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Background Public health concerns relating to international investment liberalization have centred on the potential for investor-state dispute settlement (ISDS)-related regulatory chill. However, the broader political and economic dimensions that shape the relationship between the international investment regime and non-communicable disease (NCD) policy development have been less well explored. This review aimed to synthesise the available evidence using a political economy approach, to understand why, how and under what conditions transnational corporations may use the international investment regime to promote NCD prevention policy non-decisions. Main body Methods: Mechanisms explaining why/how the international investment regime may be used by transnational health-harmful commodity corporations (THCCs) to encourage NCD prevention policy non-decisions, including regulatory chill, were iteratively developed. Six databases and relevant grey literature was searched, and evidence was extracted, synthesized and mapped against the various proposed explanatory mechanisms. Findings: Eighty-nine sources were included. THCCs may be incentivised to use the ISDS mechanism since the costs may be outweighed by the benefits of even just delaying regulatory adoption, particularly since the chilling effect tends to ripple out across jurisdictions. Drivers of regulatory chill may include ambiguity in treaty terms, inconsistency in arbitral rulings, potential arbitrator bias and the high cost of arbitration. Evidence indicates ISDS can delay policy adoption both within the country directly involved but also in other jurisdictions. Additionally, governments are adopting standard assessments of public health regulatory proposals for trade and ISDS risk. Various economic, political and industry-related factors likely interact to increase (or decrease) the ultimate risk of regulatory chill. Some evidence indicates that THCCs take advantage of governments’ prioritization of foreign investment over NCD prevention objectives to influence the NCD prevention regulatory environment. Conclusions While ISDS-related regulatory chill is a real risk under certain conditions, international investment-related NCD prevention policy non-decisions driven by broader political economy dynamics may well be more widespread and impactful on NCD regulatory environments. There is therefore a clear need to expand the research agenda on investment liberalization and NCD policy beyond regulatory chill and engage with theories and approaches from international relations and political science, including political economy and power analyses.

Background While there is a growing body of legally-focused analyses exploring the potential restrictions on public health policy space due to international trade rules, few studies have adopted a more politically-informed approach. This paper applies an integrated political economy and power analysis approach to understand how power relations and dynamics emerging as a result of the international trade and investment regime influence nutrition and alcohol regulatory development in a case study of South Africa. Methods We interviewed 36 key stakeholders involved in nutrition, alcohol and/or trade/investment policymaking in South Africa. Interview transcripts and notes were imported into NVivo and analyzed using thematic analysis. We used a conceptual framework for analyzing power in health policymaking to guide the analysis. Results Under the neoliberal paradigm that promotes trade liberalization and market extension, corporate power in nutrition and alcohol policymaking has been entrenched in South Africa via various mechanisms. These include via close relationships between economic policymakers and industry; institutional structures that codify industry involvement in all policy development but restrict health input in economic and trade policy decisions; limited stakeholder knowledge of the broader linkages between trade/investment and food/alcohol environments; high evidentiary requirements to prove public health policy effectiveness; both deliberate use of neoliberal frames/narratives as well as processes of socialization and internalization of neoliberal ideas/values shaping perceptions and policy preferences and ultimately generating policy norms prioritizing economic/trade over health objectives. Conclusions Exposing power in policymaking can expand our own ideational boundaries of what is required to promote transformative policy change. This work points to a number of potential strategies for challenging corporate power in nutrition and alcohol policymaking in the context of international trade and investment liberalization in South Africa.

