世界卫生组织-东南亚健康的经济和商业决定因素

SEA‐HE‐217

EconomicandCommercialDeterminantsofHealthinSouth‐EastAsia:RegionalconsultationReport

17‐19October2023,Bangkok,Thailand

TableofContents

BACKGROUND

5

AIMSANDOBJECTIVESOFTHECONSULTATIONS

7

SUMMARYOFTHEPRESENTATIONSANDDISCUSSIONS

7

SUMMARYOFPROCEEDINGS

9

PARTI.INTRODUCTIONOFTHECDHCONCEPTANDIMPACTSONHEALTH

9

SESSIONI:INAUGURATIONSESSION

9

1.MEETINGOBJECTIVES

9

2.REGIONALDIRECTOR’SMESSAGE

9

3.MEETINGPROTOCOL

11

SESSIONII:INTRODUCTIONOFWHO’SAPPROACHTOWARDTHECOMMERCIALDETERMINANTSOFHEALTH(CDH)

11

SESSIONIII:REGIONALOVERVIEWOFBRIEFSCOPINGOFCDH

14

1.OVERALLFINDINGOFCDHINSEARBYDR.MONIKAARORA

14

2.REGIONALCONCERNSONFREETRADEAGREEMENT,PATENTS,REGULATIONAFFECTINGHEALTHSYSTEM,BYDRMANISHA

SHRIDHAR,REGIONALADVISORINTELLECTUALPROPERTYANDTECHOLOGYREGULATION(IPT),WHOSEARO

17

3.REGIONALPERSPECTIVESONUNHEALTHYFOODANDBEVERAGE,DRANGELADESILVA,REGIONALADVISORNUTRITIONAND

HEALTHRESEARCH,WHOSEARO

19

4.ILOAPPROACHTOWORKERS’HEALTHANDRESPONSIBLEBUSINESS,DRYUKAUJITA(OSH‐ILO)

22

SESSIONIV:COUNTRYEXPERIENCESONMAINCOMMERCIALDETERMINANTSOFHEALTHONPEOPLE’SHEALTH(FOCUSONNCD

RISKFACTORSE.G.TOBACCOCONTROL,SUBSTANCEABUSEANDALCOHOLCONSUMPTION,UNHEALTHYFOODANDBEVERAGES,OR

AIRPOLLUTIONETC.)

23

1.THAILANDEXPERIENCECDHAFFECTINGNCDRISKFACTORSBYDRPAIROJSAONAUM,THAIHEALTHPROMOTIONFOUNDATION23

2.INDONESIAEXPERIENCE:DRPRIHANDRIYOSRIHIJRANTIM.EPID.,PROJECTMANAGEROFFICER(PMO)DIRECTORATEGERAL

OFDISEASEPREVENTIONANDCONTROL,MINISTRYOFHEALTH

24

3.NEPALEXPERIENCE:MS.HIRAKUMARINIRAULA,DIRECTOR,NURSINGANDSOCIALSECURITYDIVISION,DEPARTMENTOF

HEALTHSERVICES,MOHP

26

4.PANELDISCUSSION:BANGLADESH,BHUTAN,TIMORLESTE

28

SESSIONV:COUNTRYEXPERIENCESONKEYCDHONHEALTHCARESERVICESANDHEALTHSERVICEDELIVERIES(E.G.INFANT

FORMULAS,MEDICALDEVICES,VACCINES,PHARMACEUTICALPRODUCTS,TELECOMMUNICATION&DIGITALHEALTH,

TRANSPORTATIONSYSTEM,ETC.)

30

1.THAILANDEXPERIENCE’SONCDHINHEALTHCARESERVICESANDSERVICEDELIVERIES,MS.SULADDAPONGUTTA,IHPP,

THAILAND

30

2.PANELDISCUSSION:BANGLADESH,INDONESIA,SRILANKA,MALDIVES

33

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SESSIONVI:COUNTRYEXPERIENCESONECONOMICGAINS/LOSTFROMCOMMERCIALPRODUCTSANDACTIVITIES

35

SESSIONVII:SOUTH‐EASTASIACOUNTRIESPERSPECTIVEON“ECONOMYOFWELL‐BEINGANDWELLNESSPRODUCTS”

