Food systems for sustainable healthy diets in low- and middle-income countries

Profound food system transformation is needed to transform the food system to mitigate climate change and other environmental degradation and to deliver healthier diets which prevent all forms of malnutrition. Whilst a range of principles and policies for achieving a healthy and sustainable diet are described in the literature, national attempts to translate this into policy have been patchy and with limited success. This project will provide contextualized understanding of impact pathways and policy recommendations for achieving a healthy sustainable diet in countries through food system transformation, focusing on LMICs, within a wider global context. The overall project objective is to develop evidence to support the discussion and promotion of food system transformation contributing to healthier and more sustainable diets in LMICs. There are three parts to this project, addressing the following three research questions:

• What nutrition-sensitive policies, programmes and interventions, across the food system, could promote a transition to heathier diets from more sustainable food systems, and how, taking into consideration enabling and disabling factors?’
• What evidence is there on the levels of contamination of selected microbiological and chemical hazards, across the food supply chain for fruit and vegetables in Africa, and what factors influence it?
• How can the public health community address food and beverage industry influence (and associated lack of government regulation) on healthiness of diets through the use of human rights and the ‘right to healthy food’?

People

At LSHTM

• Helen Walls (PI)
• Susannah Mayhew
• Busiso Moyo

At the University of Greenwich, UK

• Paula Domingues-Salas
• Sai Srinivasa Sudharshan Kondapalli

Independent consultant

• Penelope Milsom

Strengthening health policy analysis

Health Policy Analysis is a critical element of the broader field of Health Policy and Systems Research. It specifically considers how policies emerge, are formed and are implemented, and pays particular attention to the forces influencing decision-making: actors, power and politics; institutions, interests and ideas.  The policy process orientation of such analysis draws from the theories and ideas of various well-established fields in higher income country settings - such as, policy studies and public administration, and political and organisational sciences. At the same time, HPA draws on ideas about the political economy of development in its applications within low and middle income countries (LMICs).

In broad terms, such analysis offers insights about how policy change unfolds – and it helps us understand the political forces that explain what has sometimes been called the ‘implementation gap’ in global health policy debates. These forces also always shape health system development, working across local, national and global levels. Yet despite its valuable insights, it remains a small area of work within health policy and systems research – and one where the scholarship is dominated by scholars based in high income countries.

Our objectives in this area of work are:

• to deepen understanding of the principles, theories and applications of health policy analysis
• to outline critical methodological steps for doing HPA and HPSR work
• to support the emergence of a body of LMIC scholars doing HPA work in LMICs

Led by the Health Policy and Systems Division at the University of Cape Town, South Africa, this work has entailed, first, the production of two open access anthologies of papers. Second, through the HPA Fellowship programme, support has been provided for 20 LMIC doctoral scholars pursuing their degrees within higher education institutions located exclusively in Africa and Asia. The programme of work has been funded by the Alliance for Health Policy and Systems Research.

People and partners

• Lucy Gilson
• Health Policy and Systems Division, University of Cape Town, South Africa
• Alliance for Health Policy and Systems Research
• HPA Fellows cohort 1 and 2

Publications

Open access Readers:

• Gilson L, Orgill MS, Shroff ZC (2018) A Health Policy Analysis Reader: The politics of policy change in low and middle income countries. Geneva: Alliance for Health Policy and Systems Research/ World Health Organization. 
• Gilson L (ed) (2012) Health Policy and Systems Research: A Methodology Reader. Geneva: Alliance for Health Policy and Systems Research/ World Health Organization.  

