The One Health agenda has progressed from a conceptual acknowledgement of human–animal–environment interdependence to a global framework for coordinated action, exemplified by the Quadripartite One Health Joint Plan of Action (2022–2026). The Joint Plan sets out high-level objectives across six action tracks, while the 2023 national implementation guide supports countries in adopting and adapting those objectives to their own contexts. This paper examines nursing as a systems profession within One Health, using the six action tracks as an analytic framework. Across the tracks, we distinguish established nursing functions from opportunities for those functions to be more explicitly recognised, formalised and evaluated during national implementation. We identify four recurring functions: continuity and coordination; early recognition, monitoring and escalation; risk communication, education and community engagement; and the implementation of preventive and protective practices. Their application varies across action-track objectives, including outbreak preparedness and response, food safety, antimicrobial stewardship and environmental health. The scope and form of these contributions also vary according to professional regulation, education, workforce capacity, service configuration and participation in governance. We derive track-informed implications for national adaptation, workforce development, service design and research, and identify the conditions under which nursing contributions can be explicitly recognised and evaluated within national One Health implementation.
The National Essential Medicines List (NEML) selection process is a foundational component of an essential medicines based policy, and the NEML itself is a key policy tool. The World Health Organization (WHO) provides guidance for policy development that aligns with the Accountability for Reasonableness (AFR) framework, along with a model Essential Medicines List (EML) to support NEML selection process development. An effective selection process is one that aligns with international guidelines and leads to the selection of a NEML that addresses the priority healthcare needs of a nation. This study uses a previously developed 16-item instrument to measure NEML selection process design effectiveness for all countries with publicly available information and examines AFR condition sub scores. NEML selection process design for countries with publicly available information was identified through a document review. A 16-item instrument was used to score the NEML selection process design effectiveness. AFR conditions sub scores were also determined by aggregating item scores mapped to each condition. Of 159 WHO member countries with a NEML, 143 (90
Integrated loan-and-grant aid models are increasingly promoted as a means of addressing fragmentation in global health. However, empirical evidence on how these complex aid models function in the real world remains limited. This study explored how the outcomes and structural constraints of Korea’s Concessional-loan and Grant-linked Aid (CGA) model are represented within institutional evaluation processes. This study employed qualitative content analysis of eight end-of-project evaluation reports of CGA projects in the healthcare sector, implemented across six low- and middle-income countries between 2015 and 2025. Treating the evaluation reports as policy artefacts, we applied a sequential hybrid analytical approach, combining inductive thematic coding with deductive mapping onto the WHO Health System Building Blocks as system domains and the OECD-DAC Evaluation Criteria as evaluative lenses. A total of 73 text segments were analysed across the eight reports. The evaluation narratives consistently highlighted immediate, facility-level operational gains, particularly in terms of service delivery, workforce capacity, and medical technology utilisation. However, a recurring pattern of ‘conditional success’ emerged, wherein these achievements coexisted with persistent structural vulnerabilities. The analysis identified critical ‘timeline mismatches’ between the rapid deployment of capital infrastructure through concessional loans and the more gradual processes of human capacity-building through grants. Furthermore, the narratives portrayed long-term system integration as constrained by high staff turnover and limited domestic fiscal capacity for ongoing maintenance. The evaluation narratives suggested that, within the studied cases, operational improvements associated with blended-aid arrangements coexisted with continuing challenges to sustained health system integration. They portrayed such integration as contingent not only on financial alignment but also on the coordination of implementation timelines and capacity-development cycles. The findings support considering project-level mechanisms for cross-agency coordination and post-project continuity during early-stage project planning and host-country arrangements. Ultimately, the evaluation narratives highlight the value of reflexive approaches that examine underlying structural constraints alongside reported project-level achievements. Not applicable.
