Asserting public health interest in acting on commercial determinants of health in sub-Saharan Africa: insights from a discourse analysis

Ethics approval

As the evidence was obtained from public domain secondary evidence from document review and stakeholder interaction was implemented after consent for review and validation, beyond external peer review of the methods noted in the acknowledgements, this process was not subject to an IRB review. Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research.

Searches, data extraction, analysis and review

Searches were implemented in October 2021 using CDOH-relevant and Africa-relevant search terms, and specific terms for the different actors, detailed in the online supplemental appendix 1 on Methods.17 Separate searches were made for each category of actor in open search engines: Google and Scielo; journal libraries: PubMed, Medline, African Journals online and Google Scholar; and institutional websites. Journal papers, reports, briefs, blogs and other media post-2010 in English were included that after review by authors were by or about the seven categories of actors, commercial determinants and health. Papers in French or Portuguese that had pertinent information in an English abstract/summary were also included and the summary information captured. The voice expressed was used to allocate papers to the specific actor category. New papers were not actively sourced after triangulation from different sources provided a saturation of information on framings, priorities, actions and actors.

Beyond the general search for SSA, to capture as feasible the diversity of country economic and social contexts, searches were also carried out and documents sourced from government websites from a sample of countries from different regions and different economic and language groups, including South Africa, Mozambique and Zambia; Kenya, Tanzania and Uganda; and Ghana, Nigeria, Sierra Leone and Democratic Republic of Congo. Further papers found in references or raised in key informant (KI) review feedback were included. A total of 300 papers were used in the full analysis and report18 with 90 of those included cited in this paper, together with the four further papers cited on the methods.

As an exploration of discourse, the evidence was thus obtained from both peer-reviewed and non-peer-reviewed sources, with 28% from journal papers, books and theses, largely from academia, 66% from online reports, strategy and policy documents, from actors other than academia, and 6% from formal media, spread across all actors.17 That inclusion of wider sources in a discourse analysis is important was supported by this evidence that only including peer-reviewed journal papers would have led to a bias towards the voice of academic actors.

Data extraction, including direct quotations, used a commonly structured data table for each actor that was revised after review for completeness, clarity and quality by all authors.17 The data table organised evidence within areas identified from the aims of the discourse analysis, namely on: (1) the framings of CDOH and their health impacts; (2) the articulated priorities and action on CDOH; and (3) whether framed at local, national, regional or global level. A manual thematic content analysis implemented by RL and SG and reviewed by all authors identified patterns in the discourse, priorities and actions, first within each actor group, and then across actors.

Following data extraction and analysis, nine KIs were purposively selected and 45 minute semistructured discussions implemented with KI consent in November–December 2021. KIs provided stakeholder review, validation and discussion of key areas of evidence and implications raised in the discourse analysis, further detailed in the online supplemental appendix 1 on Methods.17 Table 1 lists the papers searched and included and the KIs by actor and level.

Limitations

Given the wide nature of the field and time and resource limitations, notwithstanding the range of literature sourced, we note a number of limitations. This was not a systematic review. It does not disaggregate individual countries, nor intend to examine system or implementation issues. Together with discourse analysis of documents in other languages, these are important areas for follow-up research that this analysis may contribute useful groundwork for. Some relevant discourse, work and views of some actors and local communities may be poorly reported online or in the public domain. Inclusion of publications in English and the sampling of country-specific searches imply some linguistic and geographical exclusion. Inclusion of KIs from francophone and lusophone countries and diverse regions and actors assisted to validate findings, however, and the searches were extensive, covering all SSA subregions and actors, including those representing other sectors that impact on health, as well as membership-based movements. In its totality, the literature exposed some consistent common and contrasting views.

Mixed discourse from international agencies

The features of international agency discourse on CDOH shown in table 2 indicate that while a number of UN agencies use rights frameworks to engage with commercial practices, including on food, housing and health services, the common proposition by many international actors is that there is a win–win outcome between health and economic returns, particularly when commercial health services relieve financial pressures on public systems.19 Private actors are encouraged to play a role in universal health coverage (UHC), even while observing that the different interests around social and financial returns make ‘private sector participation intrinsically complicated’.20 While corporate harms are noted, current performance standards such as the International Finance Corporation’s Performance Standards on Social and Environmental Sustainability give transnational corporations (TNCs) operating in SSA leeway to voluntarily apply standards.8 Human rights due diligence is observed to currently remain largely ‘an expectation’ not an obligation for commercial actors,21 positioning the state more as facilitator than regulator of business.

A cautious discourse on CDOH risks from regional and Africa continental organisations

While some actors at Africa continental level strongly encourage expanding commercial practice as essential for health, the evidence in table 2 indicates that others are more cautious on the risks. For example, the IMF Africa Department comments that ‘[o]nly partnerships will help solve the health challenges the continent faces’.22 In the face of state duties and health risks, however, others from continental and regional organisations, as noted in table 2, more explicitly raise equity and longer term consequences. A commercial focus on technologies for use in high-level services is argued to poorly address wider population health needs. Liberalised trade in the African Continental Free Trade agreement is observed to potentially enable the production and distribution of health technologies and products in SSA, but with a caution that its benefits may concentrate in wealthier corporates and countries and that reduced tariffs could diminish the public sector revenues and capacities needed to mitigate negative impacts.23 24 Genetic engineering of vectors and genetic modification of seed and food products are criticised for carrying untested population level and ecological risk, threatening local farmer managed seed systems and crop diversity, raising risks of zoonotic-related and environmental-related disease.25 Negotiating SSA interests in international treaties affecting CDOH, such as the post-2020 global biodiversity framework, is thus called for, including through building power outside formal negotiating processes.25