Special issue:

• Gilson, L., Shroff, Z. C., & Shung-King, M. (2021). Introduction to the Special Issue on “Analysing the Politics of Health Policy Change in Low-and Middle-Income Countries: The HPA Fellowship Programme 2017-2019”. International Journal of Health Policy and Management. 10.34172/ijhpm.2021.43
• Guinaran RC, Alupias EB, Gilson L. (2021) The Practice of Power by Regional Managers in the Implementation of an Indigenous Peoples Health Policy in the Philippines. International Journal of Health Policy and Management.  In Press. doi:10.34172/ IJHPM.2020.246
• Ramani S, Gilson L, Sivakami M, Gawde N. (2021) Sometimes resigned, sometimes conflicted, and mostly risk averse: primary care doctors in India as street level bureaucrats. International Journal of Health Policy and Management. In Press. doi:10.34172/IJHPM.2020.206
• Derkyi-Kwarteng, ANC, Agyepong IA, Enyimayew N, Gilson L. (2021) A Narrative Synthesis Review of Out-of-Pocket Payments for Health Services under Insurance Regimes: A Policy Implementation Gap Hindering Universal Health Coverage in Sub-Saharan Africa. In Press. doi:10.34172/IJHPM.2021.38
• Parashar R, Gawde N, Gilson L. (2021) Application of “actor interface analysis” to examine practices of power in health policy implementation: an interpretive synthesis and guiding steps. International Journal of Health Policy and Management. In Press. doi:10.34172/IJHPM.2020.191
• Okeyo I, Lehmann U, Schneider H. (2021) Policy adoption and the implementation woes of the intersectoral first 1000 days of childhood initiative, in the Western Cape province of South Africa. International Journal of Health Policy and Management. In Press. doi:10.34172/IJHPM.2020.173
• Mukuru M, Kiwanuka SN, Gilson L, Shung-King M, Ssengooba F. (2021) “The Actor Is Policy”: Application of Elite Theory to Explore Actors’ Interests and Power Underlying Maternal Health Policies in Uganda, 2000-2015. International Journal of Health Policy and Management. In Press. doi:10.34172/ijhpm.2020.230
• Whyle EB, Olivier J. (2021) Towards an Explanation of the Social Value of Health Systems: An Interpretive Synthesis. International Journal of Health Policy and Management. In Press. doi:10.34172/IJHPM.2020.159

Other papers:

• Mukuru, M., Kiwanuka, S. N., Gibson, L., & Ssengooba, F. (2021). Challenges in implementing emergency obstetric care (EmOC) policies: perspectives and behaviours of frontline health workers in Uganda. Health Policy and Planning, 36(3), 260-272.
• Parashar, R., Gawde, N., Gupt, A., & Gilson, L. (2020). Unpacking the implementation blackbox using 'actor interface analysis': how did actor relations and practices of power influence delivery of a free entitlement health policy in India?. Health Policy and Planning, 35(Supplement_2), ii74-ii83.
• Whyle, E., & Olivier, J. (2020). Social values and health systems in health policy and systems research: a mixed-method systematic review and evidence map. Health Policy and Planning, 35(6), 735-751.
• Ramani, S., Sivakami, M., & Gilson, L. (2019). How context affects implementation of the Primary Health Care approach: an analysis of what happened to primary health centres in India. BMJ Global Health, 3(Suppl 3), e001381

Addressing conflict of interest in pluralistic health systems: an interventional study in Pakistan

Pakistan has no organised system of primary healthcare in urban areas, and over 80% of the urban population uses for-profit private doctors as the first point of healthcare seeking. The professionalism of private doctors in Pakistan – which includes their technical knowledge and ethical practice – therefore determines the quality of care received. 

Funded by a UK Medical Research Council Research Grant, this three-year study (2020–2023):

• identifies strategies for large scale improvement in the quality of healthcare provided by private doctors in Pakistan, paying attention to addressing conflicts of interest owing to profit generation motives
• tests the effectiveness of an intervention developed through formative research to provide evidence for policy change

People

• Mishal S. Khan
• Sonia Rego
• Helena Legido-Quigley
• Virginia Wiseman

From Aga Khan University, Pakistan

• Sadia Shakoor
• Rumina Hasa
• Wafa Aftab
• Sameen Siddiqi
• Rehana Siddiqui

Publications

Is enhancing the professionalism of healthcare providers critical to tackling antimicrobial resistance in low- and middle-income countries? Human Resources for Health. Feb 2020

