied on protocols to inform design of a future AMR protocol.

Policies to prevent zoonotic spillover: a systematic scoping review of evaluative evidence.

BACKGROUND: Emerging infectious diseases of zoonotic origin present a critical threat to global population health. As accelerating globalisation makes epidemics and pandemics more difficult to contain, there is a need for effective preventive interventions that reduce the risk of zoonotic spillover events. Public policies can play a key role in preventing spillover events. The aim of this review is to identify and describe evaluations of public policies that target the determinants of zoonotic spillover. Our approach is informed by a One Health perspective, acknowledging the inter-connectedness of human, animal and environmental health. METHODS: In this systematic scoping review, we searched Medline, SCOPUS, Web of Science and Global Health in May 2021 using search terms combining animal health and the animal-human interface, public policy, prevention and zoonoses. We screened titles and abstracts, extracted data and reported our process in line with PRISMA-ScR guidelines. We also searched relevant organisations' websites for evaluations published in the grey literature. All evaluations of public policies aiming to prevent zoonotic spillover events were eligible for inclusion. We summarised key data from each study, mapping policies along the spillover pathway. RESULTS: Our review found 95 publications evaluating 111 policies. We identified 27 unique policy options including habitat protection; trade regulations; border control and quarantine procedures; farm and market biosecurity measures; public information campaigns; and vaccination programmes, as well as multi-component programmes. These were implemented by many sectors, highlighting the cross-sectoral nature of zoonotic spillover prevention. Reports emphasised the importance of surveillance data in both guiding prevention efforts and enabling policy evaluation, as well as the importance of industry and private sector actors in implementing many of these policies. Thoughtful engagement with stakeholders ranging from subsistence hunters and farmers to industrial animal agriculture operations is key for policy success in this area. CONCLUSION: This review outlines the state of the evaluative evidence around policies to prevent zoonotic spillover in order to guide policy decision-making and focus research efforts. Since we found that most of the existing policy evaluations target 'downstream' determinants, additional research could focus on evaluating policies targeting 'upstream' determinants of zoonotic spillover, such as land use change, and policies impacting infection intensity and pathogen shedding in animal populations, such as those targeting animal welfare.

Policies to prevent zoonotic spillover: protocol for a systematic scoping review of evaluative evidence.

INTRODUCTION: The increasing incidence of pathogen transmission from animals to humans (zoonotic spillover events) has been attributed to behavioural practices and ecological and socioeconomic change. As these events sometimes involve pathogens with epidemic or pandemic potential, they pose a serious threat to population health. Public policies may play a key role in preventing these events. The aim of this review is to identify evaluations of public policies that target the determinants of zoonotic spillover, examining approaches taken to evaluation, choice of outcomes measures and evidence of effectiveness. Our approach to identifying and analysing this literature will be informed by a One Health lens, acknowledging the interconnectedness of human, animal and environmental health. METHODS AND ANALYSIS: A systematic scoping review methodology will be used. To identify articles, we will search Medline, SCOPUS, Web of Science and Global Health in May 2021 using search terms combining animal health and the animal-human interface, public policy, prevention and zoonoses. We will screen titles and abstracts and extract data according to published guidelines for scoping reviews. All evaluations of public policies aiming to prevent zoonotic spillover events will be eligible for inclusion. We will summarise key data from each study, mapping policies along the spillover pathway and outlining the range of policies, approaches to evaluation and outcome measures. Review findings will provide a useful reference for researchers and practitioners, outlining the state of the evaluative evidence around policies to prevent zoonotic spillover. ETHICS AND DISSEMINATION: Formal ethical approval is not required, because the study does not involve primary data collection. The findings of this study will be disseminated through a peer-reviewed publication, presentations and summaries for key stakeholders.

COVID-19 and zoonoses in Brazil: Environmental scan of one health preparedness and response.

