P value = 0.15). A strong relationship was found between bioenergy and type of food security parameter , sociodemographic index of study location , spatial scale , and temporal scale . Programs and policies focused on bioenergy and climate mitigation should monitor multiple food security parameters at various scales over the long term toward achieving diverse sustainability goals.Achieving food security is a critical challenge of the Anthropocene that may conflict with environmental and societal goals such as increased energy access. The “fuel versus food” debate coupled with climate mitigation efforts has given rise to next-generation biofuels. Findings of this systematic review indicate just over half of the studies (56% of 224 publications) reported a negative impact of bioenergy production on food security. However, no relationship was found between bioenergy feedstocks that are edible versus inedible and food security ( Many people face food insecurity, a lack of adequate access to sufficient, safe, and nutritious food that meets their dietary needs and food preferences for an active and healthy life6. Diet-related health issues are a primary risk factor of disease globally7. Currently, the production of crops and livestock places greater land-use stress on ecosystems compared to all other land-use activities9. Maintaining the integrity of food supply amongst a range of competing ecosystem services is becoming more critical as the population increases10. For example, habitat loss from the conversion of natural lands for the production of food12 and first-generation biofuels is the leading threat to biodiversity13. These food system challenges are exacerbated by climate change, the industrialization of agriculture, and land degradation with notable implications for human and planetary health17.Providing adequate nutritious food to support a growing population while conserving natural resources is a key aspect of the United Nations Sustainable Development Goals20. For example, there is increased societal demand for bioenergy as well as a recognized need to support ecosystem health through efforts such as afforestation for biodiversity conservation and carbon dioxide removal toward ameliorating the impacts of climate change21. A shift in priority to renewable energy globally has driven an increase in bioenergy production over the past two decades in the search of alternatives to fossil fuels24. In recognition of negative trade-offs between bioenergy (interchangeably referred to as biofuels) and food security, feedstocks from second- and third-generation biofuels (next-generation biofuels), along with newer technologies, are being developed with the goal to avoid competing with lands used for food production while simultaneously lowering greenhouse gas (GHG) emissions26.Food security is a multidimensional goal that includes parameters of food availability, food prices, and food production. Although food security goals are prioritized by international organizations and national governments, they are increasingly competing with other societal and planetary goals32. While multiple studies have reviewed the effects of bioenergy expansion on food security35, none has synthesized the totality of the evidence regarding how various bioenergy feedstocks impact different aspects of food security. This study addresses this knowledge gap through a systematic literature review that examines the following question: what are the effects of various classes of bioenergy feedstocks on food security parameters ? Bioenergy feedstocks can be variously classified; given our emphasis on food security, we classified and compared bioenergy feedstocks on the basis of being edible versus inedible for human and livestock consumption , including ending hunger (SDG 2) and ensuring healthy lives (SDG 3), they may conflict with other SDGs, including increased energy access (SDG 7) and combatting climate change and its impacts (SDG 13)44). In order to better understand the effects of different types of bioenergy, various classification schemes have been proposed. The Intergovernmental Panel on Climate Change (IPCC) recognizes three classes of biofuels that include first-generation, second-generation, and third-generation biofuels, with the latter two sometimes referred to as next-generation or advanced biofuels44. First-generation biofuels are created through mature conversion technologies and comprise of feedstocks from oilseeds, grains, animal fats, and waste vegetable oils (Box 46). Second-generation biofuels are created through thermochemical and biochemical conversion technologies from lignocellulosic biomass, such as agricultural and forest residues, perennial herbaceous plants, and short-rotation woody crops. Third-generation biofuels are produced through various technologies such as conversion technologies that transform algal biomass feedstock.However, the impacts of bioenergy on food security are not always clear on the basis of the ways biofuel feedstocks are produced and given that there are multiple dimensions of food security. Bioenergy may be produced on arable land competing with food production, arable land not competing with food production, or marginal and/or degraded land ? Here, we first synthesize the number of studies based on types of bioenergy feedstocks and food security parameters examined before synthesizing the effects of bioenergy production on overall food security and specific food security parameters . Next, we present a synthesis of the findings on the basis of various scales characterizing the studies, including sociodemographic index level, spatial scale, and temporal scale. We conclude with the type of data examined (observed versus modeled studies). Findings are reported for bioenergy effects  on the basis of all bioenergy feedstocks as well as on the basis of the edibility of the feedstock as edible, inedible, or both edible and inedible feedstocks examined.Jatropha and castor, perennial switchgrass, fast-growing trees, by-products, agricultural wastes and residues, and algae. Numerous studies examined multiple feedstocks, whether only edible feedstocks (such as soy and corn), inedible feedstocks (Miscanthus giganteus and corn stover), or a combination of edible and inedible feedstock (such as corn and corn stover).Approximately half of the reviewed publications examined edible feedstocks (121 of 224 publications) and about one-third examined inedible feedstocks (64 publications). Fewer studies examined both edible and inedible feedstocks (35 publications) and a few studies did not specify the bioenergy feedstock examined (4 publications)  and food price (27%) were the most prevalent food security parameters in the studies included in this systematic review . In contrast to type of bioenergy feedstock , both the parametric and nonparametric chi-squared tests indicated strong evidence of a relationship between bioenergy and specific food security parameters  .Just over half the publications (56% of 224 publications) reported a negative impact of bioenergy production on overall food security  and approximately a quarter of the studies reported no effect (23%). Only several studies reported a positive effect of bioenergy on overall food security (13%) and a few reported both negative and positive effects (8%) Fig. . FurtherFor the food security parameter of food availability, approximately one-third of the articles reported no effect of all types of bioenergy (35% of 26 publications), approximately another third reported negative effects (31%), and just under a third reported positive effects (27%) Fig. . A few pn = 55), in addition to several studies that included multiple countries and SDI levels (n = 28). With the exception of low SDI, bioenergy production was found to generally have a negative impact on overall food security parameters on the basis of SDI (40–73%) . Specifically, the mosaic plot of standardized residuals for the SDI group by overall effect revealed that studies examining bioenergy in low SDI countries had a greater amount of positive effects than expected, while studies in low-middle SDI countries had fewer negative effects than expected  was recorded and tabulated based on the reported effects of bioenergy on overall food security parameters Fig. . Several3%) Fig. . Both thχ2 = 47.7596, permutation-based P value <0.001). A mosaic plot of standardized residuals for the spatial scale by overall effect reveals that for studies at the household spatial scale, there were more studies that indicated a positive overall effect than would be expected and fewer negative overall effects were much smaller than expected . The mosaic plot of standardized residuals for the temporal scale by overall effect revealed there were more studies that included short-term datasets and positive overall effects than would be expected if there was no relationship between temporal scale and overall effect on food security parameters . The mosaic plot of standardized residuals for the dataset type by overall effect revealed studies using observed datasets reported fewer negative effects on food security and the studies using modeled data reported more negative effects on food security than expected  Fig.  revealedHierarchical cluster analysis with Ward’s method on Gower’s dissimilarity identified four clusters on the basis of the type of bioenergy feedstock (edible versus inedible feedstocks), food security parameters, temporal and spatial scales, and SDI levels with the following characteristics: (i) cluster one had the highest proportion of negative effects of bioenergy; (ii) cluster two had the highest proportion of positive or no effect of bioenergy; (iii) cluster three had the highest proportion of both negative and positive effects of bioenergy; (iv) cluster four had a high proportion of negative effects or no effect of bioenergy Fig. ; additioThree random forest models fit based on food security parameters  –24) in tAchieving food security is a critical challenge of the Anthropocene that may conflict with the provision of ecosystem services and other societal goals related to the UN Sustainable Development Goals (SDGs) for increased energy access and combatting climate change. The potentially detrimental effects of bioenergy expansion on food security as captured in the “fuel versus food” debate coupled with efforts to mitigate climate change have given rise to next-generation biofuels including those produced from feedstocks that are inedible. This systematic review contributes to the “fuel versus food” debate by synthesizing the totality of the evidence regarding the effects of bioenergy feedstocks that are classified on the basis of edibility for human and livestock consumption on various food security parameters and, how this relationship varies on the basis of the sociodemographic index, spatial and temporal scale, and data type.P value = 0.15). However, a strong relationship was found between bioenergy and type of food-security parameter  as well as on the basis of spatial scale on which food security was measured  and the sociodemographic index (SDI) of the study location .Over half the publications identified in this systematic review (56% of 224 publications) reported a negative effect of bioenergy on food security parameters . The overall effects of bioenergy on food security were not significantly different on the basis of the edibility of the feedstocks examined for human and livestock consumption , as well as next-generation biofuels produced on marginal or degraded land, may have other positive environmental and societal benefits such as biodiversity conservation and continued provision of ecosystem services and mitigating climate change21. However, the conversion process to biofuel may be associated with higher costs and variable economic feasibility dependent on feedstock26. Indirectly, these benefits such as biodiversity conservation and the continued provision of ecosystem services have the potential to ameliorate conflict with food security51. In addition to bioenergy and food security interactions synthesized here, the implementation