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The international conference 'Closing the gap in a generation: health equity through action on the social determinants of health', November 2008 (1) was a global call to action – a call to develop and implement public policies, private sector responsibility and social action that put health equity as a central goal. Over the course of two days politicians, senior public servants, leaders of international organisations, civil society activists and academics, fromall regions of the world, discussed the issues, conclusions and recommendations made by the Commission on Social Determinants of Health (CSDH)(2). The CSDH was set up in 2005 by the World Health Organization (WHO) as a major global effort to address health inequity between and within countries (3). Its final report was presented to Dr Margaret Chan, Director General of WHO in August 2008. Here we describe the key issues debated at the November conference and outline a global research, training and policy agenda for health equity.

AbstractIndigenous peoples in Australia and similar colonised countries are subject to racism and systemic socioeconomic disadvantages, resulting in worse health outcomes compared to non‐Indigenous counterparts. Such inequities persist despite governments' attempts to reduce them. Since 2008, Australian governments have committed to a national 'Closing the Gap' (CTG) to reduce inequities in health, education, and employment outcomes between Aboriginal and Torres Strait Islander peoples and other Australians, but with limited success. We applied policy theory and a cultural safety framework developed for the research to analyse stakeholder perceptions of CTG policy implementation between 2008 and 2019. We identified policy‐shaping ideas and policy incoherence in the environment surrounding CTG policy that obstructed culturally safe policy. Top‐down, prescriptive modes of implementation were also a barrier. However, Indigenous‐led policy partnerships and community‐controlled services in the health sector have met principles of cultural safety. Identifying these strengths and weaknesses points to ways in which implementation of CTG policies can be improved to achieve cultural safety and reduce Indigenous health inequities. These results may hold lessons for similar countries such as the United States, New Zealand, and Canada.

Background: Despite greater attention to the nexus between trade and investment agreements and their potential impacts on public health, less is known regarding the political and governance conditions that enable or constrain attention to health issues on government trade agendas. Drawing on interviews with key stakeholders in the Australian trade domain, this article provides novel insights from policy actors into the range of factors that can enable or constrain attention to health in trade negotiations. Methods: A qualitative case study was chosen focused on Australia's participation in the Trans-Pacific Partnership (TPP) negotiations and the domestic agenda-setting processes that shaped the government's negotiating mandate. Process tracing via document analysis of media reporting, parliamentary records and government inquiries identified key events during Australia's participation in the TPP negotiations. Semi-structured interviews were undertaken with 25 key government and non-government policy actors including Federal politicians, public servants, representatives from public interest nongovernment organisations and industry associations, and academic experts. Results: Interviews revealed that domestic concerns for protecting regulatory space for access to generic medicines and tobacco control emerged onto the Australian government's trade agenda. This contrasted with other health issues like alcohol control and nutrition and food systems that did not appear to receive attention. The analysis suggests sixteen key factors that shaped attention to these different health issues, including the strength of exporter interests; extent of political will of Trade and Health Ministers; framing of health issues; support within the major political parties; exogenous influencing events; public support; the strength of available evidence and the presence of existing domestic legislation and international treaties, among others. Conclusion: These findings aid understanding of the factors that can enable or constrain attention to health issues on government trade agendas, and offer insights for potential pathways to elevate greater attention to health in future. They provide a suite of conditions that appear to shape attention to health outside the biomedical health domain for further research in the commercial determinants of health. ; This work was supported by the Australian NHMRC Centre of Research Excellence on the Social Determinants of Health Equity: Policy research on the social determinants of health equity (APP1078046).

How health advocates and industry actors attempt to assert their authority as a strategy of influence in policymaking remains underexplored in the health governance literature. Greater exploration of the kinds of authority sources used by health actors vis-à-vis market actors and the role ideational factors may play in shaping access to these sources provides insight into advocates' efforts to exert influence in policy forums. Using the trade domain in Australia as a case study of the way in which the commercial determinants of health operate, we examined the different ways in which health, public interest and market actors assert their authority. Drawing on a political science typology of authority, we analysed 87 submissions to the Australian government during the Trans-Pacific Partnership negotiations. We identify four types of authority claims; institutional authority, derived from holding a position of influence within another established institution; legal authority through appeals to legal agreements and precedents; networked authority through cross-referencing between actors, and expert authority through use of evidence. Combining these claims with a framing analysis, we found that these bases of authority were invoked differently by actors who shared the dominant neoliberal ideology in contrast to those actors that shared a public interest discourse. In particular, market actors were much less likely to rely on external sources of authority, while health and public interest actors were more likely to appeal to networked and expert authority. We argue that actors who share strong ideational alignment with the dominant policy discourse appear less reliant on other sources of authority. Implications of this analysis include the need for greater attention to the different strategies and ideas used by industry and public health organisations in trade policy agenda-setting for health, which ultimately enable or constrain the advancement of health on government agendas. ; This work was supported by the National Health and Medical Research Council (NHMRC) Centre for Research Excellence in the Social Determinants of Health Equity: Policy research on the social determinants of health equity (APP1078046).