Non-communicable diseases (NCDs) are rising rapidly in South Africa, prompting the introduction of the Health Promotion Levy (HPL) in 2018 to reduce the consumption of sugar-sweetened beverages. However, the levy remains below the rate recommended by the World Health Organization. One of the central institutions involved in the policy process leading up to and following the introduction of the HPL was the National Economic Development and Labour Council (NEDLAC), a statutory body designed to promote dialogue between government, business, labour, and community constituencies. This study examined NEDLAC’s mandate and its actual role in the HPL process, with particular attention to the inclusivity and transparency of its deliberations. Using an exploratory case study design, the research drew on qualitative content analysis of documents obtained through an access to information request made under South Africa’s Promotion of Access to Information Act 2 of 2000. The findings indicate that NEDLAC’s engagement with the HPL process fell short of its mandate to advance social equity and inclusive participation in economic decision-making. Community representatives, one of NEDLAC’s four official constituencies, were absent from all deliberations on the levy. In contrast, business representatives dominated the discussions, often advancing arguments aligned with the interests of the sugar industry and emphasising potential job losses despite limited supporting evidence. Moreover, the process lacked transparency, particularly regarding the authorship of NEDLAC’s HPL Report and the presentation of evidence used to support its conclusions. NEDLAC’s handling of the HPL illustrates how participatory governance structures may, in practice, enable industry influence and weaken public health objectives. To enhance the integrity and effectiveness of policy dialogue on health-related fiscal measures, NEDLAC should adopt clearer procedural guidelines to ensure inclusive representation, strengthen transparency through public access to documentation, and institutionalise the role of civil society in its processes. Such reforms are essential to align participatory mechanisms with public health goals and to safeguard them from corporate capture.
Abstract Climate extremes, conflict, and population displacement converge in the Horn of Africa to accelerate outbreaks of climate-sensitive infectious diseases, whereas existing health surveillance systems remain fragmented and largely reactive. This Perspective examines the potential of artificial intelligence (AI) to strengthen climate–health early warning by integrating satellite earth observations, routine disease surveillance, and mobility-based vulnerability indicators into anticipatory decision support systems. Drawing on global experience and region-specific constraints, we identified critical barriers to implementation, including data fragmentation, infrastructure gaps, workforce shortages, governance silos, and unresolved ethical risks. We propose a five-layer conceptual framework for an AI-enabled Climate–Health Early Warning System (CHEWS) tailored to fragile and conflict-affected settings, alongside a phased regional policy roadmap anchored within the Intergovernmental Authority on Development (IGAD). Emphasizing data sovereignty, participatory governance, and privacy-by-design, this study positions AI-CHEWS as a feasible pathway for shifting the region from reactive outbreak responses to anticipatory public health actions that enhance climate resilience and equity. Clinical Trial Number: The authors declare that they have no competing interests.
Cross-border healthcare is increasingly visible in border regions where patient mobility develops faster than the institutional arrangements needed to support care. Existing research has often examined why patients seek care abroad, while less is known about how receiving health systems organise care after cross-border patients enter local hospitals. This study examined the receiving-system challenges faced by Guangxi, China, in responding to cross-border healthcare demand from Vietnamese patients. A qualitative study was conducted in Guangxi using semi-structured interviews with 35 participants, including 6 policymakers, 9 hospital administrators, 11 healthcare providers, and 9 Vietnamese patients. Participants were recruited through purposive sampling. Data were collected between March 2024 and May 2025. Interviews were conducted in Chinese, with Vietnamese-Chinese interpretation provided when needed for Vietnamese patients. Data were analysed using thematic analysis. Six interrelated receiving-system challenges were identified across the pre-treatment, treatment, and post-treatment stages of care: pre-arrival preparation and hospital admission coordination, patient-authorized clinical documentation transfer and verification, language mediation and culturally responsive communication, patient-and-family navigation and inpatient support, billing documentation and claim-support navigation, and structured post-discharge follow-up after return to Vietnam. These challenges show that receiving cross-border patients requires practical arrangements that connect admission preparation, usable clinical information, communication, family involvement, payment documentation, and follow-up into a coherent care process. Cross-border healthcare in the Guangxi-Vietnam border setting should be understood as a receiving-system coordination challenge. For border-region health systems where formal cross-border arrangements remain limited, strengthening receiving-system readiness may help make care safer, more understandable, and more continuous for patients whose treatment trajectories cross national boundaries.