Background Trade and health scholars have raised concern that international trade and particularly investment disputes may be used by transnational health harmful commodity corporations (THCCs) to effectively generate public health regulatory chill. The purpose of this study was to contribute to the limited evidence base of trade or investment dispute-related regulatory chill using a case study of nutrition and alcohol policy in South Africa. Methods We conducted 35 semi-structured interviews with 36 key stakeholders involved in nutrition, alcohol and/or trade/investment policymaking in South Africa. Interview transcripts were analyzed using thematic analysis. We used Schram et al’s theory on three forms of regulatory chill (anticipatory, response and precedential) to guide the analysis. We report evidence on each form of regulatory chill as well as specific contextual factors that may influence the risk of regulatory chill. Results Trade obligations were found to generate a significantly greater anticipatory-type chilling effect on nutrition and alcohol regulation than South Africa’s investment treaty obligations. Response chill was reported to have occurred in relation to South Africa’s proposed tobacco plain packaging regulation while awaiting the outcome of both Australia’s investor-state and WTO state-state disputes. No cases were reported of THCCs threatening an investor-state dispute over nutrition or food regulations, but there were reported cases of THCCs using arguments related to South Africa’s trade obligations to oppose policy action in these areas. No evidence of nutrition or alcohol policy precedential chill were identified. Factors affecting the risk of policy chill include legitimacy and perceived bias of the dispute system, costs involved in pursuing a regulation/defending a dispute and capacity to pay, social acceptability of the industry, a product’s perceived risk to health and confidence in a successful dispute outcome e.g. through cross-border policy learning. Conclusions Our findings indicate that currently, South Africa’s trade obligations have a more prominent role in inhibiting nutrition and alcohol action than investment treaty-related concerns. However, given the potential for wider use of the ISDS mechanism by THCCs in the future, strategies to protect public health policy space in the context of both international trade and investment treaty and dispute settlement contexts remain important.

It is increasingly recognised within public health scholarship that policy change depends on the nature of the power relations surrounding and embedded within decision-making spaces. It is only through sustained shifts in power in all its forms (visible, hidden and invisible) that previously excluded perspectives have influence in policy decisions. Further, consideration of the underlying neoliberal paradigm is essential for understanding how existing power dynamics and relations have emerged and are sustained. In their analysis of political and governance factors, Townsend et al have provided critical insight into future potential strategies for increasing attention to health concerns in trade policy. In this commentary we explore how incorporating theories of power more rigorously into similar political analyses, as well as more explicit critical consideration of the neoliberal political paradigm, can assist in analysing if and how strategies can effectively challenge existing power relations in ways that are necessary for transformative policy change.

Lencucha and Thow tackle the enormous public health challenge of developing non-communicable disease (NCD) policy coherence within a world structured and ruled by neoliberalism. Their work compliments scholarship on other causal mechanisms, including the commercial determinants of health, that have contributed to creating the risk commodity environment and barriers to NCD prevention policy coherence. However, there remain significant gaps in the understanding of how these causal mechanisms interact within a whole system. As such, public health researchers’ suggestions for how to effectively prevent NCDs through addressing the risk commodity environment tend to remain fragmented, incomplete and piecemeal. We suggest this is, in part, because conventional policy analysis methods tend to be reductionist, considering causal mechanisms in relative isolation and conceptualizing them as linear chains of cause and effect. This commentary discusses how a systems thinking approach offers methods that could help with better understanding the risk commodity environment problem, identifying a more comprehensive set of effective solutions across sectors and its utility more broadly for gaining insight into how to ensure recommended solutions are translated into policy, including though transformation at the paradigmatic level.

Background: Complex interactions between political economy factors and corporate power are increasingly recognized to prevent transformative policy action on non-communicable disease (NCD) prevention. System science offers promising methods for analysing such causal complexity. This study uses qualitative system dynamics methods to map the political economy of diet-related NCD (DR-NCD) prevention policy-making aiming to better understand the policy inertia observed in this area globally. Methods: We interviewed 25 key policy actors. We analysed the interviews using purposive text analysis (PTA). We developed individual then combined casual loop diagrams to generate a shared model representing the DR-NCD prevention policy-making system. Key variables/linkages identified from the literature were also included in the model. We validated the model in several steps including through stakeholder validation interviews. Results: We identified several inter-linked feedback processes related to political economy factors that may entrench different forms of corporate power (instrumental, structural, and discursive) in DR-NCD prevention policy-making in South Africa over time. We also identified a number of feedback processes that have the potential to limit corporate power in this setting. Conclusion: Using complex system methods can be useful for more deeply understanding DR-NCD policy inertia. It is also useful for identifying potential leverage points within the system which may shift the existing power dynamics to facilitate greater political commitment for healthy, equitable, and sustainable food system transformation.