Inequities in access to fast and reliable internet connections, essential for digital access to services and information that are important for health, can exacerbate social inequalities in health. We evaluated the social equity of the rollout of the National Broadband Network (NBN) in Australia based on the type of digital infrastructure delivered to areas of varying socioeconomic status. We found that areas of greater socioeconomic disadvantage were significantly less likely to receive the highest quality infrastructure, controlling for level of remoteness. These social inequities in provision of quality infrastructure will shape and possibly exacerbate inequities in health. In our discussion we consider how political decisions have obstructed equitable implementation of the policy. Lessons from the Australian case study may be valuable for other countries investing in public digital infrastructure who want to ensure equity of provision and can also inform Australian policy in the NBN's remaining rollout. ; This study is part of a wider National Health and Medical Research Council funded Centre for Research Excellence in the Social Determinants of Health Equity (APP1078046) examining the policy cycle in areas that shape the distribution of power, money, and resources that affect people's daily living conditions, including infrastructure policy, and the implications for health equity.

AbstractHealth in All Policies is an approach that seeks to strengthen public policy‐making across health and other sectors in order to achieve the most favourable health impacts. There is currently interest in understanding how Health in All Policies is applied in different contexts; whether it makes a difference to policy practices, health outcomes and health equity; and what is required to equip the different sectors to work effectively to improve the health equity impacts of their policies. This article presents findings from a review of domestic policies and practices of Health in All Policies in countries across the World Health Organization Western Pacific Region. The findings illustrate that there is a strong foundation for action, particularly given prior intersectoral action and the important convening point that issues like non‐communicable diseases and transport provide for Health in All Policies within the Western Pacific Region. However, the consideration of health equity in Health in All Policies needs more explicit attention. This knowledge can be used for building capacity within the health sector and other sectors to undertake sustainable and effective intersectoral collaboration for improved health equity.

Objective: Despite the importance of the charitable food sector for a proportion of the Australian population, there is uncertainty about its present and future contributions to wellbeing. This paper describes its nature and examines its scope for improving health and food security. Methods: The review, using systematic methods for public health research, identified peer-reviewed and grey literature relevant to Australian charitable food programs (2002 to 2012). Results: Seventy publications met the criteria and informed this paper. The sector includes food banks, more than 3,000 community agencies and 800 school breakfast programs. It provides food for up to two million people annually. The scope extends beyond emergency food relief and includes case management, advocacy and other support. Weaknesses include a food supply that is sub-optimal, resource limitations and lack of evidence to evaluate or support their work towards food security. Conclusions: The sector supports people experiencing disadvantage and involves multiple organisations, working in a variety of settings, to provide food for up to 8% of the population. The limits on the sector's capacity to address food insecurity by itself must be acknowledged so that civil society, government and the food industry can support sufficient, nutritious and affordable food for all.

Objective To develop a policy formulation tool for strategically informing food and nutrition policy activities to promote healthy and sustainable diets (HSD). Design A policy formulation tool consisting of two complementary components was developed. First, a conceptual framework of the environment-public health nutrition relationship was constructed to characterise and conceptualise the food system problem. Second, an 'Orders of Food Systems Change' schema drawing on systems dynamics thinking was developed to identify, assess and propose policy options to redesign food systems. Setting Food and nutrition policy activities to promote HSD have been politicised, fragmented and lacking a coherent conceptual and strategic focus to tackle complex food system challenges. Results The tool's conceptual framework component comprises three integrated dimensions: (i) a structure built around the environment and public health nutrition relationship that is mediated via the food system; (ii) internal mechanisms that operate through system dynamics; and (iii) external interactions that frame its nature and a scope within ecological parameters. The accompanying schema is structured around three orders of change distinguished by contrasting ideological perspectives on the type and extent of change needed to 'solve' the HSD problem. Conclusions The conceptual framework's systems analysis of the environment-public health nutrition relationship sets out the food system challenges for HSD. The schema helps account for political realities in policy making and is a key link to operationalise the framework's concepts to actions aimed at redesigning food systems. In combination they provide a policy formulation tool to strategically inform policy activities to redesign food systems and promote HSD.