The COVID-19 pandemic exposed large cross-country differences in mortality, vaccination rollout, and economic recovery. We examine whether stronger pre-pandemic institutions were associated with better pandemic performance and whether vaccination rollout helps explain part of that relationship. We combine 2019 World Bank Worldwide Governance Indicators with COVID-19 outcomes, policy measures, World Development Indicators, and V-Dem electoral democracy data, estimating cross-country regressions and a temporally ordered exploratory mediation model using vaccination by September 2021 and deaths accrued in the fourth quarter of 2021. In full multivariable specifications, a one-unit increase in the WGI composite is associated with 384 fewer reported COVID-19 deaths per million, 1,860 fewer excess deaths per million, and 15.5
Research on Palestinian mental health has expanded substantially over recent decades. However, limited attention has been paid to how this body of knowledge has been historically produced. Knowledge production is not neutral but rather shaped by broader global political dynamics that influence how research is framed, prioritized, funded, and legitimized. In contexts shaped by intractable conflict and structural inequality, examining knowledge production is essential to understanding how mental health is framed. This study offers a narrative-historical examination of academic knowledge on Palestinian mental health from 1948 to 2024, situating it within broader discussions in global health. Using a narrative review approach, 193 publications indexed in PsycINFO were analyzed across three periods and three population groups: Palestinians in the Gaza Strip, the West Bank, and Israel. An eight-dimensional analytical framework is applied: discourse, psychological concepts, theoretical frameworks, methodologies, producing institutions, political positioning, population subgroups, and research objectives. The findings show that despite substantial growth in research output, the field remains largely grounded in individualized, clinical, and Western psychological frameworks. Across periods, psychological distress is primarily conceptualized through constructs such as PTSD, anxiety, and depression, with limited adaptation to the Palestinian cultural context. Political and colonial conditions are frequently treated as background context rather than analytically integrated components of explanatory models. Finally, knowledge production is shaped by the involvement of international actors and broader academic structures, with limited local epistemic leadership. These findings highlight the need for greater attention to the conditions under which mental health knowledge is produced. Contextually grounded and structurally informed approaches are required. Finally, these local findings suggest the need to examine how health knowledge is shaped within unequal global structures and apply context-sensitive approaches to mental health research.
The beverage industry plays an influential role in the US. Certain beverages, such as sugar-sweetened, have long been recognized as key contributors to poor population health with inequitable impacts. In response, multiple US initiatives have attempted to address these problems through public awareness campaigns and policies, such as taxes. Yet, the persistent and increasing reliance on unhealthy commercial products produced by the beverage industry suggests additional progress is needed. Leveraging a systems thinking approach, this study aimed to map out the complex forces limiting progress and driving inequitable impacts of unhealthy commercial beverages in the US to inform innovative thinking about future actions. We facilitated a participatory group model building project to develop a systems model that depicts the main mechanisms underlying the increasing sales, marketing, and consumption of unhealthy commercial beverages. We convened 28 national experts from government, academia, advocacy, funding agencies, and community organizations for a series of workshops and interviews and supplemented their insights with other evidence (e.g., research, public records). The final systems model makes visible the multiple interacting pathways through which industry protects their profits and maintains the status quo. Some are well known, such as normalizing product purchasing, influencing policymakers in their favor, and shaping public opinion to support their work. Others are less appreciated, such as how health and environmental consequences produced by beverage industry activities feedback into the system, ultimately leading to a greater reliance on beverage industry products and weakening political will for adopting equitable health promotion policies. While actions by advocates, public health departments, and others to address unhealthy beverages were identified, much of their impact is undermined by the large and influential control the beverage industry has on the system. Gaining traction on addressing unhealthy commercial beverages is a complex problem with reinforcing cycles that strengthen the beverage industry’s power and influence. The insights gained from the model suggest an ambitious action agenda based on systems principles that also centers the commercial determinants of health.
