Competing Frames in Global Health Governance: An Analysis of Stakeholder Influence on the Political Declaration on Non-communicable Diseases

Document Type : Original Article

Authors

1 Department of Political Science and International Relations, University of Southern California, Los Angeles, CA, USA

2 HIV, Health and Development Group, Bureau for Policy and Programme Support, United Nations Development Programme, New York City, NY, USA

Abstract

Background
Non-communicable diseases (NCDs) are increasingly recognized as a significant threat to health and development globally, and United Nations (UN) Member States adopted the Political Declaration of the Third High-level Meeting (HLM) on the prevention and control of NCDs in 2018. The negotiation process for the Declaration included consultations with Member States, intergovernmental organizations (IGOs), and non-state actors such as non-governmental organizations (NGOs) and the private sector. With NCD responses facing charges of inadequacy, it is important to scrutinize the governance process behind relevant high-level global decisions and commitments.
 
Methods
Through a review of 159 documents submitted by stakeholders during the negotiation process, we outline a typology of policy positions advocated by various stakeholders in the development of the Declaration. We document changes in text from the draft to the final version of the Declaration to analyse the extent to which various positions and their proponents were influential.
 
Results
NGOs and low- and middle-income countries (LMICs) generally pursued ‘stricter’ governance of NCD risk factors including stronger regulation of unhealthy products and improved management of conflicts of interest that arise when health-harming industries are involved in health policy-making. The private sector and high-income countries generally opposed greater restrictions on commercial factors. The pattern of changes between the draft and final Declaration indicate that advocated positions tended to be included in the Declaration if there was no clear opponent, whereas opposed positions were either not included or included with ambiguous language.
 
Conclusion
Many cost-effective policy options to address NCDs, such as taxation of health-harming products, were opposed by high-income countries and the private sector and not well-represented in the Declaration. To ensure robust political commitments and action on NCDs, multi-stakeholder governance for NCDs must consider imbalances in power and influence amongst constituents as well as biases and conflicts in positioning.

