Defining and conceptualising the commercial determinants of health.

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

Food trade among Pacific Island countries and territories: implications for food security and nutrition.

BACKGROUND: There is growing attention to intra-regional trade in food. However, the relationship between such trade and food and nutrition is understudied. In this paper, we present an analysis of intra-regional food trade in the Pacific region, where there are major concerns regarding the nutritional implications of international food trade. Using a new regional database, we examine trends in food trade among Pacific Island Counties and Territories (PICTs) relative to extra-regional trade. RESULTS: Intra-regional trade represents a small, but increasing proportion of total imports. The major food group traded within the Pacific is cereal grains and flour, which represented 51% of total intra-regional food trade in 2018. Processed and prepared foods, sweetened or flavoured beverages, processed fish, and sugar and confectionary are also traded in large quantities among PICTs. Trade in root crops is negligible, and overall intra-regional trade of healthy foods is limited, both in terms of tonnage and relative to imports from outside the region. Fiji remains the main source of intra-regional imports into PICTs, particularly for non-traditional staple foods. CONCLUSIONS: This study highlights the growth in trade of staple foods intra-regionally, indicating a role for Fiji (in particular) in regional food security. Within this overall pattern, there is considerable opportunity to enhance intra-regional trade in traditional staple foods, namely root crops. Looking forward, the current food system disruption arising from the COVID-19 pandemic and associated policy measures has highlighted the long-term lack of investment in agriculture, and suggests an increased role for regional approaches in fostering trade in healthy foods.

Framing policy objectives in the sustainable development goals: hierarchy, balance, or transformation?

Society continues to be confronted with the deep inadequacies of the current global order. Rampant income inequality between and within countries, dramatic disparities in access to resources, as seen during the COVID pandemic, persistent degradation of the environment, and numerous other problems are tied to existing systems of economy and government. Current global economic systems are implicated in perpetuating these problems. The Sustainable Development Goals (SDGs) were born out of the recognition that dramatic changes were needed to address these intersecting challenges. There is general recognition that transformation of global systems and the relationship between sectors is needed. We conduct a structured, theoretically-informed analysis of SDG documents produced by United Nations agencies with the aim of examining the framing of economic policy goals, a historically dominant domain of consideration in development policy, in relation to health, social and environmental goals. We apply a novel typology to categorize the framing of policy goals. This analysis identified that the formal discourse associated with the SDGs marks a notable change from the pre-SDG development discourse. The 'transformational' agenda issued in the SDG documents is in part situated in relation to a critique of previous and existing approaches to development that privilege economic goals over health, social and environmental goals, and position economic policy as the solution to societal concerns. At the same time, we find that there is tension between the aspiration of transformation and an overwhelming focus on economic goals. This work has implications for health governance, where we find that health goals are still often framed as a means to achieve economic policy goals. Health scholars and advocates can draw from our analysis to critically examine how health fits within the transformational development agenda and how sectoral policy goals can move beyond a crude emphasis on economic growth.

Regional Governance for Food System Transformations: Learning from the Pacific Island Region

The unsustainability of food systems is a global policy challenge. There is an urgent need for the improved coordination and integration of policies across sectors to improve food system outcomes. The aim of this study was to examine the role and opportunities for regional governance in strengthening policy for food system transformations, using the Pacific Island region as a case study. We conducted a qualitative policy analysis, drawing on data from 21 interviews with experts and participants in Pacific Island regional food system governance, and the analysis of 17 key regional commitments (policy documents) relating to food systems. The findings indicate that the Pacific Island region has made significant progress towards improved regional food systems governance. Regional governance has been used to address multiple shared and inter-related challenges associated with food systems, improve coordination across silos, and facilitate constructive engagement on policy issues between international, regional, and national actors. However, food systems outcomes related to the economy, nutrition, and environment continue to be mixed, and there are challenges to policy coordination and effectiveness at the regional level. Interviewees envisaged a regional approach characterized by being rooted in regional values, meeting multiple objectives, balancing tensions, and providing meaningful support and resources for countries. Following food systems disruptions associated with the COVID-19 pandemic, this study suggests that there is an opportunity to strengthen regional food system governance through paradigm change, the development of new modes of coordination, and increasing the dynamic interactions between regional institutions, countries, and communities.