of bioenergy strategies for climate mitigation can negatively or positively impact other parameters of planetary health such as biodiversity and water resources53, and loss of ecosystem services through land-use change54 and thus need to also be examined. This points to the need for programs and policy to adopt an integrative and multifaceted framework such as the food–water–energy–biodiversity–social systems (FWEBS) framework to monitor trade-offs and identify cross-sector efficiencies in meeting societal demands and addressing challenges21.While the overall effects of bioenergy on food security outcomes were not significantly different on the basis of the edibility of the feedstocks examined, it is important to recognize the multiple implications of bioenergy production for achieving other environmental and societal goals of the SDGs that were not examined in this systematic review. The feedstocks that were classified as edible for human and livestock consumption on the basis of our edibility schematic are all classified as first-generation biofuels according to the IPCC classification scheme and none are classified as second-generation and third-generation biofuels55. In order to be a feasible alternative to fossil fuels, bioenergy production should provide a balance of energy, environmental, and economic benefits, while not competing for food security either directly or indirectly. Within both edible and inedible feedstocks, numerous trade-offs exist among environmental and economic costs associated with cultivation, energy efficiency and greenhouse gas emissions, and production costs26. However, evidence synthesized in this review highlights that the reported effects between edible and inedible feedstocks on food security are not significantly different.Overall, findings suggest a critical need for programs and policies focused on bioenergy expansion to take an integrative and long-term approach to coordinate multiple sustainability goals. Increased energy demands are directly interwoven with food systems with both risks and opportunities in economic, social, and environmental dimensions, depending on contextBioenergy projects should monitor food security on the basis of multiple food security parameters as well as spatial scales over the long-term.Given the issues of comparing food security outcomes across studies, there is a need to design more widely agreed upon international standards of multiple dimensions of food security in addition to household-level food security that is culturally relevant in different contexts. The development of such measures should be based on long-term global collaborative projects with congruent experimental designs and “big data” sharing to allow for comparison of food security outcomes over time.26. Such multisectoral engagement should adopt integrative frameworks to monitor trade-offs and identify cross-sector efficiencies in meeting societal demands and addressing challenges21. In addition, these projects should evaluate the arability of land used to produce biofuels since first-generation and next-generation biofuels can be produced on both arable and marginal/degraded lands.There is a need to foster multisectoral engagement between resource managers, communities, enterprises, scholars, and policymakers to examine the trade-offs of bioenergy expansion for multiple societal goals for supporting multiple Sustainable Development Goals in addition to food security including biodiversity, ecosystem services, climate mitigation, and cultural implicationsPolicy and regulatory frameworks are needed in order to govern the implications of bioenergy expansion for multiple societal goals including supporting incentives for the integration of bioenergy feedstock production and food crops as part of sustainably managed mixed-crop systems.Investments should support technology and infrastructure that can ameliorate the detrimental impacts of bioenergy production on food security.Our specific recommendations for the alignment of bioenergy and food security are as follows:56 and the Guidelines for Systematic Review and Environmental Synthesis in Environmental Management57 to collect evidence on the closed-frame study question: what are the effects of various classes of bioenergy feedstocks on food security parameters ? Given our emphasis on food security, we classified bioenergy feedstocks as being edible versus inedible and specifically addressed: what are the effects of bioenergy feedstocks classified as edible versus inedible on food security parameters ? We examine how this relationship varies on the basis of the sociodemographic index, spatial and temporal scale, and data type. The Population, Intervention/Exposure, Comparator, Outcome (PICO)58 framework elements were used to structure this systematic review with bioenergy production as the intervention/exposure and food security as the outcome.The design of this study applies the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)Search terms for the review protocol were identified by a panel of experts in the fields of food security, bioenergy, and global change. A selected group of search terms were tested in databases to find relevant literature and were revised through an iterative process to address the study question as well as feasibility for conducting a manageable systematic review (Supplementary Table The Covidence software program (of the Cochrane Technology Platform) was used to manage and screen publications matching the a priori inclusion criteria by a screening panel of seven reviewers. The title and abstract of each publication were screened by two reviewers from the review panel to minimize reviewer bias in identifying publications for their relevance. Discrepancies in inclusion resulting from the screening process were discussed by at least two reviewers on the review panel to resolve conflicts between reviewers. Publications with abstracts that met the inclusion criteria proceeded to the full-text screening process, with all other publications excluded from the review. The review panel critically appraised publications identified to meet the search criteria during the full-text screen to validate their inclusion Fig. .Fig. 9PR59. When a study was conducted at a global scale, all SDI levels were accounted for . On the basis of the classification scheme of feedstock edibility presented in the Background, bioenergy feedstocks examined in the studies were classified as either edible, inedible, both edible, and inedible (where multiple feedstock types were examined), or not specified. Food-security parameters were categorized as either food availability, food prices, food production, or multiple food security parameters . Given the multidimensionality of food security parameters, we were not able to compare studies on the basis of units. For example, food availability included aspects affecting the overall availability of food, such as food insecurity, current, and potential food access/availability, farmer livelihoods, and risk of hunger. Food price included aspects affecting the price of food such as the rise and/or decrease in food prices for consumers and producers, absolute price, price volatility, price elasticity, animal feed prices, food and land prices, commodity markets, and cost of diets. Finally, food production included aspects affecting the production of food such as food crop displacement due to land-use change, food production processes, manufacturing, exports in multiple agricultural sectors, effects of inter-cropping on food production, stakeholder perceptions regarding the effect of bioenergy expansion on food production, and reductions in resources needed for food production, including land, water, and fertilizer. The spatial scale of the study within each publication examined was classified at the following levels: household, community, regional (region within a country), national, multinational, global, and those with “multiple” scales examined. Household-level scales considered the effect of bioenergy production for an individual household, while the effects at the national, multinational, and global level include effects across an increasingly vast spatial scale. The temporal classification of studies within each publication included either short-term studies with data collected over a period of <6 years, or long-term studies with data collected 6 or more years. Studies were further classified as using observed field data, or those using predicted and/or modeled data analyses of bioenergy expansion with secondary data sources. Finally, a qualitative synthesis of the effects of bioenergy production on food security parameters was summarized for each publication.The following information was extracted from the final set of publications from the full-text screen by a member of the screening panel (definitions proceeding): 1) publication title, (2) publication author(s) and year, (3) location and sociodemographic index, (4) bioenergy feedstock examined, (5) food security parameter(s) measured, (6) spatial scale, (7) temporal scale, (8) observed or modeled data, and (9) summary of effects of bioenergy production on food security parameters  negative effect; (2) positive effect; (3) both negative and positive effects; and (4) no effect . Negative effects of bioenergy on food security were classified based on evidence that indicated any reduction in the availability of food experienced by a small-holder, increased food prices for consumers, increased volatility of food prices, and any reduction in food production which would translate to reduced producer income. Conversely, positive effects of bioenergy on food security were classified based on evidence from the studies that indicated increased food availability, reduced food prices for consumers, and increased food production or increased producer income. In cases where both negative and positive effects of bioenergy on food security were found, the effects were accounted for as “both negative and positive effect”. For example, reduced food price for consumers was classified as a positive effect while the reduced price for producers was classified as a negative effect. Alternately, increased food price for consumers was classified as a negative effect while increased prices for producers classified as a positive effect. Finally, classification of no effect was generally used in scenarios such that if certain conditions were met, there would not be an impact on food security. For example, in a future projection scenario, if inedible feedstocks were produced on marginal land, there would be no impact in food security negativeoverall food security across attributes of food security parameters, SDI, spatial scale, temporal scale, and type of the data used in each study. The figures throughout the “Results” section present a quantitative synthesis of the effects of bioenergy production on all parameters examined across the different bioenergy feedstocks. In addition, relationships among variables with the type of bioenergy effect were assessed with parametric or permutation-based (1000 permutations used) chi-square tests, and associated mosaic plots. Two different multidimensional explorations were conducted to explore the complex relationships among the various attributes of the studies included in this systematic review  was assessed through partial dependence plots64. All analyses were completed with R 4.0.2 using RMarkdown with original source code and dataset available upon request from the lead author; more details on statistical methods and specific packages used are in the The publications were quantitatively synthesized through tabulation of frequencies of effects of bioenergy production on c review . The staSupplementary Table 1Supplementary Material


