Economic and commercial determinants of health in small island developing states: NCDs, mental health conditions, injuries and violence
Executive summary
This Technical Paper is the first in a series of Technical Papers on economic and commercial determinants of health in Small Island Developing States (SIDS). It was prepared and first presented as a draft discussion paper ahead of the SIDS ministerial conference on the prevention and control of NCDs and mental health held in Barbados in June 2023. This revised version reflects comment and review provided subsequently. It focuses on how commercial determinants contribute to negative health outcomes in SIDS and gives recommendations for action to address them. Specifically, it outlines the economic and commercial determinants of noncommunicable diseases (NCDs), mental health conditions, injuries, and violence. It does not explore the full scope and potential of commercial actors as health partners.
SIDS are a distinct group of countries facing shared commercial and economic determinants of health due to their geography, remoteness, small populations, narrow resource bases, low production capacity, dependence on external supply of essential products, undiversified economies and low gross domestic product (GDP). Commercial and economic determinants are dimensions of the broader social determinants of health that describe how economic factors and commercial practices structure varied conditions of daily life that are, in turn, intermediary determinants of health and health equity. These are determinants of what healthcare is available, to whom it is available and at what cost, whether housing and broader physical environments are safe and health-promoting, the workplace health protections and compliance with them, and the legal right and capacity of States to regulate for health. They also underpin global health challenges such as biodiversity loss and climate change, which are each consequences of unsustainable commercial practices and exceedingly detrimental to well-being and livelihoods in SIDS.
Understanding these determinants—including the power imbalances between regulators and commercial actors that underpin them and the ways in which global governance shapes them—is a necessary step towards better and more equitable health outcomes in SIDS. It is crucial to recognize that as countries often dependent on single industries and imports of food, medicines, vehicles and other products, SIDS are especially vulnerable to harm from the negative impacts of economic and commercial determinants of health — their negative externalities. For example, the asymmetry between their economic weight and that of both multinational commercial actors and their major trading partners may leave SIDS exposed to greater pressure from industry and disadvantageous terms in trade agreements.
Prevailing economic and development approaches have not only failed to avert a growing burden of NCDs, mental health conditions and injuries in SIDS, but also fostered economic and policy conditions—particularly with respect to trade—that have empowered commercial actors, particular transnational businesses, relative to the public sector. This power asymmetry has exposed SIDS to negative externalities from the commercial determinants of health. This includes the actions of some commercial actors to exert influence over health outcomes in SIDS via direct means, such as marketing and lobbying, and indirect means, such as shaping knowledge and societal norms.
At the national level given the small size and close-knit social fabric of SIDS, local commercial actors play critical roles in the health of their communities. In order to fulfil the potential of these commercial actors to be partners for health and well-being of SIDS populations it is essential to shift their practices from health-harming to health-promoting. This will be possible when there is potential for alignment between health and their business model, products and services. When their interests are misaligned, they risk negatively affecting local health and well-being—a problem exacerbated by their often-privileged positions in local communities and national political processes. These circumstances make shifting local commercial actors away from health-harming and toward health-promoting practices a priority.
It is essential that SIDS and partners address health-harming commercial practices and the underlying power asymmetry between commercial actors and the public sector. This will enable SIDS to take regulatory and other action to correct negative externalities by, for example, reducing exposure to health-harming products and their marketing, improving diets, developing safer infrastructure and lived environments, and curbing air pollution. Salutogenic action is also needed including incentivising commercial actors to promote physical activity, improve food environments and other environments, and support communities affected by climate-related events and disasters.
The same characteristics that underpin their shared challenges also provide SIDS unique opportunities for using “whole of Island” approaches that leverage their small sizes and close-knit social fabrics to act across sectors and levels to address population health and ecosystem impacts with integrated policies and interventions based on adaptative governance structures and community leadership. Such approaches are particularly needed for addressing the inherently cross-sectoral and structural challenges of addressing the economic and commercial determinants of health. Moreover, as regionally and globally united networks of countries facing common challenges, SIDS also hold immense potential for collaborating in creating and implementing these solutions.
A comprehensive response requires action to explore alternative economic approaches that prioritize well-being, embrace Indigenous knowledge and participation, and support health-aligned businesses and, in particular, health-aligned local businesses. It also requires action across sectors, such as taxes on harmful products that also raise needed revenue, as well as policy coherence, such as the alignment of trade and broader fiscal policies with health goals. Conflict-of-interest tools for safeguarding public health policies from commercial interests should be developed and community participation for decision-making and accountability should be promoted to protect and accelerate other efforts to address the commercial determinants.