Linking health and finance ministries to improve taxes on unhealthy products.

The World Health Organization recommends economic measures such as taxes on tobacco, alcohol and unhealthy foods and beverages as part of a comprehensive strategy for prevention of noncommunicable diseases. However, progress in adopting these so-called health taxes has been hampered, in part, by different approaches and perceptions of key issues in different sectors of government. Health promotion is the responsibility of health policy-makers, while taxation is the mandate of finance ministries. Thus, strengthening cooperation between health and finance policy-makers is central to the successful adoption and implementation of effective health taxes. In this paper we identify the shared concerns of finance and health policy-makers about health taxes with the aim of enabling more effective cross-sector cooperation towards both additional financing for health systems and changes in unhealthy behaviours. For example, new approaches to supporting health taxation include the growing priority for health-system financing due to the growing burden of noncommunicable diseases, and the need to address the health and economic damage due to the coronavirus disease 2019 pandemic. As a result, high-level efforts to achieve progress on health taxes are gaining momentum and represent important progress towards using the combined expertise of health and finance policy-makers.

L'Organisation mondiale de la Santé recommande l'adoption de mesures économiques telles que des taxes sur le tabac, l'alcool ainsi que les boissons et aliments nocifs pour la santé dans le cadre d'une vaste stratégie de prévention des maladies non transmissibles. Cependant, les progrès en la matière ont rencontré des obstacles, notamment en raison de la différence d'approche et de perception des principaux enjeux à divers niveaux du gouvernement. La promotion de la santé relève de la politique sanitaire, tandis que la taxation est la mission du ministère des Finances. Accentuer la coopération entre les responsables de la santé et des finances est donc indispensable à la réussite de l'instauration et de la mise en œuvre de taxes sanitaires efficaces. Dans le présent document, nous identifions les préoccupations partagées tant par les responsables de la santé que par ceux des finances concernant les taxes sanitaires, dans le but d'intensifier la collaboration entre les secteurs. Objectif: débloquer des fonds supplémentaires pour les systèmes de santé et favoriser l'abandon des comportements nuisibles à la santé. Parmi les nouvelles approches de soutien aux taxes sanitaires, citons par exemple une plus grande priorité accordée au financement du système de santé afin de réduire la charge croissante que font peser les maladies non transmissibles, et la nécessité de réparer les dégâts économiques et sanitaires causés par la pandémie de maladie à coronavirus 2019. Ainsi, les efforts visant à développer les taxes sanitaires gagnent du terrain et représentent une avancée considérable vers une valorisation de l'expertise conjointe entre ministère de la Santé et ministère des Finances.

La Organización Mundial de la Salud recomienda la adopción de medidas económicas como los impuestos sobre el tabaco, el alcohol y los alimentos y bebidas poco saludables como parte de una estrategia global de prevención de las enfermedades no transmisibles. Sin embargo, los avances en la adopción de estos llamados impuestos saludables se han retrasado, en parte, por los diferentes enfoques y percepciones de las cuestiones clave en los distintos sectores del gobierno. La promoción de la salud es competencia de los responsables de formular las políticas sanitarias, mientras que la fiscalidad es el mandato de los ministerios de Hacienda. Por lo tanto, el fortalecimiento de la cooperación entre los responsables de formular las políticas sanitarias y financieras es fundamental para el éxito de la adopción y aplicación de sistemas fiscales sanitarios eficaces. En este documento, se identifican las preocupaciones que comparten los responsables de formular las políticas financieras y sanitarias en relación con los impuestos saludables, con el fin de permitir una cooperación intersectorial más eficaz, tanto en lo que respecta a la financiación adicional de los sistemas sanitarios como a la modificación de los comportamientos poco saludables. Por ejemplo, entre los enfoques nuevos para apoyar la fiscalidad sanitaria se encuentran la creciente prioridad de la financiación de los sistemas sanitarios debido a una mayor carga de enfermedades no transmisibles, y la necesidad de solucionar los daños sanitarios y económicos debidos a la pandemia de la enfermedad por coronavirus de 2019. En consecuencia, los esfuerzos de alto nivel para lograr avances en materia de impuestos saludables están cobrando impulso y representan un avance importante hacia el uso de la experiencia combinada de los responsables de formular las políticas sanitarias y financieras.