Health-related data are collected from a variety of sources for different purposes, including secondary use for population health monitoring (HM) and health system performance assessment (HSPA). Most of these data sources are not included in databases of international organizations , limiting their use for research activities and policy making. This study aims at identifying and describing collection methods, quality assessment procedures, availability and accessibility of health data across EU Member States (MS) for HM and HSPA.A structured questionnaire was developed and administered through an online platform to partners of the InfAct consortium form EU MS to investigate data collections applied in HM and HSPA projects, as well as their methods and procedures. A descriptive analysis of the questionnaire results was performed.Information on 91 projects from 18 EU MS was collected. In these projects, data were mainly collected through administrative sources, population health interview or health examination surveys and from electronic medical records. Tools and methods used for data collection were mostly mandatory reports, self-administered questionnaires, or record linkage of various data sources. One-third of the projects shared data with EU research networks and less than one-third performed quality assessment of their data collection procedures using international standardized criteria. Macrodata were accessible via open access and reusable in 22 projects. Microdata were accessible upon specific request and reusable in 15 projects based on data usage licenses. Metadata was available for the majority of the projects, but followed reporting standards only in 29 projects. Overall, compliance to FAIR Data principles  was not optimal across the EU projects.Data collection and exchange procedures differ across EU MS and research data are not always available, accessible, comparable or reusable for further research and evidence-based policy making. There is a need for an EU-level health information infrastructure and governance to promote and facilitate sharing and dissemination of standardized and comparable health data, following FAIR Data principles, across the EU.The online version contains supplementary material available at 10.1186/s13690-021-00780-4. Health data are collected worldwide from various sources for different purposes, including the secondary use for health monitoring (HM), public health surveillance, health system performance assessment (HSPA) and health research in general. HM is an intermittent or episodic performance and analysis of measurements aimed at detecting changes in the health status of populations or in the physical or social context . PopulatComparability of research findings is fundamental for comparisons across different geographical areas and over time but is often limited by differences in indicator definitions, data collection methods and tools, and the use of different classifications. Comparability of research results can be ensured through standardization of data collection methods and quality assessment procedures. Standardization of metadata is also important in health information systems for the description of health data, considering that metadata facilitates data comparisons, access to and reuse of public information. Metadata can be defined as “explanatory texts documenting statistical data and providing summary information on definitions of populations, objects, variables, the methodology and quality, and the statistical production process in general” .The present study is part of the Joint Action (JA) on Health Information InfAct (Information for Action), that was launched in 2018 and will end in 2021. Through the collaboration of 40 partners from 28 EU MS and 4 associated countries, the JA works towards a sustainable infrastructure for EU health information that will support evidence-based policy and innovative, high quality research. The aims of this study were to identify and compare data collection methods and related harmonization and quality assessment procedures, and to perform a pilot mapping exercise on availability and accessibility of health data for HM and HSPA in EU MS.i)Source of information, types of data sources used , census, administrative data);ii)Methodology, tools and approaches for data collection ;iii)Quality assurance procedures and quality dimensions or criteria considered Availability of microdata  or macrodata (aggregated results), metadata, and data formats ;v)Accessibility and standard for exchange and sharing of data and metadata .Databases fostered by selected international organizations  and EU research networks  providing EU health indicators were scoped to analyse their underlying methodologies and procedures. In light of those experiences, a questionnaire ; Accessible ; Interoperable ; and Reusable (data and collections have a clear usage license and provide accurate information on provenance) [The sections of the questionnaire on health data availability and accessibility were developed according to the FAIR Data Principles, which are a set of guiding principles in order to make data venance) .The inclusion criteria for the projects were as follows: i) health data provided by the project should be representative of the population at national or regional level; ii) health data should cover topical areas of population HM and/or HSPA; iii) the project should not focus on rare diseases, infectious diseases or cancer; iv) health data should be accessible as microdata or macrodata but not included in databases of international organizations; and v) the project should have produced scientific outputs . Eligible projects could be part of European health research networks , but the related data or indicators should not be included in databases of international organizations .The final version of the questionnaire was administered from June to October 2019 to InfAct partners through the LimeSurvey online platform . A set oInformation about 91 projects , regional (20/91), or both levels (26/91). The main objectives of the projects are elaboration of HM indicators (70/91), health data collection (57/91), elaboration of HSPA indicators (30/91), standardization and harmonization of methods and procedures (29/91), and development and/or validation of specific tools (23/91).The health data sources reported in the projects Table  were mosThe projects are mostly related to HM 84/91), followed by health system performance monitoring (27/91) and HSPA (21/91). Common tools and methods for health data collection , healthcare utilization (46/91), unhealthy lifestyles 35/91) and mental health (33/91) Fig. . Informa5/91 and The areas defined in the protocols of the projects Table  are mostThe indicators elaborated from the collected health data were mainly prevalence (59/91), outcome measures (52/91), incidence (47/91), performance measures (25/91), and attack rates (8/91). Other indicators reported by the respondents were sick-leave indicators, synthetic prognostic scores, social and geographical inequalities indicators, temporal trends measures, and burden of disease indicators . The elaborated indicators were used for monitoring (73/91), policy planning (66/91), research purposes (66/91) and health services evaluation (30/91). The funding source for the majority of the projects (84/91) was public . Other funding sources reported were pharmaceutical companies  and scientific societies .Health data collected or used by 30 projects were shared with EU research networks and projects  , details on availability of health information are reported for less than 91 projects identified in the study. Collected health data are stored as microdata (41/86), macrodata (12/86), or both (33/86). Most projects with microdata (59/74) have a global unique and eternally persistent identifier or study identifier. Out of 45 projects with macrodata, only 14 have an interactive system for users to perform further data aggregation and/or stratification. The available formats of the collected health data are first of all electronic files (75/86), followed by scientific publications (40/86), websites (33/86) and CD-ROM in one project.The majority of the projects (50/84) had a publicly available description of the dataset purpose and content or metadata. The metadata followed reporting standards in 29 projects, of which 7 were international reporting standards, such as those defined by Eurostat , details on accessibility of health information are reported for less than 91 projects identified in the study. Health data were accessible to external users in 34/86 projects, as microdata (21/34) or macrodata (28/34). Microdata were only available to users upon specific request followed by approval, while macrodata were available to all users in open access (22/22) or upon request followed by approval (18/22). The access to microdata or macrodata was mostly granted by scientific committees or through a formal agreement between institutions  –16 have The availability and accessibility of health data and information provide several opportunities that are not limited to a possible wider utilization of the datasets but also include the possibility of data linkage across datasets and the development of new indicators used for HM and HSPA. Restrictions in data processing observed in most projects restrict these advantages, including national and international collaborations and partnerships that could enhance research activities and their relevance and outputs. Other important aspects of health datasets are availability and accessibility of metadata and metadata reporting standards; the latter is defined as “the rules by which information about data is recorded in order to facilitate understanding of the origin, derivation, and/or provenance of the data” . MetadatImproving data access will enhance research activities, reduce inequality and increase the diversity of scientific outputs . These iDespite the undisputable value of data accessibility and data sharing, there are concerns regarding ethical and legal issues that cannot be disregarded, namely those regarding intellectual property, privacy and confidentiality. Data access in most projects requires approval granted by a scientific committee or a formal agreement between institutions. The request for approval guarantees the compliance of the projects with the General Data Protection Regulation (GDPR) on data protection and privacy in the EU and the European Economic Area (EEA) , althougLimitations of this study concern the identification and contact of survey respondents. Members of the JA InfAct were highly collaborative and assisted the research team in this task by forwarding the questionnaire to public health professionals engaged in health data management at national or international level. This is a convenience sampling method but it enabled the distribution of the survey instrument in all 28 MS and 4 associated countries. In addition, the selection of projects was subjective and by no means comprehensive. We realize that this approach may have resulted in a selection of the best performing data collections at the national and international level and that the observed compliance to quality and other standards may be a positively biased reflection of national practices. They also send the message, however, that it is well possible to engage in data sharing and international collaboration that result in more and better research output and policy support. Another limitation of the study regards data reusability; in particular, we did not address whether the different projects provided open access analytical pipelines for a full reuse of their methodologies, such as source codes and related documentation, analytical softwares, and more. We focused on data and metadata availability as the minimum requirement for research data reusability.The main challenges for health information in Europe, as identified in this study, are differences between and within countries in health data availability, accessibility, quality and comparability. Adherence to guidelines and protocols on standardized procedures in data collection, analysis and reporting is essential to ensure the comparability of research outputs. Likewise, adherence to EU policies on open data  and to FAdditional file 1. Questionnaire for Member States regarding health data collection methods and procedures. Questionnaire used for the cross-sectional studyAdditional file 2. Glossary of terms: Description of terms used in the survey questionnaireAdditional file 3. Projects identified through the survey on data collection methods and procedures. List of identified projects


