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This article argues that health outcomes, specifically nutrition related health outcomes, are socially determined, and can be linked to a wider political economy in which peoples' dietary consumption is structurally determined, evolving from political, economic and social forces. The article examines trade and investment agreements as regulatory vehicles that cultivate poor dietary consumption and inequalities in health outcomes between and within countries. How does this happen? The liberalization of trade and investment, and unfettered influence of powerful economic interests including transnational food and beverage companies has resulted in trade agreements that enable excess availability, affordability and acceptability of highly processed, nutrient poor foods worldwide, ultimately resulting in poor nutrition and consequently oral and other non-communicable diseases. These trade and nutrition policy tensions shine a spotlight on the challenges ahead for global health and development policies, including achievement of the Sustainable Development Goals.

The emerging global trade and investment regime is a site of ongoing contestation between states, powerful industry actors and civil society organisations seeking to infuence the formation of legal rules, principles, practices and institutions. The inclusion of major transnational tobacco, alcohol and ultraprocessed food companies seeking to influence governments in these processes has resulted in the expanded distribution and consumption of unhealthy commodities across the globe, overshadowing many of the positive impacts for health hypothesised from liberalised trade. The growing number of pathways for market actors to exert undue influence over national and international regulatory environments provided by agreements, such as the Comprehensive and Progressive Agreement for Trans-Pacific Partnership, has given many cause to be concerned. In the context of continued commitment by states to international trade and investment negotiations, we present several avenues for public health scholars, advocates and practitioners to explore to rebalance public and private interests in these deals.

Critical social and economic resources, such as employment, education, and health services, increasingly require online access, highlighting the growing need to address equity of access to high-speed broadband telecommunications. Ensuring access to broadband requires the necessary infrastructure which, in Australia, is the National Broadband Network (NBN). In this paper, we use policy implementation theory to examine the translation of the government's NBN policy into service delivery, specifically in relation to the choice of policy instruments to install the broadband infrastructure, the associated barriers and enablers to their implementation, and the equity considerations that are emerging as the policy is implemented. We conducted a rapid review of NBN policy documents and academic and grey literature to map the NBN policy instruments and to examine how key contextual, political, and technical aspects of NBN policy implementation are likely to affect equity. Our findings indicate a range of equity concerns in the implementation of NBN policy. The instrument choice of a public–private 'hybrid' organisation to implement NBN policy has created a fertile ground for competing political, social, and commercial priorities, thereby affecting how the policy is implemented and thus increasing the risks to equity as it competes with other priorities. As these mixed public–private instruments become more prevalent as policy tools to deliver major infrastructure, determining the best means to safeguard equity is a vital consideration to ensure the benefits are distributed fairly.

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.

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.

Purpose and setting: Infrastructure is a global multi-trillion dollar market presenting many opportunities and risks for sustainable development. This article aims to foster better conceptualisation of the connections and tensions between infrastructure policy and public health in the light of the Sustain-able Development Goals, especially 'good health and wellbeing' (number 3) and 'industry, innovation and infrastructure' (number 9), based on findings from interviews with a purposive sample of senior practicing Australian infrastructure policy makers. Principal findings: We use an institutional framework to explore the ideas, actors, rules and mandates, and procedures underpinning the inclusion of health in infrastructure policy. Informants defined infrastructure as the construction and provision of services that facilitate economic, environmental and social outcomes. The tendency to default to infrastructure as essential for economic success has fundamental challenges for the SDGs, particularly the politically driven pursuit of 'mega-project' legacies, sector-specific siloed governance arrangements, and inadequate conceptualisations of costs and benefits. Conclusions: Public health and infrastructure policy are mutually re-enforcing given they both concern the public interest with implications for all 17 SDGs. Positioning health and wellbeing as fundamental societal outcomes from infrastructure decisions would go a long way to helping achieve the SDGs. ; This research was funded by a Sydney University Kickstart Grant, funded by the Balnaves Foundation. Patrick Harris is funded by an Australian National Health and Medical Research Council Fellowship (APP1090644).

OBJECTIVE: While there is urgent need for policymaking that prioritises health equity, successful strategies for advancing such an agenda across multiple policy sectors are not well known. This study aims to address this gap by identifying successful strategies to advance a health equity agenda across multiple policy domains. DESIGN: We conducted in-depth qualitative case studies in three important social determinants of health equity in Australia: employment and social policy (Paid Parental Leave); macroeconomics and trade policy (the Trans Pacific Partnership agreement); and welfare reform (the Northern Territory Emergency Response). The analysis triangulated multiple data sources included 71 semistructured interviews, document analysis and drew on political science theories related to interests, ideas and institutions. RESULTS: Within and across case studies we observed three key strategies used by policy actors to advance a health equity agenda, with differing levels of success. The first was the use of multiple policy frames to appeal to a wide range of actors beyond health. The second was the formation of broad coalitions beyond the health sector, in particular networking with non-traditional policy allies. The third was the use of strategic forum shopping by policy actors to move the debate into more popular policy forums that were not health focused. CONCLUSIONS: This analysis provides nuanced strategies for agenda-setting for health equity and points to the need for multiple persuasive issue frames, coalitions with unusual bedfellows, and shopping around for supportive institutions outside the traditional health domain. Use of these nuanced strategies could generate greater ideational, actor and institutional support for prioritising health equity and thus could lead to improved health outcomes.

Objective: The current short communication aimed to provide a new conceptualisation of the policy drivers of inequities in healthy eating and to make a call to action to begin populating this framework with evidence of actions that can be taken to reduce the inequities in healthy eating. Design: The Healthy and Equitable Eating (HE2) Framework derives from a systems-based analytical approach involving expert workshops. Setting: Australia. Subjects: Academics, government officials and non-government organisations in Australia. Results: The HE2 Framework extends previous conceptualisations of policy responses to healthy eating to include the social determinants of healthy eating and its social distribution, encompassing policy areas including housing, social protection, employment, education, transport, urban planning, plus the food system and environment. Conclusions: As the burden of non-communicable diseases continues to grow globally, it is important that governments, practitioners and researchers focus attention on the development and implementation of policies beyond the food system and environment that can address the social determinants of inequities in healthy eating. ; This research was supported by The Australian Prevention Partnership Centre through the National Health and Medical Research Council Partnership Centre grant scheme (grant number GNT9100001) with the Australian Government Department of Health, the NSW Ministry of Health, ACT Health and the HCF Research Foundation. At the time of the research, M.C. and E.M. were working for the NSW Ministry of Health and J.G. was working for the ACT Government, who are funders of The Australian Prevention Partnership Centre.

The commercial determinants of health (CDoH) describe the adverse health effects associated with for-profit actors and their actions. Despite efforts to advance the definition, conceptualization, and empirical analyses of CDoH, the term's practical application to mitigate these effects requires the capacity to measure the influences of specific components of CDoH and the cumulative impacts of CDoH on the health and well-being of specific populations. Building on the Global Burden of Disease Study, we begin by conceptualizing CDoH as risk factor exposures that span agency and structural influences. We identify 6 components of these influences and propose an initial set of indicators and datasets to rank exposures as high, medium, or low. These are combined into a commercial determinants of health index (CDoHi) and illustrated by 3 countries. Although now a proof of concept, comparative analysis of CDoH exposures by population, over time and space, and their associated health outcomes will become possible with further development of indicators and datasets. Expansion of the CDoHi and application to varied populations groups will enable finer targeting of interventions to reduce health harms. The measurement of improvements to health and wellness from such interventions will, in turn, inform overall efforts to address the CDoH.