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AbstractThe consumption of harmful commodities drives the noncommunicable disease (NCD) epidemic globally and in Pacific small island developing states. Multisectoral committees are commonly chosen avenues to facilitate policy coherence across government sectors in regulating the commercial determinants of health (CDoH), but these committees often fail to function as intended. This paper aims to explore the institutional conditions that enable or constrain multisectoral committees in facilitating policy coherence for tobacco control in Fiji and Vanuatu. An exploratory, qualitative research design was applied, incorporating a two‐case study design with within‐case analysis and cross‐case synthesis. Data collection consisted of 70 in‐depth interviews in 2018 and 2019. Data collection and analysis were informed by an analytical framework drawn from the institutional collective action framework. The results show that the current amount of authority behind the investigated multisectoral committees in Fiji and Vanuatu is inadequate to meaningfully bring stakeholders together for an issue with high complexity. Moreover, multisectoral discussions on tobacco control have a high risk to break down, as the collaboration may generate unwanted impacts to one or more actors and the net benefits are perceived to be low. The authority behind multisectoral committees might be strengthened by the chairmanship of a cross‐sectoral, high‐level government official and the allocation of more resources for managing intersectoral engagement. Divergent preferences might be brought closer together by showcasing the socioeconomic costs of NCDs and policies affecting the availability, affordability, accessibility, and desirability of tobacco and raising awareness about CDoH in nonhealth sectors.

AbstractMultisectoral governance has been recognized to be vital to regulate harmful commodity industries, yet countries struggle with reaching policy coherence due to government agencies' conflicting mandates and industry interference. Limited empirical evidence is available on how interests, ideas, and institutions intersect and influence multisectoral governance in low‐ and middle‐income countries, particularly in Pacific small island developing states (PSIDS), often exploited by vested industry interests and whose non‐communicable disease crisis commands urgent action to regulate harmful commodities. This study assessed the ways interests, ideas, and institutions intersect and shape multisectoral tobacco governance in PSIDS. Interviewee data collected in Fiji and Vanuatu show that the idea of individual responsibility, the limited recognition of commercial determinants of health, the centralization of authority, and the vulnerabilities of small island developing states, (including small population, land, economy, geographic isolation, and status as a developing economy), prevent these states from achieving policy coherence in multisectoral tobacco governance.

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.

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.

AbstractThe growing number of public policy measures challenged through investor‐state dispute settlement has raised critiques that international investment agreements could lead governments to avoid introducing new policy measures out of a fear that these could be challenged by foreign investors, often referred to as 'regulatory chill'. While the body of work on regulatory chill is still in its infancy, there is a need to interrogate extant studies to better understand the state of the knowledge and the methodological approaches being employed to produce an evidence base. Grounded in a critical review of the existing literature, this paper develops a conceptual framework of regulatory chill, identifying it as one possible policy response wherein investment agreements are internalised by policy makers as considerations during their policy decision‐making. Three distinct bodies of work were identified in the literature which helped to populate this framework, including analysis of investment treaty language and awards, interviews with policy makers to explore internalisation of such treaties, and case studies of suspected regulatory chill policy responses. The conceptual framework is intended to help drive forward a cohesive research agenda on regulatory chill that can underpin the ongoing investment treaty reform.

AbstractInequities 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.

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.

Background:Insufficient progress has been made towards reducing health inequities, due in part to a lack of action on the root causes of health inequities. At present, there is a limited evidence base to guide policy decision making in this space.
Key points for discussion:This paper proposes new principles for researchers to conduct health equity policy evaluation. Four key principles are presented: (1) where to evaluate – shifting from familiar to unfamiliar terrain; (2) who to evaluate – shifting from structures of vulnerability to structures of privilege; (3) what to evaluate – shifting from simple figures to complex constructs; and (4) how to evaluate – shifting from 'gold standard' to more appropriate 'fit-for-purpose' designs. These four principles translate to modifying the policy domains investigated, the populations targeted, the indicators selected, and the methods employed during health equity policy evaluation. The development and implementation of these principles over a five-year programme of work is demonstrated through case studies which reflect the principles in practice.
Conclusions and implications:The principles are shared to encourage other researchers to develop evaluation designs of sufficient complexity that they can advance the contribution of health equity policy evaluation to structural policy reforms. As a result, policies and actions on the social determinants of health might be better oriented to achieve the redistribution of power and resources needed to address the root causes of health inequities.