Billions of people worldwide lack access to surgical care; this is in part driven by severe shortages in the global surgical workforce. Task shifting, the movement of tasks to associate clinicians or non-specialist physicians, is a commonly implemented yet often contentious strategy to expand the surgical workforce. A more complete understanding of the global distribution and use of surgical and anaesthetic task shifting is needed to strengthen strategic planning efforts to bridge the gap between surgical and anaesthetic providers. We aimed to document the use of task shifting worldwide with an in-depth review of the literature and subsequent confirmation of practices through a provider survey. We did a literature search according to PRISMA guidelines. We searched PubMed, Embase, The Cochrane Library, CINAHL, WHOLIS, and five regional databases for journal articles published between Jan 1, 1995, and Aug 29, 2014, for titles or abstracts mentioning surgical or anaesthetic care provision by associate clinicians or non-specialist physicians. We also searched article references and online resources. We extracted data for health cadres performing task shifting, the types of tasks performed, training programmes, and supervision of those performing tasks and compared these across regions and income groups. Additionally, we then undertook an unvalidated survey to investigate the use of task shifting at the country level, which was sent to surgeons and anaesthetists in 19 countries across all major regions of the world. We identified 62 studies. The review and survey provided data for 163 and 51 countries respectively, totalling 174 countries. Surgical task shifting occured in 30 (33%) of 92 countries. Anaesthetic task shifting occured in 108 (65%) of 165 countries. Task shifting was documented across all World Bank income groups. Where relevant data were available, in high-income countries, associate clinicians were commonly supervised (100% [four countries] for surgery and 90% [20 countries] for anaesthesia). In low-income countries, associate clinicians undertook surgical and anaesthetic procedures without supervision (100% for surgery [five countries] and 100% for anaesthesia [22 countries]). Task shifting is used to augment the global surgical workforce across all geographical regions and income groups. Associate clinicians are ubiquitous among the global surgical workforce and should be considered in plans to scale up the surgical workforce in countries with workforce shortages. Reporting bias is likely to have favoured the more novel and successful task shifting initiatives, which could have caused our results to underestimate the absolute number of countries that use task shifting. Although surgical and anaesthetic task shifting has been described in many countries, further research is required to assess outcomes, especially in low-income and middle-income countries where supervision is less robust. None.

It is increasingly recognised within public health scholarship that policy change depends on the nature of the power relations surrounding and embedded within decision-making spaces. It is only through sustained shifts in power in all its forms (visible, hidden and invisible) that previously excluded perspectives have influence in policy decisions. Further, consideration of the underlying neoliberal paradigm is essential for understanding how existing power dynamics and relations have emerged and are sustained. In their analysis of political and governance factors, Townsend et al have provided critical insight into future potential strategies for increasing attention to health concerns in trade policy. In this commentary we explore how incorporating theories of power more rigorously into similar political analyses, as well as more explicit critical consideration of the neoliberal political paradigm, can assist in analysing if and how strategies can effectively challenge existing power relations in ways that are necessary for transformative policy change. Keywords: Health Policy, Power, Neoliberalism, Trade Policy Copyright: [C] 2022 The Author(s); Published by Kerman University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution License ( Citation: Milsom P, Smith R, Walls H. Expanding public health policy analysis for transformative change: the importance of power and ideas: Comment on \"What generates attention to health in trade policy-making? Lessons from success in tobacco control and access to medicines: a qualitative study of Australia and the (comprehensive and progressive) Trans-Pacific Partnership.\" Int J Health Policy Manag. 2022;11(4):521-524. doi:10.34172/ijhpm.2020.200