Agricultural policy, food choice and nutrition in rural Malawi

There has been a resurgence of interest in agricultural input subsidy (AIS) programmes to boost agricultural productivity and food security. However there is considerable debate regarding the effectiveness and efficiency of AIS investments, including their impact on nutrition. AIS are almost always applied to production of staple crops and aim to increase their productivity and smallholder incomes, usually also with nutrition objectives. However, the overall impact on nutrition is unclear, not least because staples tend to be calorie-dense but low in other nutrients. AIS targeting maize, for example, may lead to increased concentration of production and consumption of maize and could reduce the intake of nutrient-rich foods. Alternatively, if the maize prices fall in real terms, this may enable consumers to purchase other goods including other food items. There is little evidence to determine the direction of impact.

The aim of this research is to examine the impact of Malawi’s AIS programme targeting mostly maize on overall food choices, by examining not just price and consumption of maize but crucially the effects of the AIS programme on consumption of other foods. It will also explore the wider context of food preferences and trade-offs, including by gender and socio-economic status. 

Approach

• Mixed methods

Publications 

• Reyes LI, Constantinides SV, Bhandari S, Frongillo EA, Schreinemachers P, Wertheim-Heck S, Walls H, Holdsworth M, Laar A, Nguyen T, Turner C, Wellard K, Blake CE. Actions in global nutrition initiatives to promote sustainable healthy diets. Global Food Security (in press). 2021.
• Matita M, Johnston D, Walls H. Understanding the drivers of food choice to improve population nutrition: An application of economics to public health. Malawi Journal of Economics. 2021;2(1):59-65.
• Matita M, Chirwa EW, Johnston D, Mazalale J, Smith R, Walls H. Does household participation in food markets increase dietary diversity? Evidence from rural Malawi. Global Food Security. 2021;28:100486.
• Walls H, Baker P, Chirwa E, Hawkins B. Food security, food safety and healthy nutrition: Are they compatible? Global Food Security. 2019;21:69-71.
• Walls HL, Johnston D, Mazalale J, Chirwa E. Why we are still failing to measure the nutrition transition. BMJ Global Health. 2018;3:e000657.
• Others in progress.

People involved (staff as well as students)

• Helen Walls (PI; LSHTM),
• Deborah Johnston (SOAS University of London),
• Ephraim Chirwa (University of Malawi),
• Mirriam Matita (University of Malawi),
• Jacob Mazalale (University of Malawi),
• Tayamika Kamwanja (University of Malawi),
• Richard Smith (University of Exeter)
• Penelope Milson (RD Student; LSHTM)
• Aloisia Katsande (RD Student; LSHTM)

Other outputs

• Agricultural Input Subsidies project website  Observations from the field: Agri-nutrition research in Malawi (Helen Walls)
• Collecting data on agricultural policy, food choice and dietary diversity in rural Malawi (Gift Masala, Bridget Masanche, Masiye Mazalale)
• ‘I haven’t eaten in three days’: Understanding personal experience of food insecurity in rural Malawi

Project status

• Ongoing

Migration, gender and health system response in South Africa: A focus on the movement of healthcare users and workers

This project investigates the intersection of migration, population mobility, and gender with health systems through the application of a set of innovative qualitative and quantitative research methods, applying an intersectionality lens. The research is undertaken in South Africa, a country that has faced high levels of both historical and contemporary inward, outward, and internal migration and population mobility. The research focuses on the mobility of both healthcare users and healthcare workers within, into, and out of South Africa and their interactions with the public health system.  It will include piloting and evaluating an innovative method of tracking healthcare user and worker movement over time using social media (WhatsApp), which will generate new data on how movement by both healthcare users and healthcare workers within, into, and out of South Africa interacts with their experiences of the health system. This is paired with new quantitative analysis of existing data sets on the movements of both healthcare users and healthcare workers within, into and out of South Africa. Specifically, this quantitative analysis includes the Tourism South Africa Border Survey, and the first ever analysis of data from the National Department of Health regarding patients travelling into South Africa under regulated bilateral agreements between the government of RSA and 11 neighbouring countries, and others.