39

1.MR.ODDHANSSEN,TECHNICALSPECIALISTONHEALTH,TAXATIONANDFINANCING,UNDP

39

2.DR.SARAWUTBOONSUK,DEPUTYDIRECTORGENERAL,DEPARTMENTOFHEALTH,THAILAND

41

3.DR.IFTIKHAR,TRADEANDDEPARTMENT,GOVERNMENTOFMALDIVES

43

PARTIIECONOMYOFWELLBEINGANDEQUITY

44

SESSIONI:GLOBALREPORTONCOMMERCIALDETERMINANTSOFHEALTH–PRESENTATIONBYMS.JULIETTEMCHARDY,

CONSULTANT,ECONOMICANDCOMMERCIALDETERMINANTS,DEPARTMENTOFSOCIALDETERMINANTSOFHEALTH(WHOHQ)

44

SESSIONII:EQUITYLENSONCOMMERCIALDETERMINANTSOFHEALTH:3PRESENTATIONS

48

1.CONSUMERPROTECTIONOFPEOPLE’SVOICESBYDRVINYAARIYARATNE,SAVODAYA,SRILANKA

48

2.COMMUNITY’SVOICESBYPROFESSORSHARADONTA,NEPALPUBLICHEALTHFOUNDATION

50

3.COLLABORATIVEAPPROACHFORBETTERHEALTHBYDRTHANSIEN,PEOPLE’SHEALTHASSOCIATIONOFMYANMAR

51

SESSIONIII:BRAINSTORMSESSIONS:PEOPLEEXPERIENCEOFCDHTHROUGHOUTTHELIFE‐COURSEANDEQUITYLENSONCDH

ACROSSLIFE‐COURSE

52

Q1:

53

Q2:WHATARETHECRITICALCONCERNS?

55

Q3:WHATACTIONSCANINDIVIDUALSTAKE?

57

Q4:WHOISRESPONSIBLEFORCURBINGNEGATIVESANDENHANCINGPOSITIVES?

59

Q5:WHATDOESTHEPUBLICSECTORNEEDTODO?

61

Q6:WHATARETHEACTIONSTOADDRESSEQUITYGAPSFORVULNERABLEPOPULATION?

63

PARTIII:REGIONALPOSITIONONCOMMERCIALDETERMINANTSOFHEALTH

65

SESSIONSI,II,III:COUNTRYPRESENTATIONSONUNDERSTANDINGOFBURDEN,SECTORS,ACTIVITIES,ANDSYSTEMSFORTHECDH

ANDACTIONPOINTS:BANGLADESH,BHUTAN,NEPAL,INDONESIA,MALDIVES,TIMORLESTE,SRILANKA,THAILAND,MYANMAR

65

1.TOP3‐5CDHTOBECRITICALLYCONCERNSINTHENEXT5YEARS

65

2.COMMERCIALDRIVERS/ACTORSTHATHAVEDIRECTIMPACTSONPEOPLEHEALTH

66

3.EXISTINGECONOMICMODELS/SYSTEMSTHATMAYREDUCEORUNDERMININGHEALTHFORALL

68

4.EXISTINGPUBLICPRIVATEPARTNERSHIPSANDGOVERNANCETHATCANMANAGECDH

70

5.PUBLICHEALTHAPPROACHTOCDH

72

6.COUNTRYACTIONPOINTSIN2024‐2025

75

7.RECOMMENDATIONSFORWHO

76

SESSIONIV:REGIONALMECHANISMSRESPONDINGTOCOMMERCIALDETERMINANTSOFHEALTH

77

1.DRSHAMIMHAYDERTALUKDER,SEARNCDALLIANCE

77

2.DRYUKAUJITA,ILO

78

3.THAKSAPHON(MEK)THAMARANGSI,WHOSEARO

80

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SESSIONV:REGIONALPERSPECTIVESONCOMMERCIALDETERMINANTSOFHEALTH:COMPILATIONANDSYNTHESISOFCOUNTRY

PRESENTATIONS

81

COMPILATIONANDSYNTHESISOFCOUNTRYPRESENTATIONS

81

SESSIONVI:RECOMMENDATIONSFORWHO

85

ANNEX1:LISTOFATTENDINGPARTICIPANTS

87

ANNEX2:PROGRAMME

92

ANNEX3:REGIONALDIRECTOR’SMESSAGE

96

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Background

Increasingly,publichealthandmedicalprofessionalshavewitnessedcommercialsystemandproductinfluencesoverpopulationhealthbehavioursandconditionsthatchangepeople’swaysoflife.Forexample,NCDsweredescribedas‘lifestylediseases’duetotheirassociationwithbehavioursincludingtobaccouse,alcoholuse,unhealthydiet,andphysicalinactivity.Behavioursandconsumptionpatternsareincreasinglyrecognizedassociallyconstructedactions,orcommerciallydriven,heavilyinfluencedbylarge-scaleproduction,marketing,anddistributingofservicesandproductsmakingthemreadilyavailableandappealingtodifferentgroupsofthepopulation.

