As noted in the introduction, a discourse analysis can show how the different actors frame and use narratives to influence policy and action on CDOH, particularly where conflicts of interest may arise between commercial and public health objectives. The findings point to some major areas of common and divergent discourse, to tensions and synergies between public health and commercial objectives and to the role power differentials play in their interaction.
Key areas of common and divergent discourse
Within the multiple issues noted in table 2 and Results: framings and priorities in CDOH, three areas, highlighted in bold in table 2, emerge as major domains of discourse and are discussed in this section.
In the discourse on human rights in relation to CDOH, while some private actors in SSA argue for harmonised laws and standards across countries, civil society and private business/investors largely represent polar opposite views on the role of rights in managing CDOH. Civil society most strongly articulates a rights discourse, linking social rights to state duties and socioeconomic justice within countries and internationally. Civil society links the expanding power of commercial entities in areas harmful to health to states relinquishing their duties, ignoring breaches of environmental, labour and social rights. In contrast, many businesses and funders see—and some explicitly state—rights claims to be a barrier to their economic activity and prefer voluntary, ‘responsibility’ approaches, even while using liberal freedom of choice rights in marketing practices.
Within this, the position of international and regional agencies and states on rights is both important and variable. SSA governments, despite many including rights to health in their constitutions, make limited use of ‘rights’ language, but do commonly refer to regulating hazardous products, work, market practices and services. Some rights instruments and standards from UN agencies and the African Commission on Human and Peoples’ Rights include duties to control commercial activity that is harmful to health. Ratification by SSA states of such international standards is seen by some to have supported domestic regulation to manage health risks. However, some international and regional agencies, particularly economic institutions, seek rather to persuade or incentivise voluntary ‘good business practice’, rather than enforcing it by law.
In a context of mixed messaging, the evidence suggests that SSA states navigating negotiations and regulation with powerful TNCs, and weakened by trade rules and global dispute settlement procedures, may choose less conflictual paths with corporates and economic sectors. The findings suggest that these choices are generating distrust between civil society and states, with more common reference to conflictual than alliance action between them, and of civil society protest, litigation and shadow reporting to claim rights. These tensions may be seen as counterproductive when the continent needs to advance positions grounded in equity, collective responsibility and community well-being in global platforms, such as in the global biodiversity negotiations noted earlier.25
A second major area of converging or conflicting discourse relates to the role of commercial activity in the health sector. All actors state commitments to UHC but with different understandings of what this implies. For civil society, numerous academic voices, and WHO, UHC depends on quality, accessible public sector health services. They express caution that commercial involvement will undermine equity, universalism and financial protection. Private-for-profit services are observed to focus on more profitable personal care, biomedical, hospital services, shifting resources and policy attention to these areas and leaving deficits in comprehensive primary healthcare (PHC) and population health approaches.
SSA governments and some continental actors raise similar concerns, and call for private sectors to complement public sector efforts to achieve UHC. Continental, subregional and state actors view regulation, oversight, information and mutual accountability between states and private actors as necessary to avoid negative consequences or to leverage beneficial impact from private actors in health services. They also note challenges in doing this, due to power, resource and capacity imbalances and inadequate information flows between large private actors and states.
In contrast, there is a growing and countervailing discourse, particularly from business and investors and also from some international and continental actors, proposing that private sector engagement and involvement is essential to attain UHC and to ‘modernise’ the health sector, particularly to meet funding gaps, to introduce technology and digital innovation, expertise and business models to improve quality and extend service outreach and to meet demands for pandemic-related health security.
Some SSA investors and businesses, however, raise concerns around unequal access of local and small enterprises to private investor resources, including for domestic health technology development, with consequences for equity in health services. There appears to be a potential convergence of interests between SSA domestic actors, including local producers, to build shared approaches and policy demands around health services and technologies to manage these tensions and to engage from an African lens in global processes. This has already been visible in the coalition across domestic business, governments, academia and civil society in SSA around the TRIPS Waiver and local production of vaccines and other health technologies.