Linking health and finance ministries to improve taxes on unhealthy products Relier les ministères de la Santé et des Finances pour renforcer les taxes sur les produits nocifs pour la santé Vinculación de los ministerios de Sanidad y Hacienda para mejorar los impuestos sobre los productos perjudiciales para la salud ربط وزارتي الصحة والمالية لتحسين الضرائب المفروضة على المنتجات غير الصحية 卫生部和财政部联手提高不健康产品相关税收 Взаимодействие министерства здравоохранения и министерства финансов в деле улучшения использования налогов, взимаемых с продукции, не поддерживающей здоровый образ жизни

The World Health Organization recommends economic measures such as taxes on tobacco, alcohol and unhealthy foods and beverages as part of a comprehensive strategy for prevention of noncommunicable diseases. However, progress in adopting these so-called health taxes has been hampered, in part, by different approaches and perceptions of key issues in different sectors of government. Health promotion is the responsibility of health policy-makers, while taxation is the mandate of finance ministries. Thus, strengthening cooperation between health and finance policy-makers is central to the successful adoption and implementation of effective health taxes. In this paper we identify the shared concerns of finance and health policy-makers about health taxes with the aim of enabling more effective cross-sector cooperation towards both additional financing for health systems and changes in unhealthy behaviours. For example, new approaches to supporting health taxation include the growing priority for health-system financing due to the growing burden of noncommunicable diseases, and the need to address the health and economic damage due to the coronavirus disease 2019 pandemic. As a result, high-level efforts to achieve progress on health taxes are gaining momentum and represent important progress towards using the combined expertise of health and finance policy-makers.

The tension between national consistency and jurisdictional professional expansion: The case of pharmacist-administered vaccinations.

BACKGROUND: The COVID-19 pandemic has highlighted the importance of coordinating policies on vaccinations at the national level. In Australia, the regulation and management of pharmacist-administered vaccination programs are the responsibility of each of the eight jurisdictions (six states and two territories), and have been developed independently of each other, leading to substantial variation. Consequently, there are variations regarding which vaccines pharmacists can administer, the minimum age, and whether these vaccines are publicly funded. OBJECTIVE(S): To identify opportunities for a nationally consistent approach to pharmacist-administered vaccinations in Australia. METHODS: This policy analysis used the Multiple Streams Framework to identify barriers and enablers within the three "streams" of problem, policy, and politics, and how they affected the development of a national approach. Data were drawn from semi-structured interviews with 13 key policy actors and documents (pre-budget submissions and parliamentary inquiry reports). Themes were generated around actor interests, current and proposed pharmacist vaccination programs, and policymaking processes. RESULTS: From the pharmacy sector, there was little clarity around the need for a nationally consistent approach. This issue was linked to their ultimate goal of expanding pharmacist vaccination programs; it was seen as a means for states/territories with smaller programs to 'catch up' to other jurisdictions. There was also no unified policy approach from this sector; additionally, decision-makers within jurisdictional health departments faced different service delivery models, policy priorities, agendas, and policy actor relationships. Lastly, there was no federal body that had the capacity to coordinate a national approach. Possible enablers include refining the problem definition and re-framing it to a patient-centric model. CONCLUSIONS: Coordination of vaccination policies is an ongoing policy issue with implications for pharmacist vaccination programs and other health policy areas in which a national approach is being considered. This analysis provides insight into how this may be developed in the future.