Productstargetedtowardschildrenandadolescentswithlonglastingimpactsontheirhealthincludetobacco,alcohol,andunhealthydietsleadingtoillhealthconditionsamongchildrenandadolescents.Advertisementsoftobaccotargetingadolescentscauseharmtotheyounggeneration.AlcoholconsumptionamongadolescentsreportedinGSHSovertheyearsreveals,thatearlyinitiationofalcoholisat12-13yearsoldinmanycountries.Childhoodoverweightandobesityisestimatedtoaffectapproximately41millionin2016andalmosthalfofalloverweightchildrenunder5livedinAsia.Childhoodobesityresultsinanincreasedriskofcardiovasculardisease,diabetes,andlungdiseases.

Recently,WHOattemptedtodefinethecommercialdeterminantsofhealth(CDH)astheconditions,actionsandomissionsbycorporateactorsthataffecthealth,arisinginthecontextoftheprovisionofgoods,orservices,forpayment,whichincludecommercialactivities,aswellastheenvironmentinwhichcommercetakesplace,withbeneficialordetrimentalimpactsonhealth.

Thecommercialsystemimpactsmuchofsocietallivingandactionssuchassocialdeterminantsofhealth(incomedisparities,education,housingconditions,stigmaonpopulationexploitedinillicittrades)whicharethenon-medicalfactorsthatinfluencehealthoutcomesandinequities.Thesedeterminantsholdthekeytoturningthetideofrisingglobalhealthchallengesandhealthinequities.CDHexertsdramaticimpactsonhealthfromthelocaltogloballevel,acrosssectors,settingsandpopulations.

TheburdenofCDHimpactsfallsinequitablybetweenregionsandcountries.InSouth-EastAsia,commercialdeterminantsofchildandadolescenthealth,women’shealth,andworkers’health,liesinnotonlytheunhealthyproducts,butalsothewholesystemofsupplychainsofproductswithinacountry,orthroughtransnationalestablishments,causinglabourexploitationofchildren,women,workers,includinghumantraffickingforlabourexploitation.Impactsofcommercialproducts,services,andactivitiesonhealthrequirepublichealthinterventiontochangecorporatepracticesandprotectpeople’shealth.

Businessstructures,regulatoryregimes,andtaxsystemsthatallowprofitstoflowtoothercountries,awayfromthecountryorregionwheredamaginghealthimpactsandcostsareincurred,compoundstheproblem,particularlywheretheseprofitsaredriventhroughtheexploitationofpopulation,thenaturalenvironment,inadequatelabourlawsandsocialprotectionssystems.ConsumerprotectionsandrightsofconsumersareinvariablyeffectiveinmostcountriesinSouth-EastAsia.Whilevoicesofresearchandacademicstoprotectpeople’shealththroughhealthimpactstudiesarediminishing,asinfluenceofinternationaltradeandeconomicdevelopmentsareintertwined.BuildingonexperiencesofFCTCimplementationandcooperateinterferenceontobaccoprevention,WTOplayscriticalrolesinseveraltradeagreementsinfluencingLMICs,whileTrade-relatedAspectsofintellectualproperty

(TRIPS)isinfluencingdisclosureofcontentofproductsaswellaslabellingdisclosurepolicies.

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TheWHOExecutiveBoard152ndSessionAgendaitem16,December2022onSocialDeterminantsofHealthreportedbytheDirector-General,mentionedinparagraph22thatWHOSecretariat’ssupportforcountriestostrengthenunderstandingofthecommercialdeterminantsofhealth.Althoughmuchhasbeendonetolookathowspecificprivatesectorproductsandpractices,notablythetobaccoindustry,haveimpactedonpublichealthoutcomesbyWHOandotheractors,thereareincreasingcallsforWHOtotakeamoresystematicapproachtodeterminingthecontributionofharmfulproductsandcommercialpracticestotheglobalburdenofdiseaseandtodevelopapproachesthatallowforleveragingtheco-benefitsofworkingwiththeprivatesector,whilesafeguardingagainstconflictsofinterest.