The role of community health workers (CHWs) in the West Africa Ebola outbreak has been highlighted to advocate for increasing numbers of CHWs globally to build resilience, strengthen health systems, and provide emergency response capacity. However, the roles CHWs played, the challenges they faced, and their effectiveness during the outbreak are not well documented. This study assessed the impact of Ebola on community-based maternal, newborn, and child health (MNCH) services, documented the contribution of CHWs and other community-based actors to the Ebola response, and identified lessons learned to strengthen resilience in future emergencies.BACKGROUNDThe role of community health workers (CHWs) in the West Africa Ebola outbreak has been highlighted to advocate for increasing numbers of CHWs globally to build resilience, strengthen health systems, and provide emergency response capacity. However, the roles CHWs played, the challenges they faced, and their effectiveness during the outbreak are not well documented. This study assessed the impact of Ebola on community-based maternal, newborn, and child health (MNCH) services, documented the contribution of CHWs and other community-based actors to the Ebola response, and identified lessons learned to strengthen resilience in future emergencies.This mixed methods study was conducted in Guinea, Liberia, and Sierra Leone, with data collected in four Ebola-affected districts of each country. Qualitative data were collected through in-depth interviews and focus group discussions with stakeholders at national, district, and community levels. Quantitative program data were used to assess trends in delivery of community-based MNCH services.METHODSThis mixed methods study was conducted in Guinea, Liberia, and Sierra Leone, with data collected in four Ebola-affected districts of each country. Qualitative data were collected through in-depth interviews and focus group discussions with stakeholders at national, district, and community levels. Quantitative program data were used to assess trends in delivery of community-based MNCH services.There was a sharp decline in MNCH service provision due to weak service delivery, confusion over policy, and the overwhelming nature of the outbreak. However, many CHWs remained active in their communities and were willing to continue providing services. When CHWs received clear directives and were supported, service provision rebounded. Although CHWs faced mistrust and hostility from community members because of their linkages to health facilities, the relationship between CHWs and communities proved resilient over time, and CHWs were more effectively able to carry out Ebola-related activities than outsiders. Traditional birth attendants, community health committees, community leaders, and traditional healers also played important roles, despite a lack of formal engagement or support. Service delivery weaknesses, especially related to supply chain and supervision, limited the effectiveness of community health services before, during, and after the outbreak.RESULTSThere was a sharp decline in MNCH service provision due to weak service delivery, confusion over policy, and the overwhelming nature of the outbreak. However, many CHWs remained active in their communities and were willing to continue providing services. When CHWs received clear directives and were supported, service provision rebounded. Although CHWs faced mistrust and hostility from community members because of their linkages to health facilities, the relationship between CHWs and communities proved resilient over time, and CHWs were more effectively able to carry out Ebola-related activities than outsiders. Traditional birth attendants, community health committees, community leaders, and traditional healers also played important roles, despite a lack of formal engagement or support. Service delivery weaknesses, especially related to supply chain and supervision, limited the effectiveness of community health services before, during, and after the outbreak.CHWs and other community-level actors played important roles during the Ebola outbreak. However, maintenance of primary care services and the Ebola response were hampered because community actors were engaged late in the response and did not receive sufficient support. In the future, communities should be placed at the forefront of emergency preparedness and response plans and they must be adequately supported to strengthen service delivery.CONCLUSIONSCHWs and other community-level actors played important roles during the Ebola outbreak. However, maintenance of primary care services and the Ebola response were hampered because community actors were engaged late in the response and did not receive sufficient support. In the future, communities should be placed at the forefront of emergency preparedness and response plans and they must be adequately supported to strengthen service delivery.

We write on behalf of 207 health professionals, academics, and researchers, and 25 health and human rights organisations from many countries (appendix). We wish to bring to the attention of The Lancet's readers alarming events taking place in Turkey, where the state has been waging a campaign of terror and punishment against thousands of health professionals and academics.