A third area where views differ between actors, which also underlies the first two, is how CDOHs relate to overall economic and development paradigms. All actors see wider development conditions as relevant, but differently. Here too, the widest divergence in expressed views is between civil society and corporates or investors. Corporates express no harms at all in their own activities and, in contrast, identify benefit from their products, models and economic activity. For corporates and investors, the continent is fertile ground for market opportunities and commercial operations, with primary concerns around decreasing risk. Civil society, some continental/subregional organisations and states and many academics, in contrast, raise and seek to make visible multiple areas of harm to health from CDOH in SSA, such as in chronic and zoonotic disease risk, pollution, obesogenic environments, food insecurity, ecological degradation and deficits in key inputs to health and social protection. They propose multisectoral ‘One Health’ responses, participatory health impact assessments, financial and regulatory measures and more comprehensive, updated public health laws, backed by strengthened public sector capacities. They also give more focus to deeper drivers in liberalised trade, loss of tax revenue, financial outflows and extractive, agribusiness systems and urbanisation, depleting natural and public resources and distorting or weakening public services. Associated with this was a call for greater investment in local research and development and production of health-related technologies; for regional harmonisation of tax policies to avoid a ‘race to the bottom’ in attracting investment; and for a more critical discourse, including from finance ministers on global IP, tax and biodiversity rules that do not serve SSA policy goals.14 37 47 48
Underlying this divergence in lens are differences in the political economy paradigm driving policy. Some see liberalised trade, capital accumulation and enhanced global integration as essential for economic activity, with indirect but ultimate benefit for health and ecological well-being, notwithstanding transitional harms. Others critique this model as generating poverty, inequality, public sector decline and degradation of natural resources, undermining health, both in the immediate and long term. SSA actors, including some business voices, identify inequity in benefit from the current global political economy as pertinent to CDOH, arguing for inclusive economic policies, such as investment in domestic and small scale producers, to improve health. A focus on CDOH inherently opens a deeper discussion on these political economy debates, one that box 1 indicates the COVID-19 pandemic has also fostered. It implies choices on whether to focus on health protections within current economic policies or whether health, together with other socioeconomic and ecological challenges, motivates more radical thinking on development. Commercial interests and power are influential CDOH in these policy debates, as discussed later.
Tensions/synergies between commercial and public health objectives
The findings in table 2, exemplified in Results: framings and priorities in CDOH, suggest some areas of tension and potential synergy between commercial and public health objectives in SSA.
There are different values applying in commercial markets and public health activities. The discourses raise in various ways the collective, social and economic rights framings in public health, the expectation of equity, redistributive justice, transparency and informed participation; the duties to do no harm to health that apply to all, including corporate entities; and the precautionary principle that implies protection of public health in the face of uncertainty. These values contrast with the liberal, individual freedoms and the profit and value for money goals in commercial market activity.
There is an apparent synergy noted in the production of commodities that contribute to health, particularly when production systems and products avoid health risks and ecological damage. Even in the production of potentially health promoting commodities such as food, there is a risk to health in market investment in ultra-processed or genetically modified foods and falling local food production and consumption, when tax, trade, marketing and pricing policies favour commercial over health objectives. There are also tensions between commercial and public health goals in the model of healthcare adopted. Private sector health services and PPPs are noted to favour biomedical, personal and hospital care and to avoid less profitable population health, PHC, ‘One Health’ and cross-sectoral interventions that reach lower-income communities. These are left for public sector and not-for-profit actors to invest in, despite these services being essential to manage key health burdens and for equity and universalism. Hence, while there is a wide articulation of commitments to health across all actors, there are also contrasting expectations of what rights and laws take precedence when there is conflict between public health and commercial interests. This is evident in IP debates, or when regulatory controls of TNC practices that are harmful to health unleash trade disputes. These competing values need to be recognised and explicitly addressed in negotiations between health and commercial interests. While the longer term impact of COVID-19 is still unfolding in SSA, including through conditions applied to debt relief and economic support, it has provoked dialogue on economic models and raised the profile of public health. This suggests opportunities for strengthened health-promoting values and approaches and building synergies, but the opposite may also be the case, further deepening tensions between commercial and public health objectives.