The emergence of the COVID-19 pandemic reinforced the central role of the One Health (OH) approach, as a multisectoral and multidisciplinary perspective, to tackle health threats at the human-animal-environment interface. This study assessed Brazilian preparedness and response to COVID-19 and zoonoses with a focus on the OH approach and equity dimensions. We conducted an environmental scan using a protocol developed as part of a multi-country study. The article selection process resulted in 45 documents: 79 files and 112 references on OH; 41 files and 81 references on equity. The OH and equity aspects are poorly represented in the official documents regarding the COVID-19 response, either at the federal and state levels. Brazil has a governance infrastructure that allows for the response to infectious diseases, including zoonoses, as well as the fight against antimicrobial resistance through the OH approach. However, the response to the pandemic did not fully utilize the resources of the Brazilian state, due to the lack of central coordination and articulation among the sectors involved. Brazil is considered an area of high risk for emergence of zoonoses mainly due to climate change, large-scale deforestation and urbanization, high wildlife biodiversity, wide dry frontier, and poor control of wild animals' traffic. Therefore, encouraging existing mechanisms for collaboration across sectors and disciplines, with the inclusion of vulnerable populations, is required for making a multisectoral OH approach successful in the country.

An environmental scan of one health preparedness and response: the case of the Covid-19 pandemic in Rwanda.

BACKGROUND: Over the past decade, 70% of new and re-emerging infectious disease outbreaks in East Africa have originated from the Congo Basin where Rwanda is located. To respond to these increasing risks of disastrous outbreaks, the government began integrating One Health (OH) into its infectious disease response systems in 2011 to strengthen its preparedness and contain outbreaks. The strong performance of Rwanda in responding to the on-going COVID-19 pandemic makes it an excellent example to understand how the structure and principles of OH were applied during this unprecedented situation. METHODS: A rapid environmental scan of published and grey literature was conducted between August and December 2020, to assess Rwanda's OH structure and its response to the COVID-19 pandemic. In total, 132 documents including official government documents, published research, newspaper articles, and policies were analysed using thematic analysis. RESULTS: Rwanda's OH structure consists of multidisciplinary teams from sectors responsible for human, animal, and environmental health. The country has developed OH strategic plans and policies outlining its response to zoonotic infections, integrated OH into university curricula to develop a OH workforce, developed multidisciplinary rapid response teams, and created decentralized laboratories in the animal and human health sectors to strengthen surveillance. To address COVID-19, the country created a preparedness and response plan before its onset, and a multisectoral joint task force was set up to coordinate the response to the pandemic. By leveraging its OH structure, Rwanda was able to rapidly implement a OH-informed response to COVID-19. CONCLUSION: Rwanda's integration of OH into its response systems to infectious diseases and to COVID-19 demonstrates the importance of applying OH principles into the governance of infectious diseases at all levels. Rwanda exemplifies how preparedness and response to outbreaks and pandemics can be strengthened through multisectoral collaboration mechanisms. We do expect limitations in our findings due to the rapid nature of our environmental scan meant to inform the COVID-19 policy response and would encourage a full situational analysis of OH in Rwanda's Coronavirus response.

Global Health Diplomacy (GHD) and the integration of health into foreign policy: Towards a conceptual approach.

Since the end of the Cold War, health has gone from a peripheral concern in foreign policy negotiations to a prominent place on the global political agenda. While the rise of health onto the foreign policy agenda is by now old news, the driving forces behind its expansion into new political spheres remain understudied and undertheorized. This article builds on empirical findings from a four-country study of the integration of health into foreign policy, and proposes a conceptual approach to GHD to improve understanding of the conditions under which health is successfully positioned on the foreign policy agenda. Our approach consists of three dimensions: features of institutions and the interest various actors represent in GHD; the ideational environment in which GHD operates; and issue characteristics of the specific health concern entering foreign policy. Within each dimension, we identify specific variables that, in combination, make up the explanatory power of the proposed approach. The proposed approach does not relate to, or build upon, a single social sciences, public health, or international relations (IR) theory, but can be seen as a heuristic device to identify dimensions and variables that may shape why certain health issues rise onto the foreign policy agenda.

