WHO South-East Asia Regional Office consultation on the commercial determinants of health
About the consultation
The WHO South-East Asia Regional Office organised this landmark consultation on the economic and commercial determinants of health in South-East Asia to bring together representatives and participants from nearly all the Region’s Member States, spanning various government sectors. This marked the Region’s first consultation on this subject and only the second such consultation of its kind globally.
It was a vital opportunity for Member States to exchange knowledge and insights. It also enabled the Secretariat to develop a clearer understanding of regional- and country-specific priorities, experiences, and strategies concerning the commercial determinants of health. The participation of regional civil society, specialists, and practitioners from other intergovernmental organisations also provided an indispensable set of perspectives.
Juliette briefed the participants on WHO’s progress in developing the WHO Global Report on the Commercial Determinants of Health. Participants provided reflections and questions for her consideration and response.
About these remarks
The remarks below are a tidied record of a deep-dive technical briefing delivered at the consultation, which fed into the Regional Office’s subsequent mapping report on the commercial determinants of health in the Region. The remarks were delivered in Part II of the consultation, Economy of Wellbeing and Equity, Session I: Global report on commercial determinants of health.
Mandate
The basis for WHO’s work on the commercial determinants of health, and for the Global Report, is the mandate provided by Member States. WHO draws principally on two World Health Assembly resolutions and a declaration on the social determinants of health. These focus on the need to tackle the inequitable distribution of power, to engage all segments of society, and to foster collaboration while safeguarding against conflicts of interest. They are supported by numerous other resolutions focused vertically on commercially related risk factors — tobacco, alcohol, unhealthy foods, road safety, physical activity, medicines and many more — which recognise the role of commercial actors as partners or participants in health-sector processes.
Rationale for the Global Report
WHO and its Member States are already doing significant work on specific commercial products and practices. The rationale for the Global Report is twofold. First, it builds on these vertical approaches with a more systematic analysis that determines the overall contribution of harmful commercial products and practices to the global burden of disease. Second, it enables the co-benefits of working with the commercial sector to be leveraged while safeguarding against conflicts of interest.
Development process
An expert group was convened to advise WHO’s newly established economic and commercial determinants unit. The recommendation for a Global Report was provided in July 2021 and initiated shortly afterwards. This included the production of a number of regional reviews — including one in the South-East Asia Region, now being updated — alongside several technical papers.
In June 2022, WHO began scoping the Global Report, starting with a concept note and then a preliminary scoping paper outlining key considerations. WHO has worked on the Report’s development with an editorial board of leading experts on the commercial determinants, who provide scientific guidance and review drafts. The scoping paper was consulted upon with experts and across WHO. WHO also ran a broader consultation across headquarters, the regions and with affiliated programmatic experts, supported by guidance from the editorial board and input from two global expert meetings and a number of topic-specific consultations.
Structure of the Report
The Report opens by setting out the basic problem posed by the commercial determinants. It then turns in Parts II and III to an analysis of impacts, and in Parts IV and V to the enablers and barriers to action. Part VI provides an analysis of the state of action, and Part VII sets out the key elements of the public-health response and what is needed for it to occur.
Problem analysis
The problem analysis presents the context, underpinning definitions and overall framing for the commercial determinants of health.
- Economic drivers of negative impacts. Commercial actors and prevailing business models are designed to put profit ahead of health and other concerns in many cases. This challenge goes to the basic market incentives and how they have been shaped by commercial actors and the public sector — and it creates the conditions for the commercial determinants we see today.
- Externalities of commercial practices. These are the uncosted aspects of a transaction that are imposed on third parties and society. The tobacco industry, for example, sells a hugely dangerous product that causes an enormous burden of ill-health and environmental damage, but pays only a small portion of this cost. The scale of externalities varies across sectors.
- Conflicts of interest and undue influence. Action to address harms to health is often prevented by commercial actors’ use of practices of power — methods of influencing public policy, the knowledge environment and public preferences.
- An equity lens on outcomes. This concerns the distributional consequences of commercial practices and products.
Theory of change
The theory of change underpinning the Global Report is that progress will come from leveraging the power and potential of the commercial sector for better health and health equity while — crucially — protecting against conflicts of interest and preventing public-health harms. A critical underpinning assumption is that commercial actors, in general, will continue to prioritise profit over health unless required to do otherwise. As a synthesis of evidence, the Global Report will test these assumptions and provide recommendations on related actions.
A working typology of industries
The scoping process has produced a working typology that places industries along an axis of alignment with the public interest.
At one end are health-harming industries, which are inherently misaligned with the public interest. These include fossil fuels, arms, tobacco, gambling and segments of the food industry whose portfolio is largely composed of unhealthy options. Their business models and need to make profit require them to continue selling products and services that are harmful to health. They grow their markets by reaching new customers and by shaping preferences and knowledge in favour of harmful products or behaviours, and they often employ practices of influence over politics and knowledge to prevent and shape regulation and to obstruct the mechanisms used to formulate and implement it. Businesses that operate exclusively in support of these actors — marketing, retail, legal, consultancy, financial and social media services and platforms — sit in the same category.
