From policy coherence to 21st century convergence: a whole-of-society paradigm of human and economic development

Human Factors in Leveraging Systems Science to Shape Public Policy for Obesity: A Usability Study

Background: despite a broad consensus on their importance, applications of systems thinking in policymaking and practice have been limited. This is partly caused by the longstanding practice of developing systems maps and software in the intention of supporting policymakers, but without knowing their needs and practices. Objective: we aim to ensure the effective use of a systems mapping software by policymakers seeking to understand and manage the complex system around obesity, physical, and mental well-being. Methods: we performed a usability study with eight policymakers in British Columbia based on a software tool (ActionableSystems) that supports interactions with a map of obesity. Our tasks examine different aspects of systems thinking (e.g., unintended consequences, loops) at several levels of mastery and cover common policymaking needs (identification, evaluation, understanding). Video recordings provided quantitative usability metrics (correctness, time to completion) individually and for the group, while pre- and post-usability interviews yielded qualitative data for thematic analysis. Results: users knew the many different factors that contribute to mental and physical well-being in obesity; however, most were only familiar with lower-level systems thinking concepts (e.g., interconnectedness) rather than higher-level ones (e.g., feedback loops). Most struggles happened at the lowest level of the mastery taxonomy, and predominantly on network representation. Although participants completed tasks on loops and multiple pathways mostly correctly, this was at the detriment of spending significant time on these aspects. Results did not depend on the participant, as their experiences with the software were similar. The thematic analysis revealed that policymakers did not have a typical workflow and did not use any special software or tools in their policy work; hence, the integration of a new tool would heavily depend on individual practices. Conclusions: there is an important discrepancy between what constitutes systems thinking to policymakers and what parts of systems thinking are supported by software. Tools may be more successfully integrated when they include tutorials (e.g., case studies), facilitate access to evidence, and can be linked to a policymaker’s portfolio.

Authority in tobacco control in Pacific Small Island Developing States: a qualitative study of multisectoral tobacco governance in Fiji and Vanuatu

OBJECTIVE

Small Island Developing States (SIDS) struggle with implementing multisectoral tobacco control measures, and health sector actors often lack capacity to forge multisectoral commitment. This study aims to explore the sources and dynamics of authority that can enable multisectoral collaboration despite the divergence of policy agendas in tobacco control.

METHODS

We applied a qualitative, explorative case study design, with data collection and analysis guided by an analytical framework that identifies sources and dynamics of authority. Seventy interviews were conducted in Fiji and Vanuatu between 2018 and 2019.

RESULTS

The key features shaping multisectoral coordination for tobacco control in Fiji and Vanuatu are the expert, institutional, capacity-based and legal authority that state and non-state actors have in tobacco governance. The amount of authority actors can secure from these sources was shown to be influenced by their performance (perceived or real), the discourse around tobacco control, the existing legal tools and their strategic alliances. SIDS vulnerabilities, arising from small size, isolation and developing economies, facilitate an economic growth discourse that reduces health sector actors' authority and empowers protobacco actors to drive tobacco governance.

CONCLUSIONS

Our results highlight the need for terms of engagement with the tobacco industry to enable governments to implement multisectoral tobacco control measures. Expanding assistance on tobacco control among government and civil society actors and increasing messaging about the impact of economic, trade and agricultural practices on health are essential to help SIDS implement the Framework Convention on Tobacco Control.

Governing ultra-processed food and alcohol industries: the presence and role of non-government organisations in Australia

OBJECTIVE

The roles of non-governmental organisations (NGOs) in regulating harmful commodity industries (HCIs) are understudied. The aim of this paper is to identify the NGOs and the roles that they play in the governance of the ultra-processed food and alcohol industries in Australia.

METHODS

We undertook an exploratory descriptive analysis of NGOs identified from an online search based on the typology we developed of type, issue area and governance function.