Thisconceptofcommercialdeterminantsofhealthneedstobecomprehendedanddeliberatewithmultisectoralauthoritiesandstakeholders.Criticalareasoffocuscouldbeconsideredaroundtobacco,alcohol,ultra-processfood,fossilfuelsthatimpactlargescalemortalities.ItisimportanttohavecrosssectoraldialoguesonpositiveandnegativeimpactsofCDH,powerrelations,systematicpathways,publichealthinterventions/solutionsincludingupstreampoliciesandopportunitiestopromotehealthinallpublicpolicies.

Commercialandeconomicdeterminantsofhealthneedtobediscussedtogetherbetweenpublichealthcommunities,professionalassociationsandeconomicsector,finance,nationalandlocalgovernmentsresponsibleforgovernanceandregulationofinternationalanddomestictrades.ThismeetingistimelytoraiseawarenessandunderstandingofCDHintheregion.

ThemeetingaimedatraisingawarenessofMemberStatesonthisimportantareaoffocusanddiscussinghealthcarecostandhealthimpactsofspecificcommercialdeterminantsofhealth.WHO’sconveningroleswithmultisectoralpartnerswillsupportmemberstatestoidentifyfurtherworkoncommercialdeterminantsincludingitsgapsandstrategicdirectionstoexerttheimportanceofpopulation’shealthasnationalcapitaltobevaluedequallytoeconomicgains.

ThismeetingwasanimportantplatformforMemberStatestoreviewtheDraftOutlineofthefirstWHOGlobalReportonCommercialDeterminantsofHealth,whichwillbepublishedin2024.MemberStatesprovidedcriticalinputsviathisconsultationonhowcountrylevelinterventionsandapproachescanbeaccelerated(fromregulatoryinterventionsorintegratedHiAP);orfacilitatedthroughpolicycoherencetools(HIA,ConflictofInterests,Transparencyregisters),orenabledthroughlocalgovernmentsaddressingCDHandengagementwithlocaleconomicoperatorsandworkingwithcivilsociety.

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AimsandObjectivesoftheConsultations

Generalobjectives

TofindcommonunderstandingandawarenessoftheeconomicandcommercialdeterminantsofhealthinSouth-EastAsia

Specificobjectives

1.Toinformmemberstatesontheconceptandpotentialimpactsofeconomicandcommercialdeterminantsofhealth(CDH)

2.Tosharecountryexperiencesoneconomicandcommercialdeterminantsofhealthandcommonchallengesfacedbycountries.

3.TosolicitinputsfortheGlobalReportonCDHfrommemberstates

4.ToconsultonpriorityactionsandwaysforwardtostrengthenunderstandingofthecommercialdeterminantsofhealthinSouth-EastAsia

TargetParticipants

1.MemberStates:highlevelofficialsfromMOH(DGlevel),NationalProgrammemanagers(onchildoradolescentnutritionFoodsafety,TobaccoControl,Chemicalsafety,etc.)and/ornationalhealthplanningorcommission;representativefromMinistryofFinance/Commerceheadingtheworkoncommercialregulations,tradeinvestments,ortaxationofproducts,ormarketsystemsaffectingthehealthofthepopulation.

2.Representativesfromacademiaorcivilsocietyorganizations(CSOs)workingonconsumerprotections,andcivicandcommunity’srightstohealth.

3.NCDAlliance,ASEAN,SARRC,ADB,WorldBank,WorldTradeOrganization(WTO),FAO,UNTAD,UNESCAP,UNHumanRights,UNDP,ILO.

4.InternationalFoundationforHealthPromotioninThailand,InternationalSocietyforHealthPromotionand

EducationIndonesia,andVHAIIndia.

AlistofattendingparticipantsisattachedasAnnex1.

SummaryofthePresentationsandDiscussions

Theregionalconsultationtookplacefrom17Octoberto19October2023,withatotalof62participantsattending.Participantsincludedgovernmentrepresentativesfromministriesofhealth,finance/commercefrom9countries.OtherparticipantswererepresentativesfromacademiaorCSOsworkingonconsumerprotection,theNCDAlliance,UNagenciesincludingILO,2participantsfromWHOheadquarters,8participantsfromWHOcountryoffices,and5participantsfromWHOSEAregionaloffice.