Objective: Despite the importance of the charitable food sector for a proportion of the Australian population, there is uncertainty about its present and future contributions to wellbeing. This paper describes its nature and examines its scope for improving health and food security. Methods: The review, using systematic methods for public health research, identified peer-reviewed and grey literature relevant to Australian charitable food programs (2002 to 2012). Results: Seventy publications met the criteria and informed this paper. The sector includes food banks, more than 3,000 community agencies and 800 school breakfast programs. It provides food for up to two million people annually. The scope extends beyond emergency food relief and includes case management, advocacy and other support. Weaknesses include a food supply that is sub-optimal, resource limitations and lack of evidence to evaluate or support their work towards food security. Conclusions: The sector supports people experiencing disadvantage and involves multiple organisations, working in a variety of settings, to provide food for up to 8% of the population. The limits on the sector's capacity to address food insecurity by itself must be acknowledged so that civil society, government and the food industry can support sufficient, nutritious and affordable food for all.

Objective To develop a policy formulation tool for strategically informing food and nutrition policy activities to promote healthy and sustainable diets (HSD). Design A policy formulation tool consisting of two complementary components was developed. First, a conceptual framework of the environment-public health nutrition relationship was constructed to characterise and conceptualise the food system problem. Second, an 'Orders of Food Systems Change' schema drawing on systems dynamics thinking was developed to identify, assess and propose policy options to redesign food systems. Setting Food and nutrition policy activities to promote HSD have been politicised, fragmented and lacking a coherent conceptual and strategic focus to tackle complex food system challenges. Results The tool's conceptual framework component comprises three integrated dimensions: (i) a structure built around the environment and public health nutrition relationship that is mediated via the food system; (ii) internal mechanisms that operate through system dynamics; and (iii) external interactions that frame its nature and a scope within ecological parameters. The accompanying schema is structured around three orders of change distinguished by contrasting ideological perspectives on the type and extent of change needed to 'solve' the HSD problem. Conclusions The conceptual framework's systems analysis of the environment-public health nutrition relationship sets out the food system challenges for HSD. The schema helps account for political realities in policy making and is a key link to operationalise the framework's concepts to actions aimed at redesigning food systems. In combination they provide a policy formulation tool to strategically inform policy activities to redesign food systems and promote HSD.

OBJECTIVE: Maximising synergies and minimising conflicts (i.e. building policy coherence) between trade and nutrition policy is an important objective. One understudied driver of policy coherence is the alignment in the frames, discourses and values of actors involved in the respective sectors. In the present analysis, we aim to understand how such actors interpret (i.e. 'frame') nutrition and the implications for building trade–nutrition policy coherence. DESIGN: We adopted a qualitative single case study design, drawing on key informant interviews with those involved in trade policy. SETTING: We focused on the Australian trade policy sub-system, which has historically emphasised achieving market growth and export opportunities for Australian food producers. PARTICIPANTS: Nineteen key informants involved in trade policy spanning the government, civil society, business and academic sectors. RESULTS: Nutrition had low 'salience' in Australian trade policy for several reasons. First, it was not a domestic political priority in Australia nor among its trading partners; few advocacy groups were advocating for nutrition in trade policy. Second, a 'productivist' policy paradigm in the food and trade policy sectors strongly emphasised market growth, export opportunities and deregulation over nutrition and other social objectives. Third, few opportunities existed for health advocates to influence trade policy, largely because of limited consultation processes. Fourth, the complexity of nutrition and its inter-linkages with trade presented difficulties for developing a 'broader discourse' for engaging the public and political leaders on the topic. CONCLUSIONS: Overcoming these 'ideational challenges' is likely to be important to building greater coherence between trade and nutrition policy going forward. ; Financial support: P.B. was supported by an Alfred Deakin Post-Doctoral Research Fellowship from Deakin University. This project was supported by funding from an Australian Research Council Discovery Project, 'Trade policy: Maximising benefits for nutrition, food security, human health, and the economy' (DP130101478).

AbstractDeindustrialisation and the closure of automotive manufacturing can differentially affect the socioeconomic prospects of workers and their communities, and contribute to social and health inequity. We used Bacchi's problematisation approach to examine the South Australian (SA) Labor government's policy responses to the General Motors Holden (GMH) Elizabeth plant closure announcement. We focused on the way that these policy responses framed the 'problem' of this major economic shock, particularly the extent to which potential social and health equity consequences were addressed. We found a narrow focus on economic strategies, neglecting the compounding impact of poverty in Playford, which may exacerbate health inequity. The community effects from the GMH closure remain uncertain and may be delayed for several years. SA requires better integrated social and economic policies to minimise social and health inequalities, as the consequences of the car manufacturing loss are realised.