Global health diplomacy in Mexico: insights from key actors in the field.

BACKGROUND: Global health diplomacy (GHD) focuses on the actions taken by diverse stakeholders from different nations -governments, multilateral agents, and civil society- to phenomena that can affect population health and its determinants beyond national borders. Although the literature on conceptual advancements of GHD exists, empirical studies about how health becomes an issue of relevance for foreign policy are scarce. We present an analysis of the entry processes of health into the foreign policy and diplomatic domains in Mexico from the perspective of key informants of three different sectors. METHODS: A purposive sample of high-rank representatives of three sectors involved in GHD was designed: Two from Health Sector (HS), four from Foreign Affairs Sector (FAS), and three from Non-governmental organizations (NGOs). Nine semi-structured interviews were conducted exploring the topics of: (1) Health concerns entering diplomatic and foreign policy; (2) Processes that allow actors to influence foreign policy and negotiation and; (3) Impact of multilateral negotiations on decision-making at the national level. RESULTS: Our analysis suggests that GHD in Mexico is hierarchically driven by the FAS and health concerns only enter foreign policy when they are relevant to national priorities (such as trade or security). HS possesses a lesser degree of influence in GHD, serving as an instance of consultation for the FAS when deciding on health-related issues at global meetings (i.e., World Health Assembly). NGOs resort to lobbying, advocacy, networking, and coalition-working practices with other sectors (academy, think-tanks) to prevent harmful impacts on local health from multilateral decisions and as a mean to compensate its power asymmetry for influencing GHD processes in relation to the government. CONCLUSIONS: GHD in Mexico occurs in a context of asymmetric power relationships where government actors have the strongest influence. However, NGOs' experience in raising awareness of health risks needs to be weighted by government decision-makers. This situation calls for capacity building on intersectoral communication and coordination to create formal mechanisms of GHD practices, including the professionalization and training on GHD among government agencies.

A pandemic treaty, revised international health regulations, or both?

BACKGROUND: A special session of the World Health Assembly (WHA) will be convened in late 2021 to consider developing a WHO convention, agreement or other international instrument on pandemic preparedness and response - a so-called 'Pandemic Treaty'. Consideration is given to this treaty as well as to reform of the International Health Regulations (IHR) as our principal governing instrument to prevent and mitigate future pandemics. MAIN BODY: Reasons exist to continue to work with the IHR as our principal governing instrument to prevent and mitigate future pandemics. All WHO member states are party to it. It gives the WHO the authority to oversee the collection of surveillance data and to issue recommendations on trade and travel advisories to control the spread of infectious diseases, among other things. However, the limitations of the IHR in addressing the deep prevention of future pandemics also must be recognized. These include a lack of a regulatory framework to prevent zoonotic spillovers. More advanced multi-sectoral measures are also needed. At the same time, a pandemic treaty would have potential benefits and drawbacks as well. It would be a means of addressing the gross inequity in global vaccine distribution and other gaps in the IHR, but it would also need more involvement at the negotiation table of countries in the Global South, significant funding, and likely many years to adopt. CONCLUSIONS: Reform of the IHR should be undertaken while engaging with WHO member states (and notably those from the Global South) in discussions on the possible benefits, drawbacks and scope of a new pandemic treaty. Both options are not mutually exclusive.

A survey of International Health Regulations National Focal Points experiences in carrying out their functions.