"Never waste a good crisis": Opportunities and constraints from the COVID-19 pandemic on pharmacists' scope of practice.

BACKGROUND: In response to the COVID-19 pandemic, many pharmacy-based or pharmacist-delivered services were introduced or amended to mitigate the pandemic's health and social impact. This happened within the context of pharmacists seeking more opportunities to increase their clinical responsibilities and play a larger role in primary care. OBJECTIVE(S): To analyse the policymaking context and pharmacy responses to COVID-19 that enable or constrain the expansion of pharmacists' scope of practice. METHODS: This study is a policy analysis of documentary data detailing changes in pharmacy policy in Australia, drawing on a "policy space analysis" framework to identify opportunities and constraints to policy reform. Data were collected from news for health professionals; federal/jurisdictional legislation and media releases; and guidelines and directives from government health departments and agencies. Changes to pharmacy practice were identified and classified according to type. For each change, potential opportunities and constraints for expanding pharmacists' scope of practice were identified. RESULTS: Four categories of changes were identified: medicines limits/restrictions; alternatives to paper prescriptions; public health measures; and community pharmacist-delivered services. Opportunities from the pandemic response that could expand scope of practice include the potential permanence of temporary measures that increase pharmacists' responsibilities; remuneration to legitimise services; political acknowledgement of medicines safety and access as a priority; and government need to quickly address crises. Constraints include the potential permanence of temporary measures that restrict pharmacists' practice; negative perceptions of pharmacists from other clinicians; intra-professional disagreements regarding pharmacy-based services; and lack of pharmacist representation in institutional structures. CONCLUSIONS: This analysis demonstrates that the pandemic responses and policy context may facilitate expansion of pharmacists' scope of practice, and identifies possible avenues to do so; it also highlights constraints that need to be further addressed to achieve this goal.

COVID-19 and Pacific food system resilience: opportunities to build a robust response.

The unfolding COVID-19 pandemic has exposed the vulnerability of the Pacific food system to externalities and has had far-reaching impacts, despite the small number of COVID-19 cases recorded thus far. Measures adopted to mitigate risk from the pandemic have had severe impacts on tourism, remittances, and international trade, among other aspects of the political economy of the region, and are thus impacting on food systems, food security and livelihoods. Of particular concern will be the interplay between loss of incomes and the availability and affordability of local and imported foods. In this paper, we examine some of the key pathways of impact on food systems, and identify opportunities to strengthen Pacific food systems during these challenging times. The great diversity among Pacific Island Countries and Territories in their economies, societies, and agricultural potential will be an important guide to planning interventions and developing scenarios of alternative futures. Bolstering regional production and intraregional trade in a currently import-dependent region could strengthen the regional economy, and provide the health benefits of consuming locally produced and harvested fresh foods - as well as decreasing reliance on global supply chains. However, significant production, processing, and storage challenges remain and would need to be consistently overcome to influence a move away from shelf-stable foods, particularly during periods when human movement is restricted and during post-disaster recovery.

Scaling-up food policies in the Pacific Islands: protocol for policy engagement and mixed methods evaluation of intervention implementation.