Background: The existing recommendations for after open liver surgery, published in 2019, contains limited evidence on the use of regional analgesia techniques. The aim of this systematic review is to summarize available clinical evidence, published after September 2013, on systemic or blended postoperative analgesia for the prevention or treatment of postoperative pain after open liver surgery. Methods: The PUBMED and EMBASE registries were used for the literature search to identify suitable studies. Keywords for the literature search were selected, with the authors’ agreement, using the PICOS approach: participants, interventions, comparisons, outcomes, and study design. Results: The literature search led to the retrieval of a total of 800 studies. A total of 36 studies including 25 RCTs, 5 prospective observational, and 7 retrospective observational studies were selected as suitable for this systematic review. Conclusions: The current evidence suggests that, in these patients, optimal postoperative pain management should rely on using a “blended approach” which includes the use of systemic opioids and the infusion of NSAIDs along with regional techniques. This approach warrants the highest efficacy in terms of pain prevention, including the lower incretion of postoperative “stress hormones”, and fewer side effects. Furthermore, concerns about the potential for the increased risk of wound infection related to the use of regional techniques have been ruled out. Pain after open liver surgery can be attributed to two major mechanisms: peripheral nociceptors stimulation  and visceral origin transmitted by sympathetic nerves ,2,3. DueIn 2015, a comprehensive review, that included fourteen studies published between November 1966 and September 2013, reported the superiority of epidural analgesia in pain relief over alternatives, but without translating into a reduction in length of hospital stay (LOS) and postoperative complication rates [The aim of this systematic review (SR) is to summarize the available clinical evidence, published after September 2013, on systemic or blended postoperative analgesia for the prevention or treatment of postoperative pain after open liver surgery.This SR was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations, and the study was registered in the International Prospective Register Of Systematic Review (PROSPERO registration number CRD42020152836) ,22. SystThe inclusion criteria were randomized controlled trials (RCTs) and prospective (POS) and retrospective (RO) studies published between October 2013 and December 2020 in the adult population (older than 18 years) on analgesia in patients who had undergone open liver surgery. Papers examining analgesia in other hepatic procedures were excluded . Only full-text papers in the English language were considered for eligibility. Studies reporting evidence on pharmacological therapies  in patients who had undergone open liver surgery that included qualitative or semiquantitative pain assessment were considered suitable for this SR.The primary outcome measure of this SR is to report evidence in terms of the reduction in pain measured with patient-derived qualitative or semiquantitative scales referable to tested analgesic therapy. The secondary outcome measures are related to safety and clinical complication as recorded in selected studies: safety , need of rescue analgesia, the total amount of opioid consumption, anesthesia recovery time, hemodynamic stability, vasopressor and fluid requirement, need for blood transfusion, postoperative complication rates, inflammatory and immune response, indicators of patients’ recovery, patient satisfaction, and LOS.p < 0.05.Two authors  independently screened and assessed titles, abstracts, and full-text papers to identify eligible articles, with FB and PA acting as arbiters. Details of the study population, type of interventions, outcomes, and other information were extracted using a standardized data extraction form that included: study design, eligibility and exclusion criteria, duration of follow-up, randomization, blinding, number and characteristics of patients, type of surgery, and drug dose and method of administration. We reported as significant efficacy those treatments that are related to http://handbook.cochrane.org, accessed on 1 September 2020).The risk of bias for all included trials was assessed according to the Cochrane Collaboration’s criteria for RCTs and non-randomized controlled trials (non-RCTs)  including 24 RCTs, 5 prospective observational (POS), and 7 retrospective observational (RO) studies were selected as suitable for this SR, and risk of bias was evaluated . In 35 oThe role of WI with local anesthetics to prevent postoperative pain after open liver surgery was evaluated in ten studies, which included a total of 1412 patients: five compared to TEA , four to placebo (RCTs), and one to systemic opioids (RCT) ,48,49,50The efficacy of a TAP block in preventing postoperative pain after open liver surgery was tested in nine studies, which included a total of 816 patients: two compared to neuraxial analgesia (2 RO), two to placebo (2 RCTs), three to systemic opioids (2 RCTs and 1 RO), one assessed the combination with NSAID-parecoxib-(RCT) and one to WI (RCT) ,51,52,53The effectiveness of TEA in pain management after open liver surgery was evaluated in four studies, which included a total of 393 patients: three compared to systemic opioids (2 RCTs and 1 POS) and one compared to a combination of systemic opioids and WI (RCT) ,38,39,54The role of NSAIDs in preventing postoperative pain after open liver surgery was evaluated in three studies, which included a total of 186 patients: two compared to placebo (RCTs) and one compared parecoxib to ketorolac (RO) ,45,55. WThe efficacy of ITM in preventing postoperative pain after open liver surgery was evaluated in four studies, which included a total of 374 patients: three compared to systemic opioids (RO and 2 RCTs) and one to TEA (PO) ,43,56,57The role of PVB in preventing postoperative pain after open liver surgery was tested in three studies, which included a total of 150 patients: one compared to TEA (RCT), one to placebo (RCT), and one to systemic opioids (RO) ,44,58. WThe effects of continuous QLB in preventing postoperative pain after open liver surgery was evaluated and compared to systemic opioids in 1 RCT that enrolled a total of 63 patients . When coAdding dexmedetomidine to pain management after open liver surgery was tested in one study (RCT) and compared to a placebo in a total of 52 patients . DexmedeDifferences in ketamine administration routes, intravenous vs. epidural, were tested to prevent pain after open liver surgery in one study (POS) which included a total of 44 patients . The twoThis SR is intended to update a previous review and PROSPECT guidelines on postoperative analgesia in open liver surgery and includes studies published between September 2013 and December 2020. Current evidence suggests that, in these patients, optimal postoperative pain management should rely on using a “blended approach” that includes the use of systemic opioids and NSAID infusion along with regional techniques . This approach warrants the highest efficacy in terms of pain prevention, including lower incretion of postoperative “stress hormones”, and fewer side effects. Furthermore, concerns on the potential for the increased risk of wound infection related to the use of regional techniques have been ruled out.Compared to the evidence reported in the review published by Hughes and Coll , there aThe present SR is intended to update a previous review article and has unique methodological features. First, the current SR presented was conducted in accordance with the PRISMA guidelines as with the previous one but was also approved and recorded by the PRISMA board. Data extraction was accomplished, with a dedicated data extraction form, using a PICOS approach intended to identify specific primary and secondary end points that namely included the efficacy and safety of the tested approaches. The current primary end point was selected to report on the efficacy of the tested therapies, thus, introducing a distinct perspective when compared to the previous review that primarily reported an “overall systemic complication rate”. The previous approach led the authors to find no differences among the reported approaches, while in the present SR the benefits of a blended approach are shown, as is the superiority of the pre-scheduled administration of NSAIDs, while opioids should be better prescribed as PCA. As secondary end points, the previous review reported LOS and pain scores at 24 postoperative hours both at rest and when moving proved unbeneficial. In the present SR, safety was the main focus of the selected secondary end points, and collected evidence excluded the potential for additional risk associated with regional analgesic strategies. Studies that included patients who underwent liver transplants have been excluded from the present SR because it was selectively intended to present the clinical management of patients undergoing an elective surgical procedure.This SR has several limitations including the methodological approach that relied on the literature search being limited to two databases (PubMed and EMBASE). Despite the potential for having missed other published studies, it is appropriate to underline that the most prestigious journals are referred to in these databases and therefore the risk of omitting major information was limited. Another possible limitation refers to the exclusion of studies that presented mixed cases of open, laparoscopic, and percutaneous procedures. This might have prevented adding details collected in some studies however enabled the selection of evidence from patients with a more homogeneous clinical background. Of note, most of the studies in each treatment section have widely different design and clinical relevance. As a result of this and other shortcomings, there are often contradicting results. We acknowledge that utilizing the GRADE approach to evaluation might have added strength to data extraction. Nevertheless, as mentioned among the study’s limitations, the limited number and heterogeneity of retrieved studies prevent reaching ultimate conclusions and the present systematic review should be considered as an updated summary of available evidence and the proposal for future studies.In conclusion, the latest evidence on postoperative analgesia in open liver surgery provides new relevant information on the effectiveness and safety of various tested approaches and supports “blended” approaches with systemic analgesic infusion (opioids and NSAIDs) along with regional techniques. Patients undergoing open liver surgery have unique clinical problems and requirements that include: the risk for hemodynamic instability due to intraoperative vascular clamping and fluid shift, potential postoperative pulmonary complications, coagulation disturbances, and metabolic abnormalities after excessive parenchymal resection, altered drugs metabolism, etc. Blended multimodal approaches were associated with the highest effectiveness and the least side effects. The NSAIDs should be better administered on a pre-scheduled structured prescription and opioids have the highest efficacy/safety profile when administered as PCA. Continuous opioid infusion, along with scheduled NSAID administration, emerged as a possible treatment after the careful analysis of available clinical evidence in this setting. None of the referenced studies specifically tested this approach that is a part of the new information presented in this systematic review as possible future research proposals. Future studies should also be addressed to identify how postoperative analgesia can effectively contribute to shortening LOS and improving functional recovery of physical and cognitive abilities.