Thethemesguidingthe3daysofmeetingswereasfollows:

.Day1:IntroductionoftheCDHConceptandImpactonHealth

.Day2:EconomyofWellbeingandEquity

.Day3:RegionalPositiononCommercialDeterminantsofHealth

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OnDay1,governmentrepresentativesreflectedonthecountryexperienceswithCDHonpeople’shealth,healthcareservicesandhealthservicedeliveries,andeconomicgains/lossesfromcommercialproductsandactivities.Representativesalsoreflectedoneconomicwellbeingandwellnessproducts.OnDay2,participantsweredividedintofivegroupsforbrainstormingsessionsonpeople'sexperiencesonCDHthroughoutthelife-courseandequitylensonCDHacrossthelife-course.OnDay3,governmentrepresentativespresentedanunderstandingofburden,sectors,activities,andsystemsforCDHandcountryactionpoints.UNagencyrepresentativesreflectedontheregionalmechanismsrespondingtoCDH.Day3concludedwithrecommendationsforWHOincludingreflectionsondraftoutlineoftheWHO’sGlobalReportonCDH.

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SummaryofProceedings

PartI.IntroductionoftheCDHConceptandImpactsonHealth

SessionI:Inaugurationsession

1.MeetingObjectives

RegionalconsultationoneconomicandcommercialdeterminantsofhealthinSouth-EastAsiastartedwithawarmwelcometoalldistinguishedparticipantsfromtheSouth-EastAsiaRegion(SEAR)countries.Dr.SuvajeeGood,RegionalAdvisorforSocialDeterminantsofHealthandHealthPromotion(RA-SDH),WorldHealthOrganizationforSouth-EastAsiaRegion(WHO-SEARO),introducedthecommercialdeterminantsofhealth(CDH)astheconditions,actionsandomissionsbycorporateactorsthataffecthealth.DrGoodelaboratedthatCDHcouldbebothpositiveornegativeinthecontextoftheprovisionofgoodsorservicesforpayment,includingcommercialactivitiesandtheenvironmentinwhichcommercetakesplacewithbeneficialordetrimentalimpactsonhealth.ShehighlightedthattheWHO'sattempttodefinecommercialdeterminantsmaynotbethemostcomprehensivebutis

stilldevelopingbasedontheevidence.

DrGoodhighlightedparticipants'geographiesacrossSEAR

countries,includingBangladesh,Bhutan,Indonesia,Maldives,

Myanmar,Nepal,SriLanka,Thailand,andTimorLeste.Participants

fromDPRKoreaandIndiacouldnotjoin.

Theprimaryobjectiveoftheconsultationsistofindacommon

understandingandawarenessofhealth'seconomicandcommercial

determinantsinSEAR.TheCDHandeconomicdeterminantsare

derivativesofthesocialdeterminantsofhealth.Thespecific

objectivesofthemeetingwerelaidout.

2.RegionalDirector’sMessage

DrJosVandelaer,WHORepresentativetoThailand,deliveredthemessagefromDrPoonamKhetrapalSingh,RegionalDirector,WHOSouth-EastAsia.HequotedDr.Khetrapal’sspeech(inAnnex3)andhighlightedthatglobalizationandcommercialactivitieshaveincreasedthescopeofeconomicopportunities,employment,accesstoessentialanddiscretionarygoodsandservicestonationalandlocalcommunities.Marketingstrategies,promotionofchoices,lobbying,donating,andfundingresearchactivities

areincreasinglyinfluencingthedecisionmakingofindividuals,families,communities,andpublicauthoritiestoadopttheproductsandpracticesthatcouldhavebeneficialordetrimentalimpactsonpeople’shealth.

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Dr.KhetrapalmentionedthatWHOrecognizestheimportanceofeconomicandcommercialdeterminantsofhealththatgeneratepositiveandnegativeimpactsonpublichealthwhileenablingpoliticaleconomicsystemsandnormsforworkingconditionsandotherrelatedactivities.Theterm“commercialdeterminantsofhealth”isusedtounderstandhowindustrialdrivencommercialactivitiesincludingalltheproductsandservicesimpactingpublichealth(healthcaredeliverysystemsandcost),influencelifestylechoices(healthyorunhealthy),andglobalhealthinequities(includingoccupationalhealthofworkersindifferentcommercialsystems).Theproductionandconsumptionof‘unhealthy’products,forexample,tobacco,alcohol,ultra-processedfoods,andsugarbeverages,impactstheearth(planetaryhealth),degradestheenvironment,communities,families,people’shealthandaddstopollution.