Key research questions 

• How do migration and population mobility affect the South African health system?
• How does the health system respond and adapt as a result of migration and population mobility?
• How do these processes intersect with gender?

Objectives

• To assess levels of migration by patients and health workers within, into and out of South Africa
• To examine the health care experiences of both migrant and non-migrant patients and health workers.
• To analyse how the South African health system adapts and responds in light of the population movements identified in Objective 1.
• To examine how the experiences and responses garnered during objectives 1-3 are shaped by gender

Approach

• Mixed methods

Publications

• Manji K, Hanefeld J, Vearey J, Walls H, de Gruchy T. Using Whatsapp messenger for health systems research: A scoping review of available literature. Health Policy and Planning. 2021; 1-16.

People involved (staff as well as students)

• Johanna Hanefeld (PI; LSHTM), Helen Walls (LSHTM),
• Jo Vearey (University of the Witwatersrand),
• Moeketsi Modisenyane (South Africa Department of Health),
• Sassy Molyneux (Oxford University and KEMRI Wellcome),
• Lucy Gilson (LSHTM, University of Cape Town),
• Jill Oliver (University of Cape Town),
• Richard Smith (University of Exeter)

Other outputs

• Migration, gender and health systems response project website

Project status

• Ongoing

 

Completed Projects

Agricultural policy, food choice and nutrition in rural Malawi

There has been a resurgence of interest in agricultural input subsidy (AIS) programmes to boost agricultural productivity and food security. However there is considerable debate regarding the effectiveness and efficiency of AIS investments, including their impact on nutrition. AIS are almost always applied to production of staple crops and aim to increase their productivity and smallholder incomes, usually also with nutrition objectives. However, the overall impact on nutrition is unclear, not least because staples tend to be calorie-dense but low in other nutrients. AIS targeting maize, for example, may lead to increased concentration of production and consumption of maize and could reduce the intake of nutrient-rich foods. Alternatively, if the maize prices fall in real terms, this may enable consumers to purchase other goods including other food items. There is little evidence to determine the direction of impact.

The aim of this research is to examine the impact of Malawi’s AIS programme targeting mostly maize on overall food choices, by examining not just price and consumption of maize but crucially the effects of the AIS programme on consumption of other foods. It will also explore the wider context of food preferences and trade-offs, including by gender and socio-economic status. 

People involved (staff as well as students)

At LSHTM

• Helen Walls (PI)
• Richard Smith

At the University of Malawi, Malawi

• Ephraim Chirwa
• Jacob Mazalale
• Tayamika Kamwanja
• Mirriam Matita

At SOAS University of London

• Deborah Johnston

Publications

• Matita M, Mazalale J, Quaife M, Johnston D, Cornelsen L, Kamwanja Zabula T, Smith RD, Walls H. Food choice responses to changes in the price of a staple crop: a discrete choice experiment of maize in rural Malawi. Food Security. 2023.
• Walls H, Matita M. Trade-offs with addressing food security and dietary diversity. BMJ Global Health. 2023;8(12):e014354
• Walls H, Johnston D, Matita M, Kamwanja T, Smith R, Nanama S. The politics of agricultural policy and nutrition: A case study of Malawi’s Farm Input Subsidy Programme (FISP). PLOS Global Health Policy. 2023;3(10):e0002410.
• Walls H, Matita M. Lessons from Malawi’s Farm Input Subsidy Programme. Nature Food. 2023; 4:734-735.
• Walls H, Johnston D, Matita M, Chirwa E, Mazalale J, Quaife M, Kamwanja T, Smith RD. How effectively might agricultural input subsidies improve nutrition? A case study of Malawi’s Farm Input Subsidy Programme (FISP). Food Security. 2023;15:21-39.
• Matita M, Chiwaula L, Chirwa EW, Mazalale J, Walls H. Subsidising improved legume seeds for increased household dietary diversity: Evidence from Malawi’s Farm Input Subsidy Programme with implications for addressing malnutrition in all its forms. Food Policy. 2022;113:102309.
• Matita M, Johnston D, Walls H. Understanding the drivers of food choice to improve population nutrition: An application of economics to public health. Malawi Journal of Economics. 2021;2(1):59-65.
• Matita M, Chirwa EW, Johnston D, Mazalale J, Smith R, Walls H. Does household participation in food markets increase dietary diversity? Evidence from rural Malawi. Global Food Security. 2021;28:100486.
• Walls H, Johnston D, Mazalale J, Chirwa E. Why we are still failing to measure the nutrition transition. BMJ Global Health. 2018;3:e000657.