BACKGROUND: The 2005 International Health Regulations (IHR (2005)) require States Parties to establish National Focal Points (NFPs) responsible for notifying the World Health Organization (WHO) of potential events that might constitute public health emergencies of international concern (PHEICs), such as outbreaks of novel infectious diseases. Given the critical role of NFPs in the global surveillance and response system supported by the IHR, we sought to assess their experiences in carrying out their functions. METHODS: In collaboration with WHO officials, we administered a voluntary online survey to all 196 States Parties to the IHR (2005) in Africa, Asia, Europe, and South and North America, from October to November 2019. The survey was available in six languages via a secure internet-based system. RESULTS: In total, 121 NFP representatives answered the 56-question survey; 105 in full, and an additional 16 in part, resulting in a response rate of 62% (121 responses to 196 invitations to participate). The majority of NFPs knew how to notify the WHO of a potential PHEIC, and believed they have the content expertise to carry out their functions. Respondents found training workshops organized by WHO Regional Offices helpful on how to report PHEICs. NFPs experienced challenges in four critical areas: 1) insufficient intersectoral collaboration within their countries, including limited access to, or a lack of cooperation from, key relevant ministries; 2) inadequate communications, such as deficient information technology systems in place to carry out their functions in a timely fashion; 3) lack of authority to report potential PHEICs; and 4) inadequacies in some resources made available by the WHO, including a key tool - the NFP Guide. Finally, many NFP representatives expressed concern about how WHO uses the information they receive from NFPs. CONCLUSION: Our study, conducted just prior to the COVID-19 pandemic, illustrates key challenges experienced by NFPs that can affect States Parties and WHO performance when outbreaks occur. In order for NFPs to be able to rapidly and successfully communicate potential PHEICs such as COVID-19 in the future, continued measures need to be taken by both WHO and States Parties to ensure NFPs have the necessary authority, capacity, training, and resources to effectively carry out their functions as described in the IHR.

Characterizing 'health equity' as a national health sector priority for maternal, newborn, and child health in Ethiopia.

Background: The pursuit of health equity is a priority in Ethiopia, especially with regards to maternal, newborn, and child health (MNCH). To date, there has been little characterization of the 'problem' of health inequity, and the normative assumptions implicit in the representation of the problem. Yet, such insights have implications for shaping the framing, incentivization, and implementation of health policies and their wider impact. Objective: In this article, we characterize how health (in)equity is represented as a policy issue, how this representation came about, and the underlying assumptions. Methods: We draw from Bacchi's 'what is the problem represented to be' approach to explore how national-level actors in the health sector constitute the problem. The data for our analysis encompass 23 key informant interviews with national health sector actors working in leadership positions on MNCH in Ethiopia, and six policy documents. Findings were derived from thematic and content analysis. Results: Health inequity is a normalized and inevitable concern that is regarded as actionable (can be altered) but not fully resolvable (can never be fully achieved). Operationally, health equity is viewed as a technocratic matter, reflected in the widespread use of metrics to motivate and measure progress. These representations are shaped by Ethiopia's rapid expansion of health services into rural areas during the 2000s leading to the positive international attention and funding the country received for improved MNCH indicators. Expanding the coverage and efficiency of health service provision, especially in rural areas, is associated with economic productivity. Conclusion: The metrication of health equity may detract from the fairness, justice, and morality underpinnings of the concept. The findings of this study point to the implications of global pressures in terms of maximizing health investments, and call into question how social, political, and economic determinants of health are addressed through broader development agendas.

What role for One Health in the COVID-19 pandemic?

This commentary discusses the contributions that One Health (OH) principles can make in improving the global response to the COVID-19 pandemic. We highlight four areas where the application of OH has the potential to significantly improve the governance of infectious diseases in general, and of COVID-19 in particular. First, more integrated surveillance infrastructure and monitoring of the occurrence of infectious diseases in both humans and animals can facilitate the detection of new infectious agents sharing similar genotypes across species and the monitoring of the spatio-temporal spread of such infections. This knowledge can guide public and animal health officials in their response measures. Second, application of the OH approach can improve coordination and active collaboration among stakeholders representing apparently incompatible domains. Third, the OH approach highlights the need for an effective institutional landscape, facilitating adequate regulation of hotspots for transmission of infectious agents among animals and humans, such as live animal markets. And finally, OH thinking emphasizes the need for equitable solutions to infectious disease challenges, suggesting that policy response mechanisms and interventions need to be reflective of the disproportionate disease burdens borne by vulnerable and marginalized populations, or by persons providing health care and other essential services to those sick.