Furthermore,theburdenofnon-communicablediseases(NCDs)washighlightedinSEARwhichaccountsfor9milliondeathsin2019accounting22%ofglobalNCDdeaths.NCDmortalityisattributedtolifestylerelatedriskfactors,includingincreasingemissionofpollutants,andburningofbiomassforindustrialdevelopment.

Thenutritiontransition(fromhome-grownorganicfoodtomassindustrialprocessedfoodproducts)hasbeenevidentinSEARcountries,whichhasledtoanincreaseinconsumptionofhighsugar,salt,andtrans-fatandhascontributedtoobesityandmetabolicdisorders.Thesalesofsugar-sweetenedbeverage(SSBs)haveincreasedeverywhereintheregion,withaparticularincreaseinIndonesiaandThailand.AlcoholuseisincreasingincountriessuchasDPRKorea,India,andThailand.Availabilityofcheapunhealthyitemsintheregione.g.,tobacco,loosecigarettes,cheapliquor,uncertifiedcontaminatedfoodandvegetables,cheapunhealthyimitatedfoodproducts,etc.isdrivingupnoncommunicablediseasesamongthepoor,rural,andlessinformativepopulation.

Herquotestressedthatthecommercialsystemofpharmaceuticalproducts,medicaltechnologies,vaccination,andhealthsupplementscandividehealthcareservicesbenefitingtherichandthepoordifferently.Commercialdeterminantsofhealthposeacomplexjuxtapositiontohealthequities.Itcanincreasehealthcarecostsincludingout-of-pocketexpendituresandwideningthegapsofhealthinequities.

Addressingdeterminantsofhealthrequirespublicpolicies(beyondthehealthsector)withattentiontotheroleofpower,equity,andgovernance.Anincreaseingovernance,sectoralaccountability,regulation,licensing,andtaxationaresomeexamplesofactionsthatcancurbtheproliferationofcommercialactivitiesthathavenegativeimpactsonhealth.Anincreaseinhealthliteracyamongconsumersandpromotionofhealthasahumanrightwouldraiseconsumerdemandforimprovedbusinessoperationandreformtocreatebetterproductsforhealthandwellbeing.

Calltoaction:Ministryofhealthandpartneragenciesshouldencourageothersectorstoadvancetheeconomyforhealthandwellbeing,promotionofwellnessandequitableaccesstohealthproducts,andincreasetheenablingenvironmentforhealthforallpopulations.DrKhetrapalstressedtheneedtofollow-uponthecommitmentstheworldleadershavemadeduringrecentG20,astheyarethedriversofsomeofthesecommercialdeterminantsofhealth,toreachoneearth,onehealthmakingtheworldahealthierplace.Herquotehighlightedthattakingthisasanopportunitytoalsounderstandtheeconomyofwell-being.Facilitatingequitableaccesstosafe,effective,quality-assured,andaffordablevaccines,therapeutics,diagnostics,andothercountermeasures,especiallyinlow-andmiddle-incomecountriesandsmallislanddevelopmentstatesisalsoaneedofthehour.

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3.Meetingprotocol

AdministrativeinstructionswereprovidedbyDrSuvajeeGoodtotheparticipants.DrGoodalsoinsistedonfollowingtheWHOcodeofconducttopreventallkindsofharassment.

SessionII:IntroductionofWHO’sapproachtowardtheCommercialDeterminantsofHealth(CDH)

MsMonikaKosinska,globalcross-cuttingleadforeconomicandcommercialdeterminantsofhealth,WHOHeadquarters,introducedtheWHO’sapproachtoCDH.MsKosinskamentionedthatthebiggestpublichealthchallengesthattheworldisfacingincludeNCDsandcommunicablediseases,climatechange,relatedemergencies,occupationalillnessesandinjuries,mentalhealthconditionsandothers.