Most National Parks (NP) and nature reserves in Rwanda have been established opportunistically in the early 1900s, without clear consideration of ensuring the protection to all threatened different taxonomical or functional groups, such as vegetation, invertebrates, fish, and birds. With the increasing conservation objectives, raised expectations into Protected Areas (PA), and within a more challenging environmental context, it is important to identify biodiversity hubs and key areas for Ecosystem Services (ES) to maximize the efficiency of conservation efforts by assisting priority areas under threats. To date, no comprehensive analysis, to the best of our knowledge has been done to assess both biodiversity and ES in Rwanda. This is a notable gap, considering that global-scale research suggests that the spatial overlap between biodiversity targets and ES is low. This study reports a nationwide assessment, mapping the richness of threatened species and three key ES Carbon Storage, Water Quantity, and Water Quality. Our analysis has shown that PAs are neither perfectly delineated to protect biodiversity nor key ES. The state of PAs offers a taxonomic protection bias in favor of mammals and birds but leaves many endangered species in other taxonomic groups in collapsing and unprotected small ecosystems scattered around the country. Rwanda’s PAs cover important carbon stock but can do better at securing higher water balance regions and clean water sources. We propose an improvement of the NP system in Rwanda to help guide the economic development along a path of green growth and ensures the well-being of both people and nature. Locating biodiversity hubs and key ES can help to connect conservationists, local people, and governments in order to better guide conservation actions. The degradation of natural ecosystems relentlessly continues to threaten the long-term survival of many species around the world . There iThis paper makes a contribution towards a better understanding of the linkage between PA, biodiversity conservation, ES, and human wellbeing, as a necessary step towards ensuring more effective and sustainable integration of ecological portion into other so many national development imperatives. It unpacks some of the home-grown realities of these linkages through the application of a multidimensional conservation approach. By doing so, it responds to five current weaknesses that are common in today’s conservation analysis in Rwanda as it has been raised by various authors –19. ThesFocusing on the protection of certain preferred species instead of ecosystems. Yet PA are not meant to protect isolated species but the entire ecosystems.Limited recourse to modern technology to correct the status quo that was established during the past when there was lack of adequate tools, even when the lack of objectivity and inefficiency are palpable.Allowing much more attention to the direct income-generation side of conservation and leave behind the mission to transfer the natural heritage to the next generation in unimpaired state.Sticking to the classic focus of PA on biodiversity failing to open the doors to the underway major shift toward broadening the goals of PA to also encompass the provision of ES for human well-being.Disregarding the contribution of PA at addressing the planet’s concerning issues such as climate change, air pollution, disasters, epidemics, etc.Due to the diffusion of remote sensing practices, ES mapping techniques have generated great interest in recent literature. Mapping provides spatial information about the state of ES which makes it an important element in the decision-making process where it is necessary to implement and monitor environmental policies , 21. We Rwanda  is a lanThe country had a projected human population of 12,089,720 in 2018 and the highest population density on mainland Africa (477 people per sq.km) . Around Rwanda’s contemporary biodiversity conservation strategy has principally centered on PA model. The PA in Rwanda are largely a colonization legacy predominantly sustained by government institutions and international NGOs. One of the drawbacks of that PA model is that it can indirectly confine the arena for conservation action within reserves, hence condemning outside landscapes to maximum exploitation, which finally creates pockets of PA in extensive human transformed habitats . In devest December 2005. Some 82 bird’s species have been recorded within the marsh and its vicinity , EN—Endangered, VU—Vulnerable, LR/cd—Lower Risk/conservation dependent, NT—Near Threatened (includes LR/nt—Lower Risk/near threatened), DD—Data Deficient, LC—Least Concern } ; 3) An i2 to the atmosphere. Their vulnerability to land use, and numerous other ecosystem services (ES) they provide make wetlands a point of increasing interest for participation in climate change mitigation strategies, such as Reduced Emissions from Deforestation and Degradation (REDD+) [Forests play a vital role for biodiversity conservation, and provide incentives to solve societal and economic well-being, whether through offering food and wood, creating income and employment, or by providing environmental services such as water and soil conservation, and climate mitigation . Particu (REDD+) , 37.We identified Rwanda’s biodiversity concentration stages at district level. This assignment wouldn’t be settled without recourse to the official shapefile of the administrative division of Rwanda into 30 districts. We have compiled an exhaustive biodiversity inventory data from a range of sites in different districts of Rwanda, and subdivided living organisms into 6 taxonomic groups: Mammals, Birds, Fish, Reptiles, Amphibians, and Plants. We unfortunately could not include invertebrates, even though they represent at least 95% of all species in East African region due to the fact that they are still largely undocumented . To ensuThe level of threat against particular species was also highly considered. We couldn’t think of any better indicator of the health and status of species than the world’s most comprehensive information source on the global extinction risk status of animal, fungus and plant species namely the International Union for Conservation of Nature’s Red List of Threatened Species (IUCN Red List) for Rwanda, under different categories such as Extinct (EX), Critically Endangered (CR), Endangered (EN), and Vulnerable (VU). IUCN revealed that 26% of mammals, 14% of birds, and 41% amphibians are threatened globally . In ordeThe endangered species from all taxonomic groups are supposedly a portion of a long list of species hence, we have assumed that the thematic maps of Rwanda’s threatened species represent a sub-set of the thematic maps of a given taxonomic group. No threatened species will appear in different locations than the locations of the species themselves.Conservation efforts have difficulty obtaining financial and social support for PA that do not demonstrate their tangible benefits for society . ES are 2 spatial resolution, have monthly/diurnal temporal resolution, supply required biophysical data, provide data for climate change impacts, land use change impacts, land management impacts, water management impacts scenarios, and provide results about baseline services such as water quality, water quantity, water regulation, carbon, etc.In developing world countries where data gaps are a major challenge the set of ES possible to analyze is generally constrained by the availability and consistence of spatial data at national scale, the cost, processing time, and level of expertise. Tools used in our investigation include Co$ting Nature (CN), Water World (WW) and ESRI’s ArcGIS 10.2.2. For a complete review of ES assessment tool, please see –65, forCIn this study, we assessed four key regulating ES: Carbon storage, Water balance, Human footprint on water quality/diarrheal disease and Human footprint on water quality/annual. These services were selected based on their significance to Rwandan context and the availability of data. All spatial analysis was conducted and maps generated respectively using ESRI’s ArcGIS 10.2.2 , CN and 2 concentration in the atmosphere [Carbon storage refers to the amount of carbon seized by terrestrial ecosystems (both aboveground and belowground) , the majmosphere . The natmosphere . By consWe downloaded 4 satellite images taken by Landsat 8 OLI/TIRS from the U.S. Geological Survey Earth Explorer, tool that gives users the ability to query, search, and order aerial photographs, satellite images and cartographic products. The images were subtracted from the following address: Path 172 Row 61; Path 172 Row 62; Path 173 Row 61; Path 173 Row 62 and the date range was from 01/01/2019 up to 31/12/2019. Images with less than 10% of cloud all captured during the same dry season were preferred to minimize natural landscape elements fluctuations related to seasonal change. The most recent Landsat 8 mission carries the Operational Land Image (OLI) and the Thermal Infrared Sensor (TIRS). OLI/TIRS data are delivered at 30 m resolution with 11 spectral bands. The images are georeferenced and hold many layers containing data collected along both visible and invisible light spectrum that can be manipulated to reveal hidden indications about pictured ground features as highlighted in We have performed radiometric and geometric calibration on downloaded images to correct and eliminate distortions caused by the Earth’s rotation and camera angles. We have combined the multiple raster datasets into a single Mosaic image on which we have performed the supervised land use/cover classification, the common technic of remote sensing in which the image processing software (ArcGIS) is given primary guidance by the operator to specify the land use/cover classes of interest. We established the distribution of primary land use/cover classes