Anti-Corruption Evidence (ACE)

 

Our work within the Anti-Corruption Evidence (ACE) research consortium brings together teams in Bangladesh, Nigeria, Tanzania and the United Kingdom to tackle corruption, one of the most difficult problems facing health policymakers in many countries. Our starting point is that corruption often arises in situations where health workers must make choices about how they balance the care they want to provide to their patients with the rewards that they obtain for their services. These tensions emerge where incentive structures are badly designed and where systems of governance, and particularly mechanisms for ensuring accountability and transparency, are weak. In these circumstances, traditional punitive measures do not work and can even be counter-productive. Instead, we are working with frontline health workers delivering healthcare and those to whom they are, in theory, accountable (including their informal networks) to:

• understand the dilemmas they face
• find ways to overcome dysfunctional managerial structures
• develop politically feasible and acceptable measures

People

• Dina Balabanova
• Eleanor Hutchinson
• Martin McKee
• Obinna Onwujekwe
• Prince Agwu
• Aloysius Odii
• Syed Masud Ahmed
• Nahitun Naher
• Mir Raihanul Islam
• Peter Binyaruka
• Masuma Mamdani
• Blake Angell
• Mushtaq Khan (ACE PI)
• Pallavi Roy
• Sonia Sezille

Publications

Abba-AjiI M, Balabanova D, Hutchinson E, McKee M. How Do Nigerian Newspapers Report Corruption in the Health System? Int J Health Policy Manag 2020 (published online).

Hutchinson E, Balabanova D, McKee M. We Need to Talk About Corruption in Health Systems. Int J Health Policy Manag. 2018;8(4):191-4.

Hutchinson E, McKee M. Balabanova D. What drives health workers to break the rules and use public resources for private gain? A review of the literature on sub-Saharan Africa, SOAS ACE Working paper 009, May 2019.

Onwujekwe O, Agwu P, Orjiakor C, McKee M, Hutchinson E, Mbachu C, Odii A, Ogbozor P, Obi U, Ichoku H, Balabanova D. Corruption in Anglophone West Africa health systems: a systematic review of its different variants and the factors that sustain them. Health Policy Plan. 2019 Sep 1;34(7):529-543.

Onwujekwe O, Agwu P, Orjiakor C, Mbachu C, Hutchinson E, Odii A, Obi U, Ogbozor A, Ichoku H, McKee M, Balabanova D. Corruption in the health sector in Anglophone West Africa: Common forms of corruption and mitigation strategies. 2018, SOAS-ACE Working Paper 005.

Naher N HM, Hoque R, Alamgir N, Ahmed SM. Irregularities, informal practices, and the motivation of frontline healthcare providers in Bangladesh: current scenario and future perspectives towards achieving universal health coverage by 2030. 2018, SOAS-ACE Working Paper 004.

Other outputs

Balabanova D, Hutchinson E, Mayhew S, McKee M. Health workers are vital to defeat COVID-19: but only if they are at work

Hutchinson E, Balabanova D, McKee M. Five reasons we aren’t talking about corruption in health systems – and why we need to start. 2018 

The health research within ACE consortium seeks to understand the structural and socio-political causes of corruption and to use those findings to support the adoption of new, feasible, high impact anti-corruption strategies in Bangladesh, Nigeria and Tanzania.

Funded by UK Aid. Learn more about ACE on the website and follow on Twitter and LinkedIn for updates.