Governing antimicrobial resistance: a narrative review of global governance mechanisms.

Antimicrobial resistance (AMR), a central health challenge of the twenty first century, poses substantial population health risks, with deaths currently estimated to be around 700,000 per year globally. The international community has signaled its commitment to exploring and implementing effective policy responses to AMR, with a Global Action Plan on AMR approved by the World Health Assembly in 2015. Major governance challenges could thwart collective efforts to address AMR, along with limited knowledge about how to design effective global governance mechanisms. To identify common ground for more coordinated global actions we conducted a narrative review to map dominant ideas and academic debates about AMR governance. We found two categories of global governance mechanisms: binding and non-binding and discuss advantages and drawbacks of each. We suggest that a combination of non-binding and binding governance mechanisms supported by leading antimicrobial use countries and important AMR stakeholders, and informed by One Health principles, may be best suited to tackle AMR.

The Political Economy of Tobacco in Mozambique and Zimbabwe: A Triangulation Mixed Methods Protocol.

Changing global markets have generated a dramatic shift in tobacco consumption from high-income countries (HICs) to low- and middle-income countries (LMICs); by 2030, more than 80% of the disease burden from tobacco use will fall on LMICs. Propelling this shift, opponents of tobacco control have successfully asserted that tobacco is essential to the economic livelihoods of smallholder tobacco farmers and the economy of tobacco-growing countries. This nexus of economic, agricultural and public health policymaking is one of the greatest challenges facing tobacco control efforts, especially in LMICs. To date, there is a lack of comparative, individual level evidence about the actual livelihoods of tobacco-growing farmers and the political economic context driving tobacco production. This comparative evidence is critically important to identify similarities and differences across contexts and to provide local evidence to inform policies and institutional engagement. Our proposed four-year project will examine the economic situation of smallholder farmers in two major tobacco-growing LMICs-Mozambique and Zimbabwe-and the political economy shaping farmers' livelihoods and tobacco control efforts. We will collect and analyze the existing data and policy literature on the political economy of tobacco in these two countries. We will also implement household-level economic surveys of nationally representative samples of farmers. The surveys will be complimented with focus group discussions with farmers across the major tobacco-growing regions. Finally, we will interview key informants in these countries in order to illuminate the policy context in which tobacco production is perpetuated. The team will develop country-level reports and policy briefs that will inform two sets of dissemination workshops in each country with relevant stakeholders. We will also conduct workshops to present our findings to the survey and focus group participants, and other members of these tobacco-growing communities, so they can directly benefit from the research to which they are contributing.

Monitoring Frameworks for Universal Health Coverage: What About High-Income Countries?

Implementing universal health coverage (UHC) is widely perceived to be central to achieving the Sustainable Development Goals (SDGs), and is a work program priority of the World Health Organization (WHO). Much has already been written about how low- and middle-income countries (LMICs) can monitor progress towards UHC, with various UHC monitoring frameworks available in the literature. However, we suggest that these frameworks are largely irrelevant in high-income contexts and that the international community still needs to develop UHC monitoring framework meaningful for high-income countries (HICs). As a first step, this short communication presents preliminary findings from a literature review and document analysis on how various countries monitor their own progress towards achieving UHC. It furthermore offers considerations to guide meaningful UHC monitoring and reflects on pertinent challenges and tensions to inform future research on UHC implementation in HIC settings.

Subnational health management and the advancement of health equity: a case study of Ethiopia.