At the same time, SIDS need international support, including debt relief and greater development finance, to allow for investments in improved social determinants including action to improve outcomes from the commercial determinants of health. This includes investment in action on specific harmful commercial practices and products, strengthening capacities for governing commercial actors, and specific initiatives for climate change mitigation and risk insurance, and protections against biodiversity loss. These also include investments in universal health coverage, early years, social protection, safe infrastructure and communities. These upfront investments will unlock long-term, sustainable and equitable development and well-being across the life course. Given that children are the ones who bear the longest periods of exposure and consequence and offer the greatest opportunity to impact for life and are the ones least able to influence the environment in which they grow up and make decisions for their lifelong health and well-being, specific interventions should be considered to promote and protect the health of children.
Opportunities for SIDS
Opportunities for SIDS to address economic and commercial determinants of health with improved outcomes for NCDs, mental health conditions, and injuries and violence could include the following.
1. Creating policy environments that enable health
Addressing commercial practices at the demand and supply side of risk factors by supporting health-promoting products and practices and regulating health-harming products and commercial practices. Actions could include:
1.1. Comprehensive best practice health taxation to raise the prices of health-harming products as well as trade rules and excise duties that support health-promoting products including safe vehicles;
1.2. Regulation of the availability and use of health-harming products (e.g., regulate alcohol outlets; smoke-free laws);
1.3. Bans or restrictions on health-harming advertising and marketing, including the advertising and marketing of health-harming products;
1.4. Bans on the promotion of health-harming products in schools, including bans on nominally educational programmes which promote health-harming product use;
1.5. Policies for sustainable local food production and processing to support improvements in the food environment and strengthen climate-resiliency;
1.6. Urban and rural planning and development policies that provide safe and inclusive urban and rural environments, including safe green and blue space for physical activity, and prevention of pollution and health-harming waste;
1.7. Integration of commercial determinants considerations into procurement policies;
1.8. Using health and health equity impact assessments as part of strengthening policy coherence between health and other policies with economic and commercial relevance to NCDs, injuries and violence, and mental health, such as trade, education, labour policy, social protection, urban planning, energy, fisheries and agriculture;
1.9. Improving data and surveillance on the commercial determinants of health including commercial influence over public policy and national, regional and international regulatory authorities;
1.10. Whole-of-government accountability for sentinel child health outcomes and behaviours as part of future proofing policy.
2. Safeguarding against conflicts of interest
Safeguarding against conflicts of interest is critical in the development, adoption, implementation, and monitoring of public health interventions, policies, strategies and approaches as recommended by WHO. This also includes ensuring conflicts of interest are fully addressed in the implementation of WHO technical packages. Actions could include:
2.1. Whole-of-government policies to prevent and manage conflicts of interests for commercial actors, especially those whose products and services are health-harming;
2.2. Access-to-information legislation to facilitate transparency, monitoring and accountability including implementation of health impact assessments.
3. Empowering community participation in governance for health and the commercial determinants of health
Investing in institutionalised and empowered community participation in governance for the commercial determinants of health, as part of a whole-of-society approach, is needed to deliver effective, equitable, long-term and health-enabling environments across the life course. This involves working with community-based organisations, Indigenous people and communities, civil society, the media and health-aligned local commercial actors, youth, people living with NCDs, and academics. Actions could include:
3.1. Institutionalising community participation as part of action on the economic and commercial determinants of health;
3.2. Strengthening commercial determinants considerations in existing health-in-all-policies approaches including Healthy Islands, healthy cities, and other settings-based approaches.
4. Strengthening governance for the commercial determinants of health in development approaches
Building public sector capabilities to integrate economic and commercial determinants of health considerations within development strategies is essential for advancing the UN Sustainable Development Goals (SDGs). This includes development finance, debt relief, tax agreements, trade mechanisms, and the governance of global public goods, such as essential medicines and key health sector inputs. Actions could include:
4.1. Exploring the adoption of innovative economic and development approaches that create enabling markets for health and reduce harm from the negative externalities of commercial products and practices;
4.2. Integrating redress for NCDs, mental health, injuries and violence related to climate change within relevant finance discussions;
4.3. Integrating economic and commercial determinants of health considerations within discussions on development financing including debt;
4.4. As part of addressing the commercial determinants of health, implementing rules that prevent profit-shifting.
5. Investing in SIDS-SIDS and triangular cooperation for action on the commercial determinants of health
Collective political leadership and action among SIDS, with the support of international partners, is critical to addressing the commercial determinants. It enables the development of regional and SIDS-level norms, protection against industry interference, and capacity building. Actions could include:
5.1. Integrating commercial determinants of health considerations within the implementation of SAMOA pathway commitments;
5.2. Exploring a ONE UN approach to the commercial determinants of health;
5.3. Considering the establishment of a SIDS Technical Network on economic and commercial determinants of health, with support from WHO and partners.