BACKGROUND: There is a crisis of non-communicable diseases (NCDs) in the Pacific Islands, and poor diets are a major contributor. The COVID-19 pandemic and resulting economic crisis will likely further exacerbate the burden on food systems. Pacific Island leaders have adopted a range of food policies and regulations to improve diets. This includes taxes and regulations on compositional standards for salt and sugar in foods or school food policies. Despite increasing evidence for the effectiveness of such policies globally, there is a lack of local context-specific evidence about how to implement them effectively in the Pacific. METHODS: Our 5-year collaborative project will test the feasibility and effectiveness of policy interventions to reduce salt and sugar consumption in Fiji and Samoa, and examine factors that support sustained implementation. We will engage government agencies and civil society in Fiji and Samoa, to support the design, implementation and monitoring of evidence-informed interventions. Specific objectives are to: (1) conduct policy landscape analysis to understand potential opportunities and challenges to strengthen policies for prevention of diet-related NCDs in Fiji and Samoa; (2) conduct repeat cross sectional surveys to measure dietary intake, food sources and diet-related biomarkers; (3) use Systems Thinking in Community Knowledge Exchange (STICKE) to strengthen implementation of policies to reduce salt and sugar consumption; (4) evaluate the impact, process and cost effectiveness of implementing these policies. Quantitative and qualitative data on outcomes and process will be analysed to assess impact and support scale-up of future interventions. DISCUSSION: The project will provide new evidence to support policy making, as well as developing a low-cost, high-tech, sustainable, scalable system for monitoring food consumption, the food supply and health-related outcomes.

Australia in 2030: what is our path to health for all?