The burden on health and health equity
The Report describes the burden on health and health equity associated with the commercial determinants of health. Under each heading, it examines the risk factors and industries involved, takes a life-course approach and looks at equity impacts.
It traces the intermediate determinants and conditions that provide the causal pathways through which commercial practices result in exposure to health-harming products, practices and environments, and in access or non-access to health-promoting goods. Drawing on the major practices set out in the Lancet series, it looks at:
- Political practices — such as lobbying.
- Scientific practices — such as funding evidence generation or distortion.
- Marketing practices — such as advertising.
- Supply-chain practices — such as pollution.
- Labour practices — such as those affecting occupational health and worker safety.
- Financial practices — such as tax avoidance or payment.
- Reputational practices — which cut across all of the above.
These practices shape the policies and environments in which we live, work and play. They shape our exposure to products and behaviours, and — through marketing and other channels — our aspirations and ideals. Core health and health-equity outcomes are shaped by commercial practices, as are leadership and governance, the availability of health information, health products and technologies, health financing, service delivery, the health workforce and public-health programmes — in both positive and negative ways.
Power, context and enablers
Commercial actors and practices do not occur in a vacuum. They operate within a pre-existing distribution of power, resources and economic structures, which shape the capacities of both the public sector and commercial actors. This is tied up with the complex interactions between the public sector, business and others in society, and with processes such as colonialism, the development of public international and economic law, and the spread of private international law — all of which form the context for how and why commercial practices shape our politics, preferences, knowledge and laws, and how they evade them.
Premise of action
The premise of action is to make change by correcting power imbalances, realigning incentives in favour of public-health interests, and targeting industries that pose risks to health. Regulating health-harming industries requires addressing their core business models and reducing their capacity to shift costs by influencing public preferences and knowledge. Effective regulations on marketing, labelling and product availability can, as part of a broader strategy, shift incentives away from the production of harmful products in the first place — and over time can shrink or eliminate particularly detrimental markets or market segments.
The response must also directly confront imbalances between the public sector and commercial entities through policies aimed at identifying, preventing and managing all forms of conflicts of interest, including policy capture. On their own, these measures are insufficient. Robust rules and policies need to be complemented by actions that enhance overall coherence within the public sector — including health-impact assessments; ensuring adequate financial and technical resources for public-health and regulatory bodies; addressing entrenched restrictions stemming from trade and investment agreements that undermine public health; and making effective use of existing exceptions to those agreements.
Enhancing the public sector’s capacity in this way mitigates the power imbalances that erode political will and the ability to formulate, adopt and enforce regulation — including regulation that can drive broader shifts in the market in favour of public health.
Action also requires supportive measures to strengthen and protect the knowledge environment, civic space and mechanisms for change within the private sector. Each of these has the potential to play a supportive role, but is also subject to targeting by commercial actors that seek to distort the knowledge environment, misdirect civil society, or constrain investor action and other internal mechanisms for change within the business community.
Drivers of change
The Global Report focuses on collaboration across the public sector; with health-aligned businesses and investors; with the UN, academia, researchers and media; and most importantly, with communities, social movements and civil society advocating for change. It is shaped by five related drivers of change:
- Public-sector intervention.
- Corporate governance and investor initiatives.
- Prioritisation of health at the international level.
- Bolstering the public-interest knowledge environment.
- Creating social demand for improved corporate and commercial practices.
The Report places central emphasis on the public sector as the main driver of change. It concentrates on addressing conflicts of interest throughout the public sector while reducing power imbalances and enhancing public-sector capacity. This requires WHO, other intergovernmental actors and Member States to lead the creation of better frameworks that can engage health-aligned commercial members of the business community — ultimately leading to stronger and more effective corporate governance.
Multilateral action on trade, investment, business and human rights, economics, environmental issues including climate and climate justice, financial mechanisms and development assistance is also essential. This will boost public-sector capacity and coherence and help ensure that the playing field is not tilted in favour of commercial actors — especially large multinational corporations. Ultimately the Global Report aims to establish a unified approach for addressing the commercial determinants of health, leveraging the successes and experiences from the contexts of tobacco and noncommunicable diseases.
Role of research, media, civil society and communities
Research, media and academia play a vital role in holding commercial actors accountable, uncovering practices and building the case for change. Communities and civil society organisations are on the front lines of responding to commercial actors, and are instrumental in ensuring transparency and building resilience against commercial influence.
The public-health response
The public-health response, detailed in Part VII, outlines the strategy for the health sector, communities and other sectors, together with the build-up of the legal, surveillance and other capacities needed to meet the commercial determinants of health challenge.
Next steps
WHO is currently finalising the first draft outline. Drafting will commence shortly, with the goal of completing the Global Report over the coming year.