BACKGROUND: Health equity is a cross-cutting theme in the United Nations 2030 Agenda for Sustainable Development, and a priority in health sector planning in countries including Ethiopia. Subnational health managers in Ethiopia are uniquely positioned to advance health equity, given the coordination, planning, budgetary, and administration tasks that they are assigned. Yet, the nature of efforts to advance health equity by subnational levels of the health sector is poorly understood and rarely researched. This study assesses how subnational health managers in Ethiopia understand health equity issues and their role in promoting health equity and offers insight into how these roles can be harnessed to advance health equity. METHODS: A descriptive case study assessed perspectives and experiences of health equity among subnational health managers at regional, zonal, district and Primary Health Care Unit administrative levels. Twelve in-depth interviews were conducted with directors, vice-directors, coordinators and technical experts. Data were analyzed using thematic analysis. RESULTS: Subnational managers perceived geographical factors as a predominant concern in health service delivery inequities, especially when they intersected with poor infrastructure, patriarchal gender norms, unequal support from non-governmental organizations or challenging topography. Participants used ad hoc, context-specific strategies (such as resource-pooling with other sectors or groups and shaming-as-motivation) to improve health service delivery to remote populations and strengthen health system operations. Collaboration with other groups facilitated cost sharing and access to resources; however, the opportunities afforded by these collaborations, were not realized equally in all areas. Subnational health managers' efforts in promoting health equity are affected by inadequate resource availability, which restricts their ability to enact long-term and sustainable solutions. CONCLUSIONS: Advancing health equity in Ethiopia requires: extra support to communities in hard-to-reach areas; addressing patriarchal norms; and strategic aligning of the subnational health system with non-health government sectors, community groups, and non-governmental organizations. The findings call attention to the unrealized potential of effectively coordinating governance actors and processes to better align national priorities and resources with subnational governance actions to achieve health equity, and offer potentially useful knowledge for subnational health system administrators working in conditions similar to those in our Ethiopian case study.

Using sustainability as a collaboration magnet to encourage multi-sector collaborations for health.

The World Health Organization Commission on Social Determinants of Health (SDH) places great emphasis on the role of multi-sector collaboration in addressing SDH. Despite this emphasis on this need, there is surprisingly little evidence for this to advance health equity goals. One way to encourage more successful multi-sector collaborations is anchoring SDH discourse around 'sustainability', subordinating within it the ethical and empirical importance of 'levelling up'. Sustainability, in contrast to health equity, has recently proved to be an effective collaboration magnet. The recent adoption of the Sustainable Development Goals (SDGs) provides an opportunity for novel ways of ideationally re-framing SDH discussions through the notion of sustainability. The 2030 Agenda for the SDGs calls for greater policy coherence across sectors to advance on the goals and targets. The expectation is that diverse sectors are more likely and willing to collaborate with each other around the SDGs, the core idea of which is 'sustainability'.

Health in All Policies (HiAP) governance: lessons from network governance.

The Health in All Policies (HiAP) approach requires formal and sustained governance structures and mechanisms to ensure that the policies of various non-health sectors maximize positive and minimize negative impacts on population health. In this paper, we demonstrate the usefulness of a network perspective in understanding and contributing to the effectiveness of HiAP. We undertook an exploratory, qualitative case study of a HiAP structure in Iran, the Kerman province Council of Health and Food Security (CHFS) with diverse members from health and non-health sectors. We analyzed relevant policy texts and interviewed 32 policy actors involved in the CHFS. Data were analyzed using within-case analysis and constant comparative methodology. Our findings suggest that CHFS governance from a network perspective drew in practice on elements of two competing network governance modes: the network administrative organization (NAO) and the lead organization mode. Our results also show that a shift from a hierarchical and market-based mode of interaction to a network logic within CHFS has not yet taken place. In addition, CHFS suffers from large membership and an inability to address complex 'wicked problems', as well as low trust, legitimacy and goal consensus among its members. Drawing on other HiAP studies and commentaries, insights from organization network theory, and in-depth findings from our case study, we conclude that a NAO may be the most effective mode of governance for tackling complex social problems in HiAP structures. Since similar studies are limited, and our single case study may not be transferable across all contexts, we suggest that further research be undertaken to explore HiAP structures from a network perspective in different institutional and cultural settings. With increasing emphasis given to HiAP approaches in national and international health policy discourse, it is important that comparative knowledge about the effectiveness of HiAP governance arrangements be developed.