Shefurtherstressedthatmanyleadingscholarsareincreasinglyidentifyingcommercialproductsandpracticesastheleadingcauseoftheglobalburdenofdiseaseandthreatstoplanetaryhealth.ReferringtoastudypublishedintheLancet,inMarch2023,sheemphasizedthatone-thirdofthedeathsgloballyareattributedtoonlyfourindustrieswhichincludetobacco,alcohol,unhealthyfoodandfossilfuels.Shehighlightedtheimportantrolethatthecommercialsectorandtheprivatesectoractorsplayinwealth,economicdevelopment,andpartnershipaspartofthemulti-sectoralapproachandthatWHOissensitivetoensuringitsworkoneconomicandcommercialdeterminantsisreflectiveofboththepositiveandnegativeexternalitiestocommercialpractices.

MsKosinskamentionedthatCDHisbecominganincreasinglyimportantareaofinquiryforpublichealthbecauseoftherolethatcommercialactorsplaythroughoutthesocialdeterminantsthatinfluenceourhealth.Ahigh-levelstrategicmeetingonthesocialdeterminantsofhealthheldinGenevain2019identifiedtheriseofCDHanditsdirectimpactonhealthparticularlynegativelyandWHOwasaskedtoscopethisfurther.Thepurposeoftheregionalconsultationistocontributetothisscoping,buildingontheexistingworkofWHOtocoverthespectrumofcorporatebehaviourfromsupplychainsthroughregulatoryinfluenceandembeddingcommercialdynamicswithinsocialdeterminants.Thelensthatneedstobeappliedonthisemergingfieldofenquiryisofpower,ofequityinhealth,andofgovernance.

MsKosinskahighlightedfourkeychallenges:

.Commercialpracticesareembeddedwithinbroadereconomicandfinancialenvironmentsandtheseeconomicdriversactastheeconomicdeterminantsandenablersthatcreatetheconditionsinwhichcommercialactorsoperateandimpactpublichealth

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.Thereisaneedtoquantifyandqualifyintermsoftheharmarisingfromcommercialpractices,andwhobearsthecostsoftheseharms–toooftenthosewhocan’taffordthem.

.Thehealthsectorneedsstrengtheningtounderstandandaddresstheimpactandtheoutcomesofnegativeexternalitiesfromthecommercialdeterminantsofhealth.

.Ensurethatthefocusisonbothconflictsofinterestandmanagementofrisksandmaintainsanequitylensonhealthoutcomesarisingfromcommercialpractices.

Therefore,itisimperativetothinkaboutthepathwaysavailabletogovernmenttoshiftcommercialpracticesfromhealth-harmingtobecominghealth-enablingandhealth-promoting.ThefirstbookpublishedonCDHdefinescommercialdeterminantsverybroadlyasanyactivityoftheprivatesector.However,recentlyintheLancetseries,aninternationalgroupofscholarsdefinedCDHassystems,practices,andpathwaysinwhichcommercialactorsdrivehealthandhealthequity.Itisessentialtostartlookingattheseimpactpathwaysandoutcomesalittlebitmoreclosely.Itisequallyimportanttomakeameaningfuldistinctionbetweenthecommercialactorsbasedonthenatureoftheirhealthimpacts.InCDH,thetermcommercialreflectsthecomplexityandtheheterogeneitythatexistswithinthebroaderprivatesector.Commercialactorscanbeprivatelyowned,buttheycanalsobeownedbythepublicsector,orindeedbynot-for-profitentities–theirclassificationasacommercialactorisnotaccordingtotheirownership,butratherwhethertheyengageincommercialpractices.

WHOisusingaworkingimpactframeworkwhichconsistsoffourdomains:twoimpactdomainsandtwoactivitydomains.Thetwomaingroupsofactivitiesthatdrivecommercialimpactsonhealthinclude:

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.Thefirstiscorecommercialbusinessoperationsthroughthesupplychaininthedesignandsaleofproductsandservice,andparticipationwithinthemarket.Thisalsoincludesmarketingactivitiesandtheirimpactonsupplychainsorontheiremployees.

.Thesecondiscommercialcitizenshiporpersonhood.Thatiswhencommercialactorsactasinstitutions,throughCSRactivities,publicrelations,politicalactivities,lobbying,butalsothroughtheircontributionstonationaltaxbudgets;nationaltaxcontributions,budgetsandthroughthird-partyactivity,suchasfundingbusinessassociationsand‘Astroturf’ornot-for-profitactors.

Theimpactscanalsobegroupedintotwodomains.First,theimpactsonphysicalorsocialenvironmentsandultimately