The Comprehensive and Progressive Agreement for Trans-Pacific Partnership (CPTPP) has generated intense debate in Thailand, concerning its implications for public health, particularly intellectual property, and access to medicines. During 2018–2022, Thailand undertook an extended in-country process to provide evidence on its economic opportunity and public health challenges for the Cabinet decision. However, there is no evidence indicating whether Thailand has decided to join the CPTPP. This study examines Thailand’s CPTPP negotiation process using a political economy framework, focusing on the institutional and actor landscape that shaped the negotiations. This study employed a qualitative research design grounded in political economy theory, integrating state-centred and power-centred analytical frameworks. Data collection comprised a document review and in-depth interviews with 31 stakeholders from the health and trade sectors, covering state officials, academics, the private sector, and civil society representatives. The findings demonstrate critical public health concerns centred on pharmaceutical access, plant variety protection, and medical device regulatory standards. The findings also reveal a complex landscape of stakeholder dynamics and power asymmetries in Thailand’s CPTPP negotiation process. Although both state and non-state actors played influential roles in shaping public discourse and decision-making, the decision-making was dominated by state trade actors, as the lead negotiating authority, marginalising health sector perspectives despite their active engagement. While civil society leveraged collaborative power to exert political pressure, structural imbalances and a lack of transparency persisted. In addition, intra-sectoral differences also existed and were influenced by institutional positioning. The study highlights the need for stronger institutional mechanisms to promote inclusive stakeholder participation and greater policy coherence between trade and public health objectives in future trade negotiations. Not applicable.
To improve equitable access to medicines and avoid inefficient pharmaceutical spending, the World Health Organization (WHO) has long promoted five core principles regarding the selection of medicines for reimbursement: 1) the establishment of a national essential medicines list (NEML); 2) a diverse, independent selection committee; 3) an evidence-based methodology for selecting medicines; 4) integration with clinical guidelines; and 5) monitoring of use and expenditure. While many countries have formally adopted these principles, their integration into financing and procurement systems varies widely. Using Kingdon’s Multiple Streams Approach (MSA) and the policy transfer framework, this study compares how WHO selection principles were adopted in two Eastern European countries: Ukraine (higher adopter) and Moldova (lower adopter). Both countries established NEMLs aligned with WHO guidance, but only Ukraine more fully embedded these principles into pharmaceutical governance. Higer adoption in Ukraine is associated with sustained donor engagement, reform momentum, and domestic leadership. In Moldova, adoption remained largely absent, associated with weak institutional capacity and episodic donor support limiting integration. This study illustrates how international guidance interacts with political windows, domestic will, and patterns of donor engagement to shape reform trajectories. The findings suggest that global health guidance is most influential when coupled with long-term technical support, local champions, and mechanisms for institutional continuity, helping to move reforms towards meaningful system change.
Contemporary crises increasingly draw health systems, humanitarian access, medical supply chains, and civilian protection into security-oriented governance. While the health consequences of war and economic coercion, and geopolitical rivalry are widely documented, less attention has been paid to the discursive processes through which such consequences are rendered legitimate, unavoidable, or politically peripheral. This paper addresses this gap by applying a critical geopolitics framework and critical discourse analysis to examine how geopolitical narratives may structure health-relevant governance during crises. Drawing on a purposive, illustrative corpus - (i) a primary corpus of institutional and policy discourse (state communications, United Nations and World Health Organization documents, sanctions guidance, and international non-governmental organizations' reports) and (ii) a secondary corpus of scholarly literature, the study identifies three recurring discursive mechanisms: securitization, exception-making, and displacement of responsibility. Across five illustrative case contexts-US-China geopolitical rivalry, the Russia-Ukraine war, the Israel-Palestine/Gaza crisis, Iran-related sanctions and protest governance, and US-Venezuela sanctions governance-the analysis suggests how security narratives can condition humanitarian access, reshape the practical meaning of civilian protection, and diffuse accountability for health harms. Rather than arguing that discourse alone causes health outcomes, the paper treats discourse as one governance condition among others: it influences what becomes politically thinkable and institutionally actionable while interacting with military, economic, legal, and health-system factors. The findings advance critical health geopolitics and peace and security scholarship by showing how health inequities can function as a diagnostic lens through which norm erosion and the normalization of exceptional governance become empirically visible.Clinical trial numberNot applicable.
Mainstream global mental health continues to privilege individual-level risk factors and biomedical approaches and treatments while sidelining the structural forces that shape mental distress. Despite calls for more socially embedded and decolonial approaches, policy and research too often neglect how structural phenomena such as globalization, colonialism, and neoliberal reforms directly drive mental health inequities. Drawing on Latin American traditions of social medicine—particularly Jaime Breilh’s paradigm of social determination of health—this debate article critiques reductionist frameworks that fragment structural causation into depoliticized lists of risk factors. We articulate a social determination approach for mental health research and practice, emphasizing the multi-level embodiment of power relations, the historical–political organization of social life, structural drivers embedded in institutions and policies, and the role of collective agency and praxis. Illustrative vignettes from Latin America (employment, discrimination, and environment) demonstrate how historically structured processes linking global political economy, institutional arrangements, and everyday social relations become embodied as mental distress, and how participatory and mixed-method research can help document these dynamics while supporting transformative, community-led responses. We argue that adopting a social determination lens can reorient global mental health policy and scholarship toward structural justice, in line with recent international calls to decolonize and politicize mental health research. Not applicable.
