Alison Barrett writes:
Public health leaders are calling for policy makers and governments to consider the role of commercial interests and entities in influencing population health, as a global study reveals how the commercial determinants of health influenced health system responses during the pandemic, as well as the availability of COVID-19 vaccines.
The research also found that commercial determinants may have contributed to the origins and spread of COVID-19 through intensive agriculture, deforestation and industrial animal farming.
Authors of the study highlight the need to regulate and address negative commercial determinants. Their comparative qualitative case study analysed 16 countries’ response to the pandemic between January 2020 and March 2022, including Australia, Ethiopia, New Zealand, Nigeria, Taiwan, South Korea, Thailand, Vietnam, Belgium, Brazil, India, Peru, South Africa, Spain, UK, and the United States.
The research found numerous examples, globally, of governments and policy making prioritising “commercial interests over what is good for the general public” in the context of the COVID-19 pandemic, according to lead author Dr Toby Freeman.
Freeman – Senior Research Fellow and Director of Research, Stretton Health Equity at the University of Adelaide’s Stretton Institute – told Croakey he would like to see the findings “contribute to the growing awareness that the interests of for-profit actors, particularly large corporations who are very powerful, can have a detrimental effect on the health of the populations”.
In the context of the COVID-19 pandemic, examples included commercial interests impacting procurement of personal protective equipment, lobbying against public health regulations aimed at reducing transmission, and by shaping work conditions – such as casualised, low income and precarious work – that influence infection risk.
“Working conditions need to improve as gig and informal work makes countries vulnerable in pandemics and can encourage spread of the virus,” Professor Fran Baum AO, Professor of Health Equity at The Stretton Institute, University of Adelaide, told Croakey.
Shining a light
Professor Martin McKee from the London School of Hygiene and Tropical Medicine, and another co-author, told Croakey the pandemic “shone a light on the weaknesses that existed within our societies, weaknesses that had been hidden for far too long”.
“But these weaknesses did not arise by chance,” he said. “They were created by political and commercial forces that had designed the conditions in which we lived to benefit the few rather than the many.”
McKee said while the British Government appears to be unwilling to tackle the problems highlighted in the study, some of the Parliamentary committees are showing “a willingness to hold the Government to account”.
He had also been “pleasantly surprised” by the willingness of the inquiry into the UK’s COVID response to “delve into the causes of the causes”.
Dr Jenn Lacy-Nicholls, Research Fellow in Commercial Determinants of Health at the Melbourne School of Population and Global Health, told Croakey in a statement that “the COVID-19 pandemic highlighted the risks of relying on for-profit companies to provide services such as healthcare and aged care”.
“This is not to say there is no role for business,” she said. “But, for some goods and services that are essential, a market-driven approach can mean that equity and access are subservient to profits.”
She said, as the authors note, there “needs to be a real conversation about ‘winding back’ privatisation and rebuilding public sector capacity, including in healthcare, aged care, logistics and others. Private equity acquisitions in healthcare are a key area for scrutiny and concern”.
Public good
Countries that “emphasised a strong public sector response” to the pandemic – Taiwan, South Korea, Thailand, Vietnam and New Zealand – tended to experience better health outcomes than those “plagued with controversies around commercial interests”, the research found.
Countries that had a stronger emphasis on governing for population health as a public good “were able to better safeguard health through public health regulations, better procurement and supporting people’s capacity to isolate,” Freeman said.
For example, the Vietnam, Taiwan and South Korean Governments were able to support universal access to masks, including prioritising to healthcare workers by effectively engaging with private mask production companies, according to findings in the study.
In contrast, Australia’s outsourcing of quarantine to the private hotel sector – rather than purpose-built facilities – and security to privatised companies – was heavily criticised.
The UK Government was criticised for outsourcing vital COVID-19 public health responsibilities – such as contact tracing and testing centres – to private companies that resulted in poor outcomes.
Baum told Croakey she hoped the paper’s finding would encourage governments to “realise the importance of governing the commercial sector in times of crisis” and the ways in which the commercial sector is often less efficient than the public sector.
Powerful pharmaceutical interests exacerbated vaccine procurement challenges. Countries including India and South Africa were prevented from manufacturing their own vaccines as the Trade-Related Aspects of Intellectual Property Rights waiver was stalled for almost two years.
Lacy-Nicholls said there “needs to be much more work on addressing the barriers that intellectual property regimes present for access to vaccines”.
Privatisation
Privatisation in the health sector undermines a country’s long-term pandemic preparedness, according to the study, which reported an analysis of 147 countries showing that “countries with greater private health expenditure had more COVID-19 cases and deaths”.
This is seen in the US where the “private model of primary care proved extremely vulnerable to the reduction in routine care”. Another key characteristic of healthcare in the US is the prominence of employer-provided health insurance. Many people lost their health insurance coverage – and thus ability to access affordable healthcare – when they lost jobs during the pandemic.
In contrast, countries with universal healthcare and a rapid government and community response meant “that the public health system was able to cope with the relatively low level of COVID cases”, according to the paper.
While noting that limited evidence is available of the commercial determinants of health influence on privatised aged care and prisons, the authors highlight some areas of concern.