Such tensions draw attention to governance and implementation issues. While multisectoral action and coordination across government is called for to manage CDOH, as for example in ‘health in all policy’ (HiAP) approaches, there are also differences noted across sectors in how to address CDOH, particularly in relation to regulation and tax measures. How these differences are resolved in policy decisions and practice relates in part to evidence, but moreso to the relative capacities and power of public health and commercial actors, the rules and procedural systems in policy, including on information disclosure, and whether key public-interest civil society actors access policy platforms.49 Policy setting on CDOH is thus a fluid space that merits attention, particularly in relation to commercial influences in policy decision making, and the power asymmetries in these interactions.
Engaging with the inequitable distribution of power in interactions on CDOH
As for other social determinants, tackling the inequitable distribution of power emerges as essential to address CDOH.50 A power analysis can help frame strategic thinking on this interaction of different interests and identify levers that can be used by public health advocates.50 51 Power increases through mechanisms of discursive power (rarely questioned ideas and narratives); agential power (active interventions); and structural power (actions undertaken by governments and advocated by influential bodies).51 52 Applying this analysis to the evidence points to areas of commercial power and countervailing power levers for public health objectives.
All three forms of corporate power are being engaged with around CDOH in SSA, and commercial actors are viewed as more agile and proactive in doing so than states.28 Examples of corporate discursive power are narratives of ‘private is best’ and ‘failing’ public sectors or that controls on businesses can lead to social and economic decline. Agential power is applied in political engagement, coalition building, information management, sponsorship and welfare-related interventions described in our findings. Commercial structural power is supported by a dominant neoliberal global paradigm, national and global processes and rule systems legitimising corporate interests and ensuring enabling environments for commercial activity in health, potentially reducing the need to exercise narrative or agential power.51
Beyond an academic understanding of the different forms of power, this raises a question of how to engage with these power levers to proactively advance public health objectives and leadership in engaging on CDOH?
There were numerous examples in SSA of challenges to narratives that weaken public health, and of countervailing discursive power, such as in the exposure of harmful practices; positioning public sector systems as essential for UHC; or showing the health, socioeonomic and biodiversity benefit from local food production systems. Information systems that monitor commercial actors and health impact assessment of commercial projects help to institutionalise evidence for public health narratives. Promotion of healthy local foods and participatory, consultative public health approaches counter narratives promoting harmful practices, particularly when backed by relevant enforced controls on marketing, labelling and false messaging.
The findings show agential power for public health in the regulation of alcohol and tobacco company sponsorships, disclosures of conflicts of interest, active measures to meet public funding commitments and provide accessible, affordable quality universal public sector health services and investments in key areas of health that are visible to and matter to the public, like reliable safe water and waste management, particularly where this involves communities and internalises social protection in corporate policies.49 The disconnect and distrust between states and civil society and the marginalisation voiced by local producers in the findings suggest a current loss in agential power by not bringing these groups together around shared public health goals.
Leveraging structural power implies engaging on local to global economic policies and rules systems that weaken the policy coherence, policy spaces and capacities to claim, protect and promote rights to health and public health within commercial practice and to advance production and consumption alternatives that align better to health objectives. With tax losses from corporate practices in low-income countries estimated at equivalent to nearly 52% of health budgets, for example, African Union, SSA finance ministries and civil society have highlighted public revenue losses due to outflows relating to TNC-related tax rules and illicit financial flows and called for action to strengthen economic governance and reform global rules. While regional harmonisation of tax laws through the African Tax Administrative Forum is proposed to avoid a ‘race to the bottom’, they also propose reform to global rules enabling tax outflows, including for tax revenue to be assigned to where revenues are produced.37 53 54 While there is report of TNC resistance to regulation, tax, pricing and policy tools that lie within the power of states to promote public health, and pressure to involve commercial actors given weakened public sectors, such engagement shows the more affirmative use of structural power to promote public health, also noted in the engagement on the TRIPS Waiver, on biodiversity or on fair benefit from sharing of genetic material.