The political consequences of industry engagement in the Public Health England’s ‘Drink-Free Days’ campaign

In September 2018, Public Health England (PHE) and Drinkaware (the alcohol industry-funded body) ran a co-branded ‘Drink Free Days’ (DFD) campaign to target middle-aged drinking. This partnership created considerable political controversy within the public health community and PHE commissioned researchers at LSHTM to evaluate the campaign. We asked:

• To what extent did the involvement of the industry funded body, Drinkaware, affect support from public health actors?
• Did the partnership with a government agency offered commercial advantages to industry actors?

The Drink Free Days campaign aimed to:

• alert increasing and higher risk drinkers, aged 40-64, to the health harms of alcohol
• encourage them to reappraise their own drinking habits
• motivate them to take several alcohol-free days each week.  

The campaign was released under PHE’s OneYou umbrella, an initiative that targets modifiable health risk factors through individual behaviour change – reducing an individual’s alcohol consumption for instance. The campaign’s radio and digital advertising was largely funded by Drinkaware, with additional digital and print materials available for download by local public health authorities and health organisations.

People

• Benjamin Hawkins
• Helen Walls
• Anna Durrance-Bagale
• Chris Turner
• Cecile Knai

Publications

 

• Hawkins B, Durrance-Bagale A, Walls H. Co-regulation and alcohol industry political strategy: A case study of the Public Health England-Drinkaware Drink Free Days Campaign. Social Science and Medicine. 2021.
• Walls H, Hawkins B, Durrance-Bagale A. Stakeholder perceptions of legitimacy and conflict of interest: The alcohol industry and the ‘Drink Free Days’ campaign in England. International Journal of Health Policy and Management. 2021.

Tobacco Companies, Public Policy & Global Health

This project analysed the corporate strategies of the global tobacco industry. In response to increasing regulation of its activities within the context of globalisation, the tobacco industry has developed innovative market and political strategies, including its use of international trade agreements to oppose new packaging requirement. 

Despite increasing regulation, tobacco companies remain highly profitable and smoking remains the single greatest avoidable cause of mortality. This project analysed the industry’s corporate and political strategies in order to strengthen tobacco control policies globally. Effective regulation of the tobacco industry at the national, regional and global levels requires a detailed and nuanced understanding of the structure and activities of the tobacco industry. 

Building on two previous phases of research, this project analysed how the tobacco industry has been affected by, and adapted to, developments in the global economy through corporate restructuring, operational rationalization, new product development, creation of new marketing modalities, entry into the e-cigarette market, opposition to ‘plain’ packaging and other strategies. 

We focused on four key themes:

1. international trade and investment (i.e. the use of trade agreements to oppose tobacco control measures)
2. illicit trade (i.e. smuggling and cotraband activities)
3. the restructuring of the tobacco industry within a global economy (i.e. mergers, acquisitions and new product development such as e-cigarettes)
4. tobacco control and global health governance (i.e. attempts to shape policies at the WHO, EU and other international organisations)

Team

• Benjamin Hawkins (for theme 1 in particular)

Publications

A Corporate Veto on Health Policy? Global Constitutionalism and Investor–State Dispute Settlement. Journal of Health Politics, Policy Law. Oct 2016

A multi-level, multi-jurisdictional strategy: Transnational tobacco companies’ attempts to obstruct tobacco packaging restrictions. PubMed. Mar 2018

The Battle for Standardised Cigarette Packaging in Europe. Palgrave. 2019

European Union implementation of Article 5.3 of the Framework Convention on Tobacco Control. Global Health. Aug 2018

Law, market building and public health in the European Union. Sage. Dec 2017

Reassessing Policy Paradigms: A Comparison of the Global Tobacco and Alcohol Industries. PubMed. Mar 2016

Transnational Tobacco Companies and New Nicotine Delivery Systems. American Journal of Public Health. Feb 2019

UK: Tobacco industry and e-cigarettes - new issue, familiar tactics. Tobacco Control. Nov 2013