Tobacco industry interference during policy development is well documented, yet evidence on how the industry responds after policies are adopted and enter into force remains fragmented across policy domains and jurisdictions. This study systematically examines post-adoption tobacco industry conduct across key tobacco control measures and develops a cross-policy taxonomy of post-adoption tactics. We conducted as coping review and qualitative evidence synthesis of peer-reviewed and grey literature, searching six data bases and Tobacco Control’s News Analysis archive. Using inductive coding, we identified recurring forms of post-adoption industry activity and synthesised these into a conceptual taxonomy – the Policy Implementation Playbook (PIP). We included 308 sources (210 peer-reviewed articles and 98 News Analysis items) spanning approximately 50 countries across all WHO regions, although documentation was concentrated in a limited number of settings. The PIP identifies five recurrent tactics. One – pre-emptive adaptation – occurs before a policy enters into force and includes stockpiling, transitional packaging, and early product or marketing adjustments. After a policy enters into force, the industry may disregard requirements, adopt token implementation that signals formal compliance while reducing practical impact, circumvent regulation through product-, design-, or channel-based tactics, or seek to influence implementation indirectly through retailers, hospitality actors, public authorities, and enforcers. Circumvention was the most frequently documented response across most policies, though its specific form varied across regulatory domains. Disregard and pre-emptive adaptation were also common, while token implementation was largely confined to health warning requirements. Smoke-free regulations more often elicited intermediary-focused strategies aimed at shaping interpretation, enforcement, and compliance. By conceptualising policy implementation as a contested political arena and synthesising recurrent tobacco industry tactics across policies, the PIP extends existing models of corporate political activity. The taxonomy provides a structured basis for anticipating post-adoption corporate conduct and strengthening regulatory design, implementation, and governance in tobacco control and the regulation of other unhealthy commodities. Not applicable.
South Korea introduced the First Generic Exclusivity (FGE) system as part of the patent linkage system to promote patent challenges and market entry of generic drugs. Evaluating the impact of FGE on the number of generic entrants is central to assessing the system. This study elucidates factors—including patent characteristics—that influence the number of FGE applicants and holders at the ingredient level. Using data from the Ministry of Food and Drug Safety, 85 ingredients with FGE applications filed between 2015 and 2025 were analyzed. For each ingredient, originator-based characteristics—including manufacturer type, patent characteristics, and drug characteristics—were collected, and the year of the first FGE application for each generic was identified. Negative binomial regression analysis was performed to determine factors affecting the number of FGE applicants, holders, and non-holders. Among 85 ingredients, the mean number of FGE applicants was 6.59 (SD = 9.52, IQR 1–9), and the mean number of FGE holders was 4.61 (SD = 8.08, IQR 0–4). Regression results showed that the number of FGE applicants was positively associated with the number of patents and approval year, but negatively associated with the reimbursement price. The number of FGE holders showed positive associations with approval year and negative associations with reimbursement price. The application year was negatively correlated only with the number of FGE holders. Although the introduction of the FGE system and the expansion of patent portfolios increased patent challenges by generic manufacturers, this did not consistently translate into actual generic market entry, underscoring the need to reexamine whether the FGE system is effectively designed to foster substantive competition.
Background The political and regulatory environment in which people live can have profound impacts on health and wellbeing through practices that prioritise commercial development and interest over public health. For Aboriginal People, this is further undermined through corporate influence over Aboriginal autonomy, political and social participation, cultural preservation, economic and land control and, free prior and informed consent and decision-making capacity over their interests, referred to as self-determination.Methods This study applies a content analysis to understand the intersection of this issue within media discourse focused on the Northern Territory of Australia. Articles were located through Factiva and Newsbank searches targeting commercial activities from the extractive resource, alcohol, and food industries that impact Aboriginal People and/or Communities from 2015 to 2025.Results One hundred and sixty-one articles were included in the analysis. The dominant narrative identified in the media articles focused on the economic contributions commercial development provided to Aboriginal Peoples (more commonly found in commercial news outlets and trade magazines), while a prominent counter-narrative focused on harm to Country and failures to consult Traditional Owners (more common in articles by the public broadcaster and Indigenous-owned media). Our findings challenge the notion of a single-victim narrative by illustrating how multiple stakeholders (i.e. industry, government, media, and at times civil society) collectively influence public discourse, which can either hinder or promote self-determination. Further, centring self-determination requires a suspension of assumptions about what is best for Aboriginal Peoples.