Keywords


  1. United Nations (UN). Political declaration of the third high-level meeting of the General Assembly on the prevention and control of non-communicable diseases. https://www.un.org/en/ga/search/view_doc.asp?symbol=A/RES/73/2.  Accessed September 9, 2019.
  2. Buse K, Tanaka S, Hawkes S. Healthy people and healthy profits? Elaborating a conceptual framework for governing the commercial determinants of non-communicable diseases and identifying options for reducing risk exposure. Global Health. 2017;13(1):1-12. doi:10.1186/s12992-017-0255-3
  3. United Nations (UN). Scope and modalities of the comprehensive review and assessment of the progress achieved in the prevention and control of non-communicable diseases. https://www.un.org/en/ga/search/view_doc.asp?symbol=A/RES/68/271. Accessed February 22, 2020.
  4. Lieberman A. UN meeting on NCDs falls short on hard commitments, civil society say. Devex. September 28, 2018. https://www.devex.com/news/un-meeting-on-ncds-falls-short-on-hard-commitments-civil-society-say-93547.  Accessed September 11, 2020.
  5. Horton R. Offline: NCDs—why are we failing? Lancet. 2017;390(10092):346. doi:10.1016/S0140-6736(17)31919-0
  6. United Nations (UN). Transforming our world: the 2030 Agenda for Sustainable Development. https://www.un.org/en/ga/search/view_doc.asp?symbol=A/RES/70/1. Accessed February 22, 2020.
  7. Casswell S. Addressing NCDs: Penetration of the producers of hazardous products into global health environment requires a strong response: Comment on “addressing NCDs: Challenges from industry market promotion and interferences.” Int J Health Policy Manag. 2019;8(10):607-609. doi:10.15171/ijhpm.2019.52
  8. Whitaker K, Webb D, Linou N. Commercial influence in control of non-communicable diseases. BMJ. 2018;360:k110. doi:10.1136/bmj.k110
  9. Stuckler D, Basu S, McKee M. Commentary: UN high level meeting on non-communicable diseases: An opportunity for whom? BMJ. 2011;343:d5336. doi:10.1136/bmj.d5336
  10. Lincoln P, Rundall P, Jeffery B, et al. Conflicts of interest and the UN high-level meeting on non-communicable diseases. Lancet. 2011;378(9804):e6. doi:10.1016/S0140-6736(11)61463-3
  11. Anon. Down from the UN NCD summit. The right road. World Nutr. 2011;2(9):458-464.
  12. Collin J, Hill SE, Eltanani MK, Plotnikova E, Ralston R, Smith KE. Can public health reconcile profits and pandemics? An analysis of attitudes to commercial sector engagement in health policy and research. PLoS One. 2017;12(9):e0182612. doi:10.1371/journal.pone.0182612
  13. Moodie R, Stuckler D, Monteiro C, et al. Profits and pandemics: Prevention of harmful effects of tobacco, alcohol, and ultra-processed food and drink industries. Lancet. 2013;381(9867):670-679. doi:10.1016/S0140-6736(12)62089-3
  14. Gilmore AB, Savell E, Collin J. Public health, corporations and the New Responsibility Deal: Promoting partnerships with vectors of disease? J Public Health (Oxf). 2011;33(1):2-4. doi:10.1093/pubmed/fdr008
  15. Garnett K, Van Calster G, Reins L. Towards an innovation principle: an industry trump or shortening the odds on environmental protection? Law, Innov Technol. 2018;10(1):1-14. doi:10.1080/17579961.2018.1455023
  16. Walshe K, McKee M, McCarthy M, et al. Health systems and policy research in Europe: Horizon 2020. Lancet. 2013;382(9893):668-669. doi:10.1016/S0140-6736(12)62195-3
  17. Galsworthy MJ, Palumbo L, McKee M. Has Big Pharma hijacked the European health research budget? Lancet. 2014;383(9924):1210. doi:10.1016/S0140-6736(14)60232-4
  18. United Nations (UN). DRAFT Political Declaration of the third high-level meeting of the General Assembly on the prevention and control of non-communicable diseases. https://www.un.org/pga/72/wp-content/uploads/sites/51/2018/06/NCD-8-June.pdf. Accessed September 9, 2019.
  19. World Health Organization (WHO). UN Interactive Hearing on NCDs. http://www.who.int/ncds/governance/third-un-meeting/interactive-hearing/en/.  Accessed September 9, 2019.
  20. World Health Organization (WHO). Third United Nations High-level Meeting on NCDs. http://www.who.int/ncds/governance/third-un-meeting/en/. Accessed September 9, 2019.
  21. Rushton S, Williams OD. Frames, paradigms and power: global health policy-making under neoliberalism. Glob Soc. 2012;26(2):147-167. doi:10.1080/13600826.2012.656266
  22. Labonté R, Gagnon ML. Framing health and foreign policy: lessons for global health diplomacy. Global Health. 2010;6:14. doi:10.1186/1744-8603-6-14
  23. Koon AD, Hawkins B, Mayhew SH. Framing and the health policy process: A scoping review. Health Policy Plan. 2016;31(6):801-816. doi:10.1093/heapol/czv128
  24. Lencucha R, Thow AM. How neoliberalism is shaping the supply of unhealthy commodities and what this means for NCD prevention. Int J Heal Policy Manag. 2019;8(9):514-520. doi:10.15171/ijhpm.2019.56
  25. Freudenberg, N. Lethal but Legal; Corporations, Consumption and Protecting Public Health. Oxford: Oxford University Press; 2014.
  26. Battams S, Townsend B. Power asymmetries, policy incoherence and noncommunicable disease control - a qualitative study of policy actor views. Crit Public Health. 2019;29(5):596-609. doi:10.1080/09581596.2018.1492093
  27. Weishaar H, Dorfman L, Freudenberg N, et al. Why media representations of corporations matter for public health policy: A scoping review. BMC Public Health. 2016;16(1):899. doi:10.1186/s12889-016-3594-8