Outbreaks in aged care facilities were a “global phenomenon” caused by multiple factors including age and health characteristics of residents and higher risk living environments worsened by insufficient resources and staff.
Concerns raised about privatised aged care include the shifting of decision-making power to private companies that may enable a lack of transparency and that staff in private aged care may have lower income and higher precarity which increases infection risk.
Similar concerns have been raised about privatisation of prisons – which is very common in Australia. The report questions how much influence governments “can have over the COVID-19 response of private prisons”.
Calls to action
Lacy-Nicholls said stronger regulations – with enforcement mechanisms – are needed to hold businesses to high standards.
“This could include mandating minimum employment standards with regards to benefits and pay, especially for essential workers,” she said.
Additionally, she said perhaps one of the most challenging issues “is that governments rely on private sector partners because they lack sufficient public resources. More progressive tax codes can serve the dual purpose of funding the public sector and closing the wealth gap.”
Similarly, Freeman said that policy makers could build up public institutions and capacity – including in policy development and in healthcare – so that we are better equipped to respond to crises, including future pandemics and climate emergencies.
“Having greater public capacity to respond will enable us to prioritise public good goals, which we found private systems often failed to do,” he said. “This could include reflection on whether the public subsidisation of private health insurance could not be better spent on public capacity to respond to pandemics or other health crises.”
Additionally, Freeman told Croakey that policy makers could work to “ensure structures don’t foster commercial interests over public good goals”.
Global perspectives
Kelley Lee, Professor in Global Health Governance at Simon Fraser University in Canada, told Croakey in a statement that during a major public health emergency such as the COVID-19 pandemic, “the pressures to respond in real time can lead to less oversight over conflicts of interest between public and private interests when it comes, for example, to government procurement, contracting and lobbying”.
Lee said “the Canadian Government needs to evaluate whether existing checks and balances were applied appropriately to ensure public interests were driving Canada’s response. There are reports of situations where this was not the case such as the procurement of PPE and disproportionately loud commercial voices in policy decisions.”
However, unlike in other countries, Canada will not be holding a public inquiry on its pandemic response, “so it is not clear how these lessons will be learned”, she said.
“An assessment is needed, not just for improving government processes, but for providing the transparency and accountability needed to rebuild public trust.”
Lee added that no two pandemics are the same so the policy responses needed next time may be quite different from those applied during COVID-19.
“In future pandemics, the private sector will also still play an important role as producers of essential goods and services, employers, and generally in helping to keep Canadian society functioning. What we need to prevent is private for-profit interests being given undue priority or insufficiently regulated, resulting in unfair competition, profiteering, inappropriate marketing and advertising, and other practices that harm the public interest.
“The key actions build on assessing how existing checks and balances were applied, and whether these need to be made more robust. As Canada moves to invest heavily in domestic biomanufacturing, rules are needed on how publicly funded research must be tied to equitable access in Canada and globally. There must also be price controls on essential services that were contracted out such as testing.”
Nicholas Freudenberg, Distinguished Professor of Public Health at the City University of New York School of Public Health, told Croakey that the study by Freeman and colleagues “makes an important contribution to the literature. Translating the lessons from this study into public health practice and policy that responds to the COVID and future pandemics is a critical priority”.
Freudenberg said that both short-term and long-term changes are needed. “In the shorter term, public health authorities need to ensure that vaccines, COVID treatments, and personal protective equipment are equitably distributed based on need and risk, not on the potential of manufacturers to maximise profits on these products. This will require even stronger international regulations and governance processes that ensure that health concerns, not commercial ones, drive such agreements.
“The COVID pandemic elevated the concept of essential workers, showing that food workers, healthcare providers, and teachers were as vital to collective security as police, soldiers or private equity investors.
“But we also learned that public policies do not yet provide these essential workers with the working conditions that enable them to sustain their essential functions. Businesses that pay essential workers inadequate wages or fail to provide health and safety protections acted as vectors of COVID infection. Correcting this misalignment should be a priority.”
Flawed food systems
In the longer term, Freudenberg said, the pandemic highlighted two long term adverse consequences of a political and economic system where profit rather than human and planetary well-being shape social arrangements.
“In recent decades, the global food industry has increasingly produced food high in calories, fat, salt, sugar and dozens of additives and supplements, business decisions that public health researchers now believe contribute to the rising global burden of diet-related diseases,” he said.
“By not confronting this threat to public health earlier, our governments created the conditions where hundreds of millions of individuals were more vulnerable to COVID infection because their diets were so reliant on highly processed products.
“By creating a food system that puts health first, by making healthy food more available, cheaper and tastier than unhealthy food, we can avoid the devastating consequences of both infectious disease epidemics and the non-communicable diseases that prey on those whose diets put them at risk.”
Similarly, he said, healthcare systems that distribute access to care based on ability to pay exacerbate the international and local health inequities that lack of access to adequate health care create.
“In the COVID pandemic, countries whose healthcare systems are most shaped by commercial actors widened gaps in health between the better off and the poor whereas those countries with more equitable access to care did better. To avoid similar gaps from subsequent pandemics, countries need to establish the principle that all people have a right to adequate healthcare.”
See Croakey’s archive of articles on the commercial determinants of health and on COVID.