RESULTS

A total of 134 relevant Australian NGOs were identified: 38 work on food issues, 61 with alcohol issues and 35 are active in both. In the food domain, 90% of NGOs engage in agenda setting, 88% in capacity building, 15% in implementation and 12% in monitoring. In the alcohol domain, 92% of NGOs are active in agenda setting, 72% in capacity building, 35% in implementation and 8% in monitoring.

CONCLUSIONS

Australian NGOs are active actors in the food and alcohol governance system.

IMPLICATIONS FOR PUBLIC HEALTH

There are many opportunities for NGOs to regulate HCI practices, building on their relative strengths in agenda setting and capacity building, and expanding their activities in monitoring and implementation. A more detailed examination is needed of strategies that can be used by NGOs to be effective regulators in the governance system.

Coherence for nutrition: insights from nutrition-relevant policies and programmes in Burkina Faso and Nigeria

There is consensus that policy coherence is necessary for implementing effective and sustainable approaches to tackle malnutrition. We look at whether policies and programmes provide a coherent pathway to address nutrition priorities and if programmes are designed to deliver interventions aligned to the nutrition policy agenda in Nigeria and Burkina Faso. A systematic desk review was performed on nutrition-relevant policy and programme documents, obtained through grey literature searches and expert recommendations. We developed a framework with an impact pathway structure that includes five process steps, which was used to guide coding, data reduction and synthesis and structure the analysis. We assessed internal coherence along process steps within a given document and external coherence across process steps for explicitly linked policy/programme pairs. The majority of policies and programmes had partial internal coherence for both countries. The identification of relevant nutrition interventions to address challenges and reach objectives was the strongest connection within policies (16 out of 45 had complete coherence), while among programmes, the strongest connection was coverage indicators that measure interventions (9 out of 21 had complete coherence). Eight programmes explicitly referenced at least one nutrition-relevant policy, with a total of 16 linked policy/programme pairs (13 pairs for Burkina Faso and 3 for Nigeria) across health, nutrition, agriculture and social focus areas. However, none of the linked pairs were assessed to have complete external coherence, suggesting that priorities at the policy level are not fully realized nor translated at the programme level. This study offers a new approach for the assessment of policy and programme coherence and specifically examines policy and programme linkages. We conclude that improved leadership on country priority setting and better alignment for nutrition within and across sectors is needed to enhance the effectiveness of nutrition investments.

Exploring Pathways of Socioeconomic Inequity in Vegetable Expenditure Among Consumers Participating in a Grocery Loyalty Program in Quebec, Canada, 2015-2017

Vegetable consumption remains consistently low despite supportive policy and investments across the world. Vegetables are available in great variety, ranging in their processing level, availability, cost, and arguably, nutritional value. A retrospective longitudinal study was conducted in Quebec, Canada to explore pathways of socioeconomic inequity in vegetable expenditure. Data was obtained for consumers who participated in a grocery loyalty program from 2015 to 2017 and linked to the 2016 Canadian census. Vegetable expenditure share (%) was examined as a fraction of the overall food basket and segmented by processing level. Panel random effects and tobit models were used overall and to estimate the stratified analysis by median income split. Consumers allocated 8.35% of their total food expenditure to vegetables, which was mostly allocated to non-processed fresh (6.88%). Vegetable expenditure share was the highest in early winter and lowest in late summer. In the stratified analysis, the low-income group exhibited less seasonal variation, allocated less to fresh vegetables, and spent more on canned and frozen compared to the high-income group. Measures of socioeconomic status were all significant drivers of overall vegetable consumption. Consumers with high post-secondary education in the low-income group spent 2% more on vegetables than those with low education. The complexity of observed expenditure patterns points to a need for more specific vegetable consumption guidelines that include provisions by processing level. Implications for education, marketing, intersectional policies, and the role of government are discussed. Governments can scale present efforts and catalyze health-promoting investments across local, state, national, and global food systems.