Opening windows and closing gaps: a case analysis of Canada's 2009 tobacco additives ban and its policy lessons.

BACKGROUND: In 2009, Canada adopted legislation (Bill C-32) restricting the sale of flavoured tobacco products, one of the first in the world. This study examines the agenda-setting process leading to the adoption of Bill C-32. METHODS: This research was conducted using a case study design informed by Kingdon's Multiple Streams framework and Heclo's policy learning approach. In-depth interviews were conducted with key informants from government, health-based non-governmental organizations (NGOs), trade associations and the cigar manufacturing sector (n = 11). Public documents produced by media (n = 19), government (n = 11), NGOs (n = 15), as well as technical reports (n = 8) and formal stakeholder submissions (n = 137) were included for analysis. Data were coded with the objective of understanding key events or moments in the lead up to the adoption of Bill C-32 and the actors and arguments in support of and opposition to Bill C-32. RESULTS: The findings point to the importance of a small but active group of NGOs who worked to publicize the issue and eventually take advantage of an open policy window. Our analysis also illustrates that even though consensus was developed about the policy problem and civil society was able to garner political support to address the problem, disagreement and dissent pertaining to the technical dimensions of the policy solution created loopholes for the tobacco industry to exploit. CONCLUSIONS: NGOs remain a critical factor in efforts to strengthen tobacco control policy. These organizations were able to mobilize support for the tobacco flavouring ban adopted at the Federal level in Canada, and although the initial Bill had major limitations to achieving the health objectives, the persistence of these NGOs resulted in amendments to close these loopholes.

Chile's role in global health diplomacy: a narrative literature review.

BACKGROUND: Global health diplomacy (GHD) has become an important field of investigation due to health concerns increasingly entering the foreign policy domain. Much of the existing academic writing focuses on North-South cooperation in global health, and emphasizes the role of security and economic interests by Northern countries as drivers of GHD. Chile presents a favourable environment for an expanded involvement in future GHD activities. However, there is little knowledge about what has been driving Chile's integration of health into foreign policy, and little effort to appropriate knowledge from international relations theories to better theoretically grasp the emergence of GHD. METHODS: To fill this knowledge gap, we conducted a narrative literature review of the driving forces behind Chile's integration of health into foreign policy. Drawing on a popular analytical framework used in international relations scholarship, we identified driving forces of the integration of health into Chile foreign policy at three levels of analysis. RESULTS: At the international/global level of analysis, the main driving forces were related to national security concerns and compliance with regulations of international organizations. At the regional level, GHD was driven by a commitment to regional solidarity through mutually beneficial cooperation in response to neoliberal reforms; health coordination in emergencies; and protection of indigenous peoples. Finally, at the domestic level, drivers identified include economic interests of various productive sectors and how health regulations might impact those; the high degree of social inequity which impacts on access to healthcare; and management of natural disasters. CONCLUSION: Health actions in the context of international relations in Chile are still mainly motivated by more traditional foreign policy interests rather than by a desire to satisfy health needs per se. This seems to conform with findings of existing GHD scholarship that emphasize the importance of security and economic interests as driving forces of GHD, and how health is often appropriated instrumentally within foreign policy settings to achieve other goals. But the review also reveals that in the context of South-South cooperation (and regional health diplomacy), solidarity and normative considerations can be important driving forces as well. Finally, the review demonstrates that there has been an evolution from chiefly domestically focused health policies (e.g. maternal and child nutrition treatment) towards internationally inspired integrated policies (e.g. maternal and child nutrition promotion aligned with international guidelines).