following . The famRed = 4, Green = 3, Blue = 2: Natural ColorRed = 7, Green = 6, Blue = 4: False Color (urban)Red = 5, Green = 4, Blue = 3: Color Infrared (vegetation)Red = 6, Green = 5, Blue = 4: Vegetation AnalysisRed = 5, Green = 6, Blue = 2: Healthy VegetationRed = 5, Green = 6, Blue = 4: Land/WaterWater balance refers to water resources available in a catchment for different purposes including, but not limited to, agriculture and domestic purposes. The flow results coupled with the basin characteristics (slopes and imperviousness) can also be used in planning for watershed management measures including but not limited to erosion control, soil moisture and land management measures . The accwww.policysupport.org/waterword) at 1 sq.km resolution. All data required for model application in Rwanda as well as anywhere in the world are provided unless substituted by user’s data [Conservation initiatives rely on spatially explicit data on the location and distribution of ES to ensure that co-benefits are fully provided by nature to the people, hence the need to map them to help guide the most effective conservation investments . We usedr’s data . It is ar’s data . WW usesr’s data . Human fImportant biodiversity hubs for different taxonomic groups are shown in . The divImportant biodiversity hubs are distributed from east to the west of Rwanda, strongly subjected to the altitude and general annual rainfall distribution, hence by the 4 local climatic regions of Rwanda. From the east to the west, the lower elevation averaged 1220 m in the swampy Akagera river valley lays the ‘East-Rwandan dry and hot lowland zone’ in which the annual rainfall ≤900 mm and the annual temperature averaged at 21°C, is dominated by savannah habitats and is mainly conquered by large mammals most of which are protected in the ANP and others scattered through the surrounding districts in relatively small unprotected natural habitats such as Ibanda-Makera natural forest (Kirehe district), Karama natural forest (Bugesera district) and Mashoza natural forest (Ngoma district). Follows the interior highlands that consist of rolling hills and valleys over which the annual rainfall reaches 1200 mm is distinctly higher than in the eastern territories and the annual temperature averaged at 19°C which makes local climatic conditions become the ‘Temperate zone of the central highlands’ . The higOsyris lanceolata , the CE Balaeniceps rex , the CE Giraffa camelopardalis (Giraffe), the Endangered (E) Albizia amara , etc. the VNP offers habitat to the famous CE Gorilla beringei beringei (Mountain Gorilla), and protection to the Vulnerable (VU) Vaccinium stanleyi, etc. NNP is home to the CE Xyris vallida, the E Tabernaemontana odoratissima, the E Casearia runsorica, the VU Kupeornis rufocinctus (Red-collared Mountain Babbler), the E Cercopithecus ascanius (Redtail monkey), etc. GMNP protects the E Cercopithecus mitis kandti (Golden Monkey), The VU Cryptospiza shelleyi (Shelley’s Crimson-wing), the E Casearia runsorica, etc. Rugezi wetland in Burera district harbors many endangered bird species such as the VU Calamonastides gracilirostris (Papyrus Yellow Warbler), the E Bradypterus graueri (Grauer’s Swamp warbler), the E Balearica regulorum (Grey Crowned Crane) and a considerable number of endemic amphibians such as the VU Hyperolius castaneus (Brown reed frog).The geographical distribution of threatened species hotspots is linked to the geographical distribution of biodiversity-rich habitats, hence on the four peripheries of Rwanda at distances from the centroid of Rwanda that harbors the most important human activity centers of the country. Threatened species hotspots are mainly located in already existing PAs, that mainly extend on three peripheries of the country, with ANP on the extreme east, VNP and Rugezi wetland on the northern periphery and GMNP and NNP on the Western periphery of Rwanda. Moreover, part of threatened species is also located on the unprotected southern periphery of Rwanda. PAs have enormously contributed to save a large number of endangered species from extinction: ANP accommodates various endangered species such as the Critically Endangered (CE) Cyperus papyrus marshes which harbors the Nearly threatened (NT) Laniarius mufumbiri (Papyrus gonolek), the CE Thalassornis leuconotus (White-backed Duck), the CE Netta erythrophthalma (Southern Pochard), the CE Microparra capensis (Lesser Jacana), the E Serinus koliensis (Papyrus Canary), the E Necrosyrtes monachus (Hooded vulture), the VU Pitta angolensis (African Pitta), the VU Numida meleagris (Helmeted Guineafowl), etc. Buhanga natural forest in Musanze district contains the CE Terathopius Ecaudatus (Bateleur), the CE Polemaetus bellicosus , etc. Shagasha natural forest in Rusizi district contains the VU species like Cercopithecus l’hoesti (L’hoest’s monkey) isolated from other groups found in NNP. Muvumba natural forest in Nyagatare District is mainly constituted by Acacia kirkii an endemic plant species to Rwanda and not occurring elsewhere in the region. The forest also shelters the E bird species Balerica regulorum (Grey crowned crane) and the Vulnerable species such as Balaeniceps rex (Shoebill). Ibanda-Makera natural forest in Kirehe district is a gallery forest associated with woodland and savannah in the east and papyrus swamp in the south toward Akagera river. The forest shelters the CE Blighia unijugate (Triangle tops), the CE Netta erythrophthalma (Southern Pochard), the VU Francolinus afer (Red-necked Spurfowl Francolin), and the VU Numida meleagris (Helmeted Guineafowl).Neverthlesss, a portion of threatened species also exist or exclusively exist in non-protected less undisturbed zones so far, particularly on the country’s southern periphery. The waters and shores of lake Kivu  and its numerous islands harbor various thematic groups of biodiversity, though its fish biodiversity is low (only harbors 26 fish species of which 15 are endemic Haplochromine), its islands are particularly important for the survivorship of water birds species who use the islands for reproduction, feeding and resting and are home to many registered endangered species on IUCN red list such as the E Ardeola idea (Madagascar Pond Heron). Rweru-Mugesera wetland complex in Bugesera, Ngoma, and Rwamagana districts accommodates ecological highly important The important areas for carbon storage are distributed mainly in places with forests in south-west, west, and north-west of Rwanda, these are respectively NNP , GMNP , and VNP ; shrubs in east of Rwanda mainly in ANP , Gabiro, Gako and Nasho military domains ; wetlands mainly in the north and south-east of Rwanda, these are Rugezi wetland (Burera district) and Rweru & Mugesera wetland complex ; and lakes, mainly Kivu , Burera and Ruhondo (Burera and Musanze districts), Muhazi , Rweru & Mugesera  and Ihema (Kayonza district). The amount of carbon storage corresponds to the amount of avoided flow of carbon into the atmosphere hence weakens further exacerbating effects to global climate change.Important areas that contribute the most to the Annual water balance in Rwanda are generally located to higher elevation and are directly related to the level of the area’s green land cover. Sources and water upstream points are attributed higher values compared to the downstream of flow, hence their points of use are not as valuable as their points of production. Spatial distribution map shows highest values in the western part of Rwanda (Congo-Nile divide) that corresponds to higher elevation, most dense vegetation, highest annual rainfall, and the source of many water flows towards the Nile river in the east and Congo river in the west.Rwanda has the highest population density on African mainland and human settlement is predominantly characterized by scattered pattern that spread on the country’s hills and highlands. The largest urban centers are located in the country’s center. Human footprint on water quality-diarrheal diseases is directly linked to human settlement, the map shows that PA such as NNP, VNP, ANP, Rugezi wetland and Rweru & Mugesera complex offer the opportunities of creation of safe water sources and effective sanitation systems that can guarantee the protection from contamination to diarrheal diseases.Human footprint on water quality  involves all sorts of pollutants that are linked to human activities that either worsen or degrade stream, river, lake, ocean, aquifer, or other body water’s turbidity or damage the water quality by rendering it toxic to humans or environment. Anthropogenic activities such as mining and quarries exploitation around wetlands and water bodies and industrial effluents from cities such as Kigali threaten by sedimentation and pollution the downstream water bodies due to poor sewage and inexistant waste treatment systems. On the other hand, the map  shows thWhile we don’t reject the fact that the biodiversity is generally well conserved and protected within PAs whilst out of them the biodiversity is highly threatened mainly due to intense human activities in Rwanda , this paOriginally conceived to conserve iconic landscapes and wildlife, PAs are now expected to achieve an increasingly diverse set of conservation, social and economic objectives. Rwanda is a country with globally significant biodiversity and a high level of human dependence on ecosystems. We assessed key regulating ES . PAs perform multiple roles that go beyond their intended conservation purposes, many of which go unnoticed and thus are seldom targeted for improvement. Such are the contribution to water balance, water quality, and carbon storage.Mapping PA and ES do not only provide spatial information about their state to help targeting areas where it is necessary to implement and monitor environmental policies, but also facilitate understanding of the real impact of current environmental