Guidelines for Operationalizing Policy Coherence for Development (PCD) as a Methodology for the Design and Implementation of Sustainable Development Strategies

Policy Coherence for Development (PCD) is considered a pillar of the 2030 Sustainable Development Agenda. It aims to promote whole of government approaches to sustainable development. Despite its prominence in development cooperation discussions, many national development professionals or stakeholders have not heard of PCD, indicating that its effectiveness is significantly limited. This article contends that the impact of PCD has not been maximized because it has been presented as a political objective or a policy tool by multilateral organizations and their member states. Instead, the article argues that PCD should be implemented as a methodology that can be adopted by domestic government and non-governmental actors alike, in order to understand trade-offs and co-benefits within and between policy sectors, thus promoting a participative approach. I-GAMMA is a research project in Mexico that examines data-driven public policy in order to promote PCD. It is based on in-depth reviews of policy documents and interviews with development actors. It is committed to open data, evidence-based policymaking, and collaborative dialogue between academics, government officials, and representatives of civil society organizations in sustainable development discussions. In the results section of this article, the project proposes participative PCD as a methodology for policy analysis through which a plurality of actors can identify mechanisms that either reinforce or undermine sustainable development strategies. This section then applies the methodology to the governance of protected natural areas in Mexico. The discussion section and the conclusions highlight the relevance of this approach for participative policymaking in sustainable development.

How Neoliberalism Is Shaping the Supply of Unhealthy Commodities and What This Means for NCD Prevention

Alcohol, tobacco, and unhealthy foods contribute greatly to the global burden of non-communicable disease (NCD). Member states of the World Health Organization (WHO) have recognized the critical need to address these three key risk factors through global action plans and policy recommendations. The 2013-2020 WHO action plan identifies the need to engage economic, agricultural and other relevant sectors to establish comprehensive and coherent policy. To date one of the biggest barriers to action is not so much identifying affective policies, but rather how a comprehensive policy approach to NCD prevention can be established across sectors. Much of the research on policy incoherence across sectors has focused on exposing the strategies used by commercial interests to shape public policy in their favor. Although the influence of commercial interests on government decisions remains an important issue for policy coherence, we argue, that the dominant neoliberal policy paradigm continues to enable the ability of these interests to influence public policy. In this paper, we examine how this dominant paradigm and the way it has been enshrined in institutional mechanisms has given rise to existing systems of governance of product environments, and how these systems create structural barriers to the introduction of meaningful policy action to prevent NCDs by fostering healthy product environments. Work to establish policy coherence across sectors, particularly to ensure a healthy product environment, will require systematic engagement with the assumptions that continue to structure institutions that perpetuate unhealthy product environments.

Comparative institutional analysis for public health: governing voluntary collaborative agreements for public health in England and the Netherlands

Democratic institutions and state-society relations shape governance arrangements and expectations between public and private stakeholders about public health impact. We illustrate this with a comparison between the English Public Health Responsibility Deal (RD) and the Dutch 'All About Health…' (AaH) programme. As manifestations of a Whole-of-Society approach, in which governments, civil society and business take responsibility for the co-production of economic utility and good health, these programmes are two recent collaborative platforms based on voluntary agreements to improve public health. Using a 'most similar cases' design, we conducted a comparative secondary analysis of data from the evaluations of the two programmes. The underlying rationale of both programmes was that voluntary agreements would be better suited than regulation to encourage business and civil society to take more responsibility for improving health. Differences between the two included: expectations of an enforcing versus facilitative role for government; hierarchical versus horizontal coordination; big business versus civil society participants; top-down versus bottom-up formulation of voluntary pledges and progress monitoring for accountability versus for learning and adaptation. Despite the attempt in both programmes to base voluntary commitments on trust, the English 'shadow of hierarchy' and adversarial state-society relationships conditioned non-governmental parties to see the pledges as controlling, quasi-contractual agreements that were only partially lived up to. The Dutch consensual political tradition enabled a civil society-based understanding and gradual acceptance of the pledges as the internalization by partner organizations of public health values within their operations. We conclude that there are institutional limitations to the implementation of generic trust-building and learning-based models of change 'Whole-of-Society' approaches.