CHAPTER 1: HOW AUSTRALIA IMPROVED HEALTH EQUITY THROUGH ACTION ON THE SOCIAL DETERMINANTS OF HEALTH: Do not think that the social determinants of health equity are old hat. In reality, Australia is very far away from addressing the societal level drivers of health inequity. There is little progressive policy that touches on the conditions of daily life that matter for health, and action to redress inequities in power, money and resources is almost non-existent. In this chapter we ask you to pause this reality and come on a fantastic journey where we envisage how COVID-19 was a great disruptor and accelerator of positive progressive action. We offer glimmers of what life could be like if there was committed and real policy action on the social determinants of health equity. It is vital that the health sector assists in convening the multisectoral stakeholders necessary to turn this fantasy into reality. CHAPTER 2: ABORIGINAL AND TORRES STRAIT ISLANDER CONNECTION TO CULTURE: BUILDING STRONGER INDIVIDUAL AND COLLECTIVE WELLBEING: Aboriginal and Torres Strait Islander peoples have long maintained that culture (ie, practising, maintaining and reclaiming it) is vital to good health and wellbeing. However, this knowledge and understanding has been dismissed or described as anecdotal or intangible by Western research methods and science. As a result, Aboriginal and Torres Strait Islander culture is a poorly acknowledged determinant of health and wellbeing, despite its significant role in shaping individuals, communities and societies. By extension, the cultural determinants of health have been poorly defined until recently. However, an increasing amount of scientific evidence supports what Aboriginal and Torres Strait Islander people have always said - that strong culture plays a significant and positive role in improved health and wellbeing. Owing to known gaps in knowledge, we aim to define the cultural determinants of health and describe their relationship with the social determinants of health, to provide a full understanding of Aboriginal and Torres Strait Islander wellbeing. We provide examples of evidence on cultural determinants of health and links to improved Aboriginal and Torres Strait Islander health and wellbeing. We also discuss future research directions that will enable a deeper understanding of the cultural determinants of health for Aboriginal and Torres Strait Islander people. CHAPTER 3: PHYSICAL DETERMINANTS OF HEALTH: HEALTHY, LIVEABLE AND SUSTAINABLE COMMUNITIES: Good city planning is essential for protecting and improving human and planetary health. Until recently, however, collaboration between city planners and the public health sector has languished. We review the evidence on the health benefits of good city planning and propose an agenda for public health advocacy relating to health-promoting city planning for all by 2030. Over the next 10 years, there is an urgent need for public health leaders to collaborate with city planners - to advocate for evidence-informed policy, and to evaluate the health effects of city planning efforts. Importantly, we need integrated planning across and between all levels of government and sectors, to create healthy, liveable and sustainable cities for all. CHAPTER 4: HEALTH PROMOTION IN THE ANTHROPOCENE: THE ECOLOGICAL DETERMINANTS OF HEALTH: Human health is inextricably linked to the health of the natural environment. In this chapter, we focus on ecological determinants of health, including the urgent and critical threats to the natural environment, and opportunities for health promotion arising from the human health co-benefits of actions to protect the health of the planet. We characterise ecological determinants in the Anthropocene and provide a sobering snapshot of planetary health science, particularly the momentous climate change health impacts in Australia. We highlight Australia's position as a major fossil fuel producer and exporter, and a country lacking cohesive and timely emissions reduction policy. We offer a roadmap for action, with four priority directions, and point to a scaffold of guiding approaches - planetary health, Indigenous people's knowledge systems, ecological economics, health co-benefits and climate-resilient development. Our situation requires a paradigm shift, and this demands a recalibration of health promotion education, research and practice in Australia over the coming decade. CHAPTER 5: DISRUPTING THE COMMERCIAL DETERMINANTS OF HEALTH: Our vision for 2030 is an Australian economy that promotes optimal human and planetary health for current and future generations. To achieve this, current patterns of corporate practice and consumption of harmful commodities and services need to change. In this chapter, we suggest ways forward for Australia, focusing on pragmatic actions that can be taken now to redress the power imbalances between corporations and Australian governments and citizens. We begin by exploring how the terms of health policy making must change to protect it from conflicted commercial interests. We also examine how marketing unhealthy products and services can be more effectively regulated, and how healthier business practices can be incentivised. Finally, we make recommendations on how various public health stakeholders can hold corporations to account, to ensure that people come before profits in a healthy and prosperous future Australia. CHAPTER 6: DIGITAL DETERMINANTS OF HEALTH: THE DIGITAL TRANSFORMATION: We live in an age of rapid and exponential technological change. Extraordinary digital advancements and the fusion of technologies, such as artificial intelligence, robotics, the Internet of Things and quantum computing constitute what is often referred to as the digital revolution or the Fourth Industrial Revolution (Industry 4.0). Reflections on the future of public health and health promotion require thorough consideration of the role of digital technologies and the systems they influence. Just how the digital revolution will unfold is unknown, but it is clear that advancements and integrations of technologies will fundamentally influence our health and wellbeing in the future. The public health response must be proactive, involving many stakeholders, and thoughtfully considered to ensure equitable and ethical applications and use. CHAPTER 7: GOVERNANCE FOR HEALTH AND EQUITY: A VISION FOR OUR FUTURE: Coronavirus disease 2019 has caused many people and communities to take stock on Australia's direction in relation to health, community, jobs, environmental sustainability, income and wealth. A desire for change is in the air. This chapter imagines how changes in the way we govern our lives and what we value as a society could solve many of the issues Australia is facing - most pressingly, the climate crisis and growing economic and health inequities. We present an imagined future for 2030 where governance structures are designed to ensure transparent and fair behaviour from those in power and to increase the involvement of citizens in these decisions, including a constitutional voice for Indigenous peoples. We imagine that these changes were made by measuring social progress in new ways, ensuring taxation for public good, enshrining human rights (including to health) in legislation, and protecting and encouraging an independent media. Measures to overcome the climate crisis were adopted and democratic processes introduced in the provision of housing, education and community development.

Onslaught of COVID-19: How Did Governments React and at What Point of the Crisis?

The COVID-19 outbreak has taken many governments by surprise. While the crisis unfolds, it is instructive to explore how different governments reacted to the onslaught of an unknown disease. This research, using very recently collected and open-source data, meets this objective. The research reveals that, regarding 7 most commonly adopted preventive measures, governments have varied notably concerning their actions in relation to infection rate, disease rate, and timing of measures. The research also illustrates variations between governments for 6 countries: Australia, New Zealand, Spain, the United Kingdom, Italy, and the United States. As revealed in the summary independent-samples t test and Hedges' g values, both Oceanian countries (Australia and New Zealand) reacted differently compared to the other countries, which may have played a role in their low death and infection rates to date.