National governments more strongly articulate health risks and the importance of state action

National government actors in table 2 articulate an even stronger discourse on direct negative health impacts of CDOH, especially on rising NCDs, while noting the challenges facing state action. While commercial activity in the health sector is noted to contribute to UHC, here too the tone is cautious around system and equity impacts. Table 2 highlights that various governments in SSA note the importance of cross-sectoral strategies on CDOH and the challenges in applying legal, tax and other public health measures in the face of the perceived economic contribution and political influence of commercial actors. Given this, Uganda’s health ministry outlines, for example, how the multisectoral nature of health risks necessitates ‘a departure from traditional, vertical public health responses’ towards mainstreaming human, animal and environmental protection in ‘One Health’ plans that cover commercial actors.26 Cooperation between health ministries and inspectorates of commercial activities is also seen to play a role in putting law into practice.27 Companies are generally viewed as resisting regulation, but those that see the value of mandatory standards for fair business practice are viewed as potential allies in encouraging wider business support, while early country adopters can enable regional standards.28

Corporate voices focus on opportunities and benefits for health from commercial activities

While the evidence in table 2 shows that private investors see political, economic and post-COVID-19 opportunities for specific areas of investment, they call for measures to ‘de-risk’ investment. Investors from within SSA focus more on strengthening inclusive and local production capacities, cautioning about ‘outsource(ing) the health security of its (Africa’s) 1.3 billion people to the generosity and the benevolence of others’29 and arguing for resource deployment to respond to equitable care for the poorest segments of society.30 The different interests call for a ‘clear policy direction and framework for public-private collaboration’ within national health strategies.31 Businesses view deficits in systems, capacities and infrastructure in SSA as fertile ground for expanding commercial activities. One corporate actor observes ‘One of the great advantages Africa has over other continents …. is that there’s far less legacy to get in the way than in other regions, creating a clean sheet on which companies can develop their own distinctive business models’.32 Corporate voices calling for more vigorous state support observe that ‘political risks and instability also tend to affect the healthcare sector more disproportionately compared to other sectors due to healthcare provision being perceived as a right, not an option by most African countries’ and that ‘the availability of cheap money in the form of aid is also a massive put off for potential for-profit investors’.33 Some SSA domestic producers raise different concerns, perceiving inequities in markets that call for more, not less, state intervention.34 For example, rather than seeing regulation as a barrier, SSA pharmaceutical manufacturers have welcomed strong unified regulatory systems to combat falsified and substandard medicinal products and the establishment of the African Medicines Agency, as this supports local producers of safe and innovative products.35

Civil society actors are more focused on harms to health from commercial activities

Civil society points more strongly than other actors to multiple areas of harm to health from commercial practices, raising in table 2 deeper drivers of these risks and linking global drivers to outcomes experienced within SSA. The interface between states and commercial forces is seen to be taking place in ‘the context of colonialism and imperialism’, with persistent assymetries in power relations and policy benefit, ‘today still dominated by corporations headquartered in the former colonial powers’.36 Tax waivers and loopholes in tax laws are argued to enable profit-shifting outside the region, adding to a range of illicit financial flows.37 In Nigeria, for example, illicit flows are estimated to have led to a potential loss to public revenue ‘equal to about three times the country’s total health budget in 2015’ as ‘Elite capture of public sector policies and resources undermines the productivity of the most important sectors of the economy and prevents the fair distribution of the benefits of growth’.38 Civil society networks in the 2020 Kampala Initiative observed that ‘These social, commercial, economic and political determinants of health have been tolerated or ignored by aid, thereby reinforcing the health inequities that aid is meant to resolve’.39 Civil society robustly asserts that for UHC ‘[u]niversal healthcare services funded through taxation and free at the point of access are the most effective, equitable ways of funding and delivering public health services’.39 40 The underfunding of such services is argued to expose health workers and communities to rights violations, particularly when ‘the voices of those most affected by health inequity are regularly tokenised or excluded from the conversation’.39 The underlying neoliberal paradigm is rejected. Noting that rather than state failure or an enthusiasm for the market, privatisation has been a consequence of liberalisation-driven cuts in state spending.18 41

Academic actors give more focus to underlying determinants of health impacts

Academic voices had the largest share of papers, covering health promoting or harming determinants relating to commodities, goods or services; business, market and political practices that advance these commodities, goods and services; and that stem from the profit motive and are used by the private sector.3 They locate the roots of CDOH in market-driven economies, globalisation and in power imbalances between commercial and public actors. ‘Big Food’ corporate strategies are argued for example, to have increased the availability, affordability and acceptability of ‘nutrient-poor products such as biscuits, margarine, and oil-heavy snacks’7 and to have enabled both commercially driven transitions from traditional foods to a ‘western’ diet and rising NCDs.4 The conflict noted between for-profit interests and public health goals is observed to pose tensions between different government goals. For example, Mukanu et al9 noted that while the Zambian government (in 1998) maintained a 25% excise tax on soft drinks amidst threats that Coca-Cola would pull out from the country, it later repealed this excise tax in 2015 ‘ostensibly for economic reasons’. The policy influence of commercial actors is identified to come from corporate marketing, policy lobbying, framing of narratives, inclusion of policy-makers as company shareholders, various forms of sponsorship and gifts through to raising trade disputes or litigating against regulatory controls.7 42–46 Lee et al43 observe in relation to sponsorship and targeted marketing of tobacco that ‘many of these strategies are now illegal or severely restricted in high-income countries’.

While still unfolding at the time of the research, the COVID-19 pandemic was alluded to as both intensifying held views and the opportunities to implement them for different actors and also as generating new thinking relevant to CDOH, as shown in box 1.

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.