  28. United Nations (UN). Scope, modalities, format and organization of the third high-level meeting of the General Assembly on the prevention and control of non-communicable diseases. https://digitallibrary.un.org/record/1483206/files/A_RES_72_274-EN.pdf.  Accessed September 11, 2020.
  29. United Nations (UN). Draft Political Declaration of the third high-level meeting of the General Assembly on the prevention and control of non-communicable diseases (dated September 18, 2018). https://www.un.org/pga/73/wp-content/uploads/sites/53/2018/09/PGA-letter-NCDs-political-declaration-silence-procedure-002-002-18-September.pdf.  Accessed September 7, 2020.
  30. Alleyne G, Nishtar S. Sectoral cooperation for the prevention and control of NCDs. In: Galambos L, Sturchio J, eds. Noncommunicable Diseases in the Developing World: Addressing Gaps in Global Policy and Research. Baltimore: Johns Hopkins University Press; 2014;133-151.
  31. World Health Organization (WHO). Tackling NCDs: "Best buys" and other recommended interventions for the prevention and control of noncommunicable diseases. https://www.who.int/ncds/management/best-buys/en/.  Accessed September 9, 2019.
  32. Townsend B, Schram A, Baum F, Labonté R, Friel S. How does policy framing enable or constrain inclusion of social determinants of health and health equity on trade policy agendas? Crit Public Health. 2020;30(1):115-126. doi:10.1080/09581596.2018.1509059
  33. Tangcharoensathien V, Chandrasiri O, Kunpeuk W, Markchang K, Pangkariya N. Addressing NCDs: challenges from industry market promotion and interferences. Int J Heal Policy Manag. 2019;8(5):256-260. doi:10.15171/ijhpm.2019.02
  34. Hawkins B, Holden C, Eckhardt J, Lee K. Reassessing policy paradigms: A comparison of the global tobacco and alcohol industries. Glob Public Health. 2018;13(1):1-19. doi:10.1080/17441692.2016.1161815
  35. Fooks GJ, Williams S, Box G, Sacks G. Corporations’ use and misuse of evidence to influence health policy: A case study of sugar-sweetened beverage taxation. Global Health. 2019;15(1):56. doi:10.1186/s12992-019-0495-5
  36. Nguyen KH, Glantz SA, Palmer CN, Schmidt LA. Tobacco industry involvement in children’s sugary drinks market. BMJ. 2019;364:1736. doi:10.1136/bmj.l736
  37. Granheim IS, Engelhardt K, Rundall P, Bialous S, Iellamo A, Margetts B. Interference in public health policy: examples of how the baby food industry uses tobacco industry tactics. World Nutr. 2017;8(2):288-310. doi:10.26596/wn.201782288-310
  38. Tselengidis A, Östergren PO. Lobbying against sugar taxation in the European Union: Analysing the lobbying arguments and tactics of stakeholders in the food and drink industries. Scand J Public Health. 2019;47(5):565-575. doi:10.1177/1403494818787102
  39. Mialon M, Swinburn B, Allender S, Sacks G. Systematic examination of publicly available information reveals the diverse and extensive corporate political activity of the food industry in Australia. BMC Public Health. 2016;16(1):283. doi:10.1186/s12889-016-2955-7
  40. Dorfman L, Cheyne A, Friedman LC, Wadud A, Gottlieb M. Soda and tobacco industry corporate social responsibility campaigns: How do they compare? PLoS Med. 2012;9(6):e1001241. doi:10.1371/journal.pmed.1001241
  41. Freudenberg N. The manufacture of lifestyle: The role of corporations in unhealthy living. J Public Health Policy. 2012;33(2):244-256. doi:10.1057/jphp.2011.60
  42. Stuckler D, McKee M, Ebrahim S, Basu S. Manufacturing Epidemics: The Role of Global Producers in Increased Consumption of Unhealthy Commodities Including Processed Foods, Alcohol, and Tobacco. PLoS Med. 2012;9(6):e1001235. doi:10.1371/journal.pmed.1001235
  43. Stuckler D, Nestle M. Big food, food systems, and global health. PLoS Med. 2012;9(6):e1001242. doi:10.1371/journal.pmed.1001242
  44. Yanamadala S, Bragg MA, Roberto CA, Brownell KD. Food industry front groups and conflicts of interest: The case of Americans against food taxes. Public Health Nutr. 2012;15(8):1331-1332. doi:10.1017/S1368980012003187
  45. Wiist W. The corporate playbook, health and democracy: the snack food and beverage industry’s tactics in context. In: Stuckler, D, Siegel, K, eds. Sick Societies: Responding to the Global Challenge of Chronic Disease. Oxford: Oxford University Press; 2011: 204-216.
  46. World Health Organization (WHO). Global Strategy on Diet, Physical Activity and Health. Geneva: WHO; 2004 https://www.who.int/dietphysicalactivity/strategy/eb11344/strategy_english_web.Pdf.   Accessed September 11, 2020.
  47. World Health Organization (WHO). Global strategy to reduce the harmful use of alcohol. Geneva: WHO; 2010 https://www.who.int/publications/i/item/9789241599931.  Accessed September 11, 2020.
  48. Delobelle P. Big Tobacco, Alcohol, and Food and NCDs in LMICs: An inconvenient truth and call to action: Comment on “addressing NCDs: Challenges from industry market promotion and interferences.” Int J Health Policy Manag. 2019;8(12):727-731. doi:10.15171/ijhpm.2019.74
  49. Torjesen I. Exclusive: Partnering with alcohol industry on public health is not okay, WHO says. BMJ. 2019;365:l1666. doi:10.1136/bmj.l1666
  50. Backholer K, Vandevijvere S, Blake M, Tseng M. Sugar-sweetened beverage taxes in 2018: A year of reflections and consolidation. Public Health Nutr. 2018;21(18):3291-3295. doi:10.1017/S1368980018003324