Establishing a Demographic, Development and Environmental Geospatial Surveillance Platform in India: Planning and Implementation

BACKGROUND

Inadequate administrative health data, suboptimal public health infrastructure, rapid and unplanned urbanization, environmental degradation, and poor penetration of information technology make the tracking of health and well-being of populations and their social determinants in the developing countries challenging. Technology-integrated comprehensive surveillance platforms have the potential to overcome these gaps.

OBJECTIVE

This paper provides methodological insights into establishing a geographic information system (GIS)-integrated, comprehensive surveillance platform in rural North India, a resource-constrained setting.

METHODS

The International Clinical Epidemiology Network Trust International established a comprehensive SOMAARTH Demographic, Development, and Environmental Surveillance Site (DDESS) in rural Palwal, a district in Haryana, North India. The surveillance platform evolved by adopting four major steps: (1) site preparation, (2) data construction, (3) data quality assurance, and (4) data update and maintenance system. Arc GIS 10.3 and QGIS 2.14 software were employed for geospatial data construction. Surveillance data architecture was built upon the geospatial land parcel datasets. Dedicated software (SOMAARTH-1) was developed for handling high volume of longitudinal datasets. The built infrastructure data pertaining to land use, water bodies, roads, railways, community trails, landmarks, water, sanitation and food environment, weather and air quality, and demographic characteristics were constructed in a relational manner.

RESULTS

The comprehensive surveillance platform encompassed a population of 0.2 million individuals residing in 51 villages over a land mass of 251.7 sq km having 32,662 households and 19,260 nonresidential features (cattle shed, shops, health, education, banking, religious institutions, etc). All land parcels were assigned georeferenced location identification numbers to enable space and time monitoring. Subdivision of villages into sectors helped identify socially homogenous community clusters (418/676, 61.8%, sectors). Water and hygiene parameters of the whole area were mapped on the GIS platform and quantified. Risk of physical exposure to harmful environment (poor water and sanitation indicators) was significantly associated with the caste of individual household (P=.001), and the path was mediated through the socioeconomic status and density of waste spots (liquid and solid) of the sector in which these households were located. Ground-truthing for ascertaining the land parcel level accuracies, community involvement in mapping exercise, and identification of small habitations not recorded in the administrative data were key learnings.

CONCLUSIONS

The SOMAARTH DDESS experience allowed us to document and explore dynamic relationships, associations, and pathways across multiple levels of the system (ie, individual, household, neighborhood, and village) through a geospatial interface. This could be used for characterization and monitoring of a wide range of proximal and distal determinants of health.

Fostering the Catalyst Role of Government in Advancing Healthy Food Environments

Effective approaches to non-communicable disease (NCD) prevention require intersectoral action targeting health and engaging government, industry, and society. There is an ongoing vigorous exploration of the most effective and appropriate role of government in intersectoral partnerships. This debate is particularly pronounced with regards to the role of government in controlling unhealthy foods and promoting healthy food environments. Given that food environments are a key determinant of health, and the commercial sector is a key player in shaping such environments (eg, restaurants, grocery stores), the relationship between government and the commercial sector is of primary relevance. The principal controversy at the heart of this relationship pertains to the potential influence of commercial enterprises on public institutions. We propose that a clear distinction between the regulatory and catalyst roles of government is necessary when considering the nature of the relationship between government and the commercial food sector. We introduce a typology of three catalyst roles for government to foster healthy food environments with the commercial sector and suggest that a richer understanding of the contrasting roles of government is needed when considering approaches NCD prevention via healthy food environments.