Access to safe water, sanitation, and hygiene (WASH) remains inadequate for large populations in South Asia, constrained by persistent structural inequalities, institutional weaknesses, and uneven development. This study investigates the complex interplay of structural, demographic, environmental, and institutional factors shaping WASH outcomes across eight South Asian countries over the period 2000—2024. Employing a Bayesian hierarchical linear model—robustly validated through alternative specifications—we provide a comprehensive probabilistic assessment of WASH outcomes. A key methodological contribution is the construction of a composite governance quality index using an autoencoder neural network based on six governance dimensions: voice and accountability, regulatory quality, political stability, control of corruption, government effectiveness, and rule of law. Urbanisation improves sanitation access and reduces open defecation but strains water access, highlighting its dualistic nature. Health expenditures consistently enhance WASH outcomes. Economic capacity, sectoral vulnerability, precipitation shocks, and governance exhibit no direct impact. Education significantly improves water access and reduces open defecation. Population density exerts small but positive effects, suggesting economies of scale in service delivery. Digitalisation also emerges as a key driver of WASH outcomes, reflecting the growing role of information technology in service delivery and accountability mechanisms. A counterintuitive positive association between inequality and WASH outcomes suggests Kuznets-style transitional dynamics, where benefits initially accrue to more affluent groups. However, these relationships shift notably when governance is modelled as a moderator. Governance quality acts as a key moderating mechanism, amplifying the benefits of growth, urbanisation, and health spending while reshaping the influence of education and inequality. Governance does not operate primarily as a direct driver of WASH outcomes. Instead, it acts as a critical enabling mechanism that shapes how structural factors translate into equitable access. Strengthening governance quality amplifies the effectiveness of sectoral investments and urbanisation policies—a finding with important implications for WASH policy and institutional reform across South Asia.
Glucagon-like peptide-1 (GLP-1) based medicines (for example Ozempic, Wegovy, Zepbound) are moving rapidly from specialist care to mass adoption in high-income countries, with measurable effects on food purchases and eating patterns. Early retail and household panel data from the United States indicate that households with a GLP-1 user reduce total grocery spending by about 5
The arms industry and the global trade in weapons pose significant direct and indirect risks to population health and equity. While health-harming industries such as tobacco, alcohol, and ultra-processed foods have been extensively examined with a commercial determinants of health lens, the commercial strategies of the arms industry remain critically underexplored in public health research. To address this gap, we conducted a scoping review of peer-reviewed literature published between 2004 and 2024. Searches were undertaken across four academic databases (Web of Science, Scopus, ABI/INFORM, and Business Source Complete) and Google Scholar. Data were extracted and analysed using deductive and inductive coding, guided by a previously published typology of commercial practices: financial, political, scientific, marketing, supply chain and waste, labour and employment, and reputational management practices. Forty-one studies met the inclusion criteria. Marketing and political practices were the most frequently reported, while supply chain and waste, financial, labour and employment, reputational management, and scientific practices were less common. Our review found that the arms industry not only engages in commercial practices identified within established commercial determinants of health frameworks but also employs additional strategies, such as bribery and corruption, worker surveillance, contesting worker illness claims, and a number of supply chain practices that extend beyond existing typologies. The majority of studies focused on firearms-related practices, particularly within the United States, while few addressed other arms industry sub-sectors such as major conventional weapons and nuclear weapons, and little attention was given to low- and middle-income countries. Despite the scale and influence of the arms industry, its commercial sector practices remain largely overlooked in public health research. Greater scrutiny and recognition of the arms industry as a commercial determinant of health is essential to mitigate the health harms and inequities associated with the global production, proliferation, and use of weapons.