Using Agent-Based Models to Develop Public Policy about Food Behaviours: Future Directions and Recommendations

Most adults are overweight or obese in many western countries. Several population-level interventions on the physical, economical, political, or sociocultural environment have thus attempted to achieve a healthier weight. These interventions have involved different weight-related behaviours, such as food behaviours. Agent-based models (ABMs) have the potential to help policymakers evaluate food behaviour interventions from a systems perspective. However, fully realizing this potential involves a complex procedure starting with obtaining and analyzing data to populate the model and eventually identifying more efficient cross-sectoral policies. Current procedures for ABMs of food behaviours are mostly rooted in one technique, often ignore the food environment beyond home and work, and underutilize rich datasets. In this paper, we address some of these limitations to better support policymakers through two contributions. First, via a scoping review, we highlight readily available datasets and techniques to deal with these limitations independently. Second, we propose a three steps' process to tackle all limitations together and discuss its use to develop future models for food behaviours. We acknowledge that this integrated process is a leap forward in ABMs. However, this long-term objective is well-worth addressing as it can generate robust findings to effectively inform the design of food behaviour interventions.

Agriculture, health, and wealth convergence: bridging traditional food systems and modern agribusiness solutions

The causes of many vexing challenges facing 21st-century society are at the nexus of systems involved in agriculture, health and wealth production, consumption, and distribution. Using food as a test bed, and on the basis of emerging roadmaps that set achievable objectives over a 1- to 3-year horizon, we introduce this special feature with convergence thinking and practice at its core. Specifically, we discuss academic papers structured around four themes: (1) evidence for a need for convergence and underlying mechanisms at the individual and societal levels; (2) strategy for mainstreaming convergence as a driver of business engagement and innovation; (3) convergence in policy and governance; (4) convergence in metrics and methods. Academic papers under each theme are accompanied by a roadmap paper reporting on the current status of concrete transformative convergence-building projects associated with that theme. We believe that the insights provided by these papers have the potential to enable all actors throughout society to singly and collectively work to build supply and demand for nutritious food, in both traditional and modern food systems, while placing the burdens of malnutrition and ill health on their core strategic agendas.

A nutrition/health mindset on commercial Big Data and drivers of food demand in modern and traditional systems

Building greater reciprocity between traditional and modern food systems and better convergence of human and economic development outcomes may enable the production and consumption of accessible, affordable, and appealing nutritious food for all. Information being key to such transformations, this roadmap paper offers a strategy that capitalizes on Big Data and advanced analytics, setting the foundation for an integrative intersectoral knowledge platform to better inform and monitor behavioral change and ecosystem transformation. Building upon the four P's of marketing (product, price, promotion, placement), we examine digital commercial marketing data through the lenses of the four A's of food security (availability, accessibility, affordability, appeal) using advanced consumer choice analytics for archetypal traditional (fresh fruits and vegetables) and modern (soft drinks) product categories. We demonstrate that business practices typically associated with the latter also have an important, if not more important, impact on purchases of the former category. Implications and limitations of the approach are discussed.

An innovative approach to addressing childhood obesity: a knowledge-based infrastructure for supporting multi-stakeholder partnership decision-making in Quebec, Canada

Multi-stakeholder partnerships (MSPs) have become a widespread means for deploying policies in a whole of society strategy to address the complex problem of childhood obesity. However, decision-making in MSPs is fraught with challenges, as decision-makers are faced with complexity, and have to reconcile disparate conceptualizations of knowledge across multiple sectors with diverse sets of indicators and data. These challenges can be addressed by supporting MSPs with innovative tools for obtaining, organizing and using data to inform decision-making. The purpose of this paper is to describe and analyze the development of a knowledge-based infrastructure to support MSP decision-making processes. The paper emerged from a study to define specifications for a knowledge-based infrastructure to provide decision support for community-level MSPs in the Canadian province of Quebec. As part of the study, a process assessment was conducted to understand the needs of communities as they collect, organize, and analyze data to make decisions about their priorities. The result of this process is a “portrait”, which is an epidemiological profile of health and nutrition in their community. Portraits inform strategic planning and development of interventions, and are used to assess the impact of interventions. Our key findings indicate ambiguities and disagreement among MSP decision-makers regarding causal relationships between actions and outcomes, and the relevant data needed for making decisions. MSP decision-makers expressed a desire for easy-to-use tools that facilitate the collection, organization, synthesis, and analysis of data, to enable decision-making in a timely manner. Findings inform conceptual modeling and ontological analysis to capture the domain knowledge and specify relationships between actions and outcomes. This modeling and analysis provide the foundation for an ontology, encoded using OWL 2 Web Ontology Language. The ontology is developed to provide semantic support for the MSP process, defining objectives, strategies, actions, indicators, and data sources. In the future, software interacting with the ontology can facilitate interactive browsing by decision-makers in the MSP in the form of concepts, instances, relationships, and axioms. Our ontology also facilitates the integration and interpretation of community data, and can help in managing semantic interoperability between different knowledge sources. Future work will focus on defining specifications for the development of a database of indicators and an information system to help decision-makers to view, analyze and organize indicators for their community. This work should improve MSP decision-making in the development of interventions to address childhood obesity.

Convergent innovation for sustainable economic growth and affordable universal health care: innovating the way we innovate

This paper introduces convergent innovation (CI) as a form of meta-innovation-an innovation in the way we innovate. CI integrates human and economic development outcomes, through behavioral and ecosystem transformation at scale, for sustainable prosperity and affordable universal health care within a whole-of-society paradigm. To this end, CI combines technological and social innovation (including organizational, social process, financial, and institutional), with a special focus on the most underserved populations. CI takes a modular approach that convenes around roadmaps for real world change-a portfolio of loosely coupled complementary partners from the business community, civil society, and the public sector. Roadmaps serve as collaborative platforms for focused, achievable, and time-bound projects to provide scalable, sustainable, and resilient solutions to complex challenges, with benefits both to participating partners and to society. In this paper, we first briefly review the literature on technological innovation that sets the foundations of CI and motivates its feasibility. We then describe CI, its building blocks, and enabling conditions for deployment and scaling up, illustrating its operational forms through examples of existing CI-sensitive innovation.

Convergent innovation for affordable nutrition, health, and health care: the global pulse roadmap

The paper outlines how the principles of convergent innovation (CI) can be applied to bring about a transformation in the pulse value chain. The paper presents three pioneering CI initiatives--two in conception and one in operation--by various actors in the pulse ecosystem, which are delivering economic and human development impact in particular segments of the pulse value chain. It goes on to propose the way forward to scale up these efforts and connect them into a roadmap so as to achieve transformation throughout society, calling into action a number of actors in the ecosystem.

Whole-of-society approach for public health policymaking: a case study of polycentric governance from Quebec, Canada

In adopting a whole-of-society (WoS) approach that engages multiple stakeholders in public health policies across contexts, the authors propose that effective governance presents a challenge. The purpose of this paper is to highlight a case for how polycentric governance underlying the WoS approach is already functioning, while outlining an agenda to enable adaptive learning for improving such governance processes. Drawing upon a case study from Quebec, Canada, we employ empirically developed concepts from extensive, decades-long work of the 2009 Nobel laureate Elinor Ostrom in the governance of policy in nonhealth domains to analyze early efforts at polycentric governance in policies around overnutrition, highlighting interactions between international, domestic, state and nonstate actors and processes. Using information from primary and secondary sources, we analyze the emergence of the broader policy context of Quebec's public health system in the 20th century. We present a microsituational analysis of the WoS approach for Quebec's 21st century policies on healthy lifestyles, emphasizing the role of governance at the community level. We argue for rethinking prescriptive policy analysis of the 20th century, proposing an agenda for diagnostic policy analysis, which explicates the multiple sets of actors and interacting variables shaping polycentric governance for operationalizing the WoS approach to policymaking in specific contexts.