policies on ecosystems and the services they provide .Rich biodiversity in protected wetlands can improve their treatment efficiency by enhancing their biogeochemical cycling  hence, eGiven that mapping ES is becoming a key tool to guide decision making, the quality of such ES maps is important in order to be able to provide the most accurate information . Our resThe method used for creating the maps for major groups of vertebrates and invertebrates has limitations as the method only identify the existence of the species in a given district but do not provide any information about specific species density, occupancy, threat and territorial range.Rwandan territory visibly contains numerous biodiversity hubs in which are concentrated exceptional level of endemic biodiversity. These zones are mainly but not limited to the officially established PAs . On those can be added regions that had enjoyed some degree of protection against human intrusion during the last decades, but also remote & inaccessible areas . Before enjoying a certain level of stability, it is important to mention that Landscape features , climatic conditions , and soil conditions  have in the first place combined to make them ‘ecological islands’ by giving them natural advantages allowing them to provide a convenient habitat, food, and nutrient to an exceptionally high number of biodiversity and provide high levels of ES. These precious regions are limited, fragile, and irreplaceable, anthropologic pressure and climate-driven may undermine the competitive advantage of these regions over others, hence the desperate need for protection. Rwanda’s NP system has been able to save many species that most probably wouldn’t survive until today. The expansion of the NP system to include the biodiversity hubs & priority area for ES provision would save the latter from further depletion and help the previous to achieve the PA’s modern time mission of nature conservation which does no longer only includes responsibilities on biodiversity protection but also upon ES.Achieving the goal of protecting the optimal fractions of biodiversity in the high densely populated Rwanda, desperately requires tools that enable the existing NP system to support the most species at the least cost. In addition, the NP system needs to reform and embrace new modern conservation responsibilities that have significantly increased compared to those they were required to deliver to at their establishment a century ago. Including biodiversity hubs and priority areas for ES provision to the wider national protection system through green corridors and PAs widening would not only save them from further impairments, but also reduce the risk of extinction of many threatened species, and boost their provision of ES. The procedures shown in this study are the freely available based models for application in data-poor but problem-rich environments therefore, they are easily transferable to other regions for assessing the benefits of PAs beyond the conservation of biodiversity. Such assessments will allow the identification of areas that require further conservation actions, as well as those that are contributing to biodiversity conservation and ES provision. As such, our results directly respond to recent calls for efficient prioritization of the location of PAs. , 7.S1 Appendix(XLS)Click here for additional data file.


Regulation of food environments is needed to address the global challenge of poor nutrition, yet policy inertia has been a problem. A common argument against regulation is potential conflict with binding commitments under international trade and investment agreements (TIAs). This study aimed to identify which actors and institutions, in different contexts, influence how TIAs are used to constrain policy space for improving food environments, and to describe their core beliefs, interests, resources and strategies, with the objective of informing strategic global action to preserve nutrition policy space.We conducted a global stakeholder analysis applying the Advocacy Coalition Framework, based on existing academic literature and key informant interviews with international experts in trade and investment law and public health nutrition policy.We identified 12 types of actors who influence policy space in the food environment policy subsystem, relevant to TIAs. These actors hold various beliefs regarding the economic policy paradigm, the nature of obesity and dietary diseases as health problems, the role of government, and the role of industry in solving the health problem. We identified two primary competing coalitions: 1) a ‘public health nutrition’ coalition, which is overall supportive of and actively working to enact comprehensive food environment regulation; and 2) an ‘industry and economic growth’ focussed coalition, which places a higher priority on deregulation and is overall not supportive of comprehensive food environment regulation. The industry and economic growth coalition appears to be dominant, based on its relative power, resources and coordination. However, the public health nutrition coalition maintains influence through individual activism, collective lobbying and government pressure (e.g. by civil society), and expert knowledge generation.Our analysis suggests that industry and economic growth-focussed coalitions are highly capable of leveraging networks, institutional structures and ideologies to their advantage, and are a formidable source of opposition acting to constrain nutrition policy space globally, including through TIAs. Opportunities for global public health nutrition coalitions to strengthen their influence in the support of nutrition policy space include strategic evidence generation and coalition-building through broader engagement and capacity-building.The online version contains supplementary material available at 10.1186/s12992-021-00764-7. Over the past 25 years since the inception of the World Trade Organization (WTO), the proliferation of international trade and investment in food and beverage markets has shaped global food environments inexorably –5. A shiScholarship in the past decade has raised concerns that trans-national companies (TNCs) and other opposed parties may use international trade and investment agreements (TIAs) as a means to contest the legitimacy of such regulations and restrict governments’ ‘policy space’ for food environment (nutrition) interventions –24. PoliWho are the actors and institutions relevant to the  food environment policy subsystem?How do they influence policy space through TIA mechanisms?What are the important networks and power dynamics?This stakeholder analysis aimed to examine how actors and institutions, in different contexts, influence TIA-related mechanisms of policy space constraint for improving food environments. The analysis was guided by three main research questions:The data was obtained from 26 literature sources and 22 interviews collected by the lead author as part of their PhD thesis. Documentary sources in the form of academic literature, institutional reports, trade and investment dispute documents, and WTO Committee meeting minutes were identified through a systematic search of 5 academic databases, 13 institutional websites, and 4 dispute databases, and detail of the search strategy is reported in a previous publication . InterviOur approach to data organisation was guided by Varvasovsky & Brugha’s (2000) practical how-to manual for stakeholder analysis . The anathe priority of different policy-related values, whose welfare counts, the relative authority of governments and markets, the proper roles of the general public, elected officials, civil servants, experts, and the relative seriousness and causes of policy problems in the subsystem as a whole.(  p195)These stakeholders are embedded in the various relevant ‘policy systems’, within both the public and private sectors. Regulation of food environments for NCD prevention involves the intersection of at least three policy systems: health, trade/commerce, and food/agriculture , interest in the issue, influence/power in the issue, position with respect to the issue, and impact of the issue on the stakeholder.To further tease out sources and types of power and influence present in the policy subsystem, we drew upon Lukes’ three dimensions of power including visible/direct influencing of decision making, institutional bias (i.e. the ‘rules of the game’), and implicit/ideological underlying core beliefs that shape how actors consider policy issues .Stakeholders/actors who influence nutrition policy spaceInterests of the different actorsBeliefs of the different actorsResources, strategies and activities (i.e. how do they use the TIA mechanisms at hand)Relationships between actorsDocumentary and interview data were uploaded to NVivo™ . We systexplicit or implicit reference to mechanisms of influence on nutrition policy space and types of power.For the sake of the analysis, these stakeholders were grouped by ‘type’ in order to develop some theoretical generalisations about shared interests and common sources of power/mechanisms of influence in nutrition policy space through TIAs. We developed an a priori set of actor /stakeholder categories expected to appear in the data. These included: government departments/ministries involved in trade and health, civil society organisations, consumer-citizens, media, trade partners, food and beverage companies and industry lobby groups, trade governance institutions, and standards-setting bodies. We inductively coded based on these categories, continuously updating and modifying the theory deductively through iterative reading of the data. We also coded for Involvement in the issue (food environment regulation and policy space with respect to TIAs);Interest in food environment regulation and policy space with respect to TIAs;Influence / power in food environment regulation policy space with respect to TIAs;Position with respect to food environment regulations; andImpact of food environment regulations and policy space on the actor/stakeholder.Coding was conducted in an iterative manner to ensure consistency in the analysis of all source documents. Once all sources had been coded once, the lead author returned to the beginning to review, add new codes and themes that arose later in the coding process, and to identify and rectify any inconsistencies. The senior author reviewed the final coded data in detail.Once the data were coded, we then conducted a stakeholder analysis guided by Varvasovsky and Brugha, as described above, organizing data corresponding to each stakeholder-type according to the following characteristics:Our findings are organised into the following sub-sections: which stakeholders can influence nutrition policy space through TIAs; what are the important networks and relationships between stakeholder groups; what are the primary coalitions operating in the policy subsystem of food environment regulations; how do these coalitions influence (constrain) policy space through TIA mechanisms; and finally, what are the strategies used to preserve policy space for food environment regulations.We identified 12 types of stakeholders (understood as single actors or entire institutions) in the literature and interviews that had particularly important roles in the food environment policy subsystem, either supporting policy space for food environment regulation, or contributing to TIA-related constraints , relevant CSOs, public health academic researchers, and championing politicians (e.g. Members of Parliament (MPs), Ministers) and/or celebrity influencers / activists.Common core policy beliefs were that obesity and diet-related NCDs are a systemic issue . Actors in this coalition were typically in favour of government intervention in markets for public health purposes, and believed that industry should have limited role and consultation in the regulatory policy process.Interests that were evident included protecting and promoting the Right to Health , and enjoying a Right to Health, or Right to Food (e.g. consumer and public interest groups). For example, through: affordability/value for money, and human rights .Issue framing centred around food environment regulations being necessary to reduce systemic drivers of obesity and NCDs, based on WHO recommendations and/or nutrition profiling models, and informed by domestic evidence (e.g. nutrition surveys) or international evidence.Power/resources: We observed that WHO and regional bodies have legitimacy but low institutional power in the policy subsystem, as recommendations and guidance are weak, non-binding instruments whereas economic treaties are strong and legally-binding. Responses indicated that Ministries of health likewise tend to have less internal government influence than ministries of economy or trade, while CSOs in health and consumer rights tend to be chronically under-funded and have limited power  to influence domestic and global governance. Championing politicians or celebrity activists (acting as ‘policy entrepreneurs’) were noted to provide an important boost of influence.This coalition typically includes trade partner governments (represented in trade forums by Ministries of Commerce/Business/Industry/Foreign Affairs and Trade), private sector organisations , and domestic  government Ministries of Commerce/Business/Industry/Foreign Affairs and Trade.Common core policy beliefs were that obesity and diet-related NCDs are individual behavioural problems and the responsibility of the consumer; belief in a neoliberal economic model/minimising barriers to commerce and government intervention in markets; scepticism about the need for/appropriateness of food environment regulations; and belief that industry stakeholders should have full consultation and influence in the regulatory policy process.Interests associated with this group included economic and export growth, lowering costs and increasing (private sector) profit. For example, we noted interests in: livelihoods , unrestricted market access, equal or favourable conditions of competition (e.g. TNCs), growing the economy , and promoting the food production and agricultural sector including key exports (e.g. Ministries of Food & Agriculture). Other interests included representing Members or constituents and gaining or maintaining political power , and reputation/public image .misleadingly target ‘high in’ products that can be part of a balanced diet when consumed in moderation, suggesting public education and physical activity as better solutions to the health problem  than for those who are really open to the market.”(P11 – referring to Marketing restrictions).TNCs are the complainants in ISDS investment disputes, and often have vast financial resources, technical capacity and personnel to dedicate to fighting a regulation, exerting direct, visible influence on policy space. With such resources, investors may “exploit the loopholes in trade agreements and the structure of the regional economy to gain unjustified advantages and political power,” taking advantage of the uncertainty in interpretation associated with many investment treaty provisions.(  p77) OneIn addition to lobbying governments to act on their behalf in trade discussion forums such as the TBT Committee, the private sector is known to lobby its host governments for more favourable conditions when negotiating regional and bilateral trade agreements , using strategic framing  . In an aParticipation in the Codex Alimentarius standard-setting process was another important identified aspect of industry and economic growth coalitions’ power and influence on TIA-related policy space for food environment regulation, as Codex is the main recognized standard-setting body for food and beverages in trade forums such as the WTO TBT and SPS Agreements. Though country delegations are the actual decision-makers, the private sector has formal and informal institutional avenues for influence within this international standards-setting body. In addition to strong industry lobbying at the national level to influence decisions relating to nutrition policy, food and beverage industry associations may have Observer status to Codex discussions, and private sector representatives are regularly invited to join Member country delegations as technical advisors . A proceIt is safe to assume that this imbalance in representation will be reflected in the dominating frames (ideology) voiced in Codex discussions. Examples of which, as observed by Thow et al. (2019), include framing FOPL as “a ‘restrictive regulatory measure’ that was being implemented in unnecessarily diverse approaches that had associated risks of limiting trade,” and that “labelling is only one intervention and by itself would not ‘solve obesity.’”(  p7) Suchappropriate consultation. Many participants believed that there is space for appropriate industry consultation in the regulatory development process; the question is, at what stage, and whether they are simply consulted or actually engaged in developing policy. The World Cancer Research Fund (2019) reported that most countries implementing FOPL to date have engaged industry at some point during the policy making process, with the dominant view that they can provide valuable input on the economic impact to their business of implementing the regulations, and any important technicalities of the regulatory or voluntary measure such as label design [They don’t necessarily have to go with industry recommendations, or give them special rights, but giving industry the ability to respond is important. They should get to weigh in on how it is rolled out (e.g. vis a vis their manufacturing cycles), and this should be taken into account. Consultation should be done across the board, including the public. This would apply to investment chapters – e.g. fair and equitable treatment. (P2 – referring to Labelling)The World Cancer Research Fund report recommended that governments “set clear guidelines for the type and scope of industry engagement, ensuring the engagement follows the normal legislative consultation procedures required under national law.”.Public health coalition actors may also act to preserve policy space, and this analysis identified three such strategies. First, CSOs can apply pressure to government leaders for transparency and accountability in public health nutrition policy development, as well as in TIA negotiation , 62. ForThough our analysis found that public health nutrition coalition actors have the greatest impact when working together, such coordinated action appeared to be less common  than it is for the industry and economic growth coalition.This study has described how stakeholders with economic interests influence the ‘food environment policy subsystem’, which spans global and national policy making, particularly with respect to international trade and investment. It has also highlighted the ways in which public health nutrition-oriented stakeholders can and do exert influence, to the benefit of nutrition policy outcomes. We identified 12 types of actors who influence policy space in the food environment policy subsystem. These actors hold various belief systems regarding the economic policy paradigm , the nature of obesity and dietary NCDs as health problems , the role of government (e.g. pro- or anti-regulation of markets), and the role of industry in solving the health problem . Certain belief systems are also apparent across institutions, in organisational culture.Based on their core beliefs, these actors and institutions can be broadly grouped into two primary coalitions: 1) a public health nutrition coalition, which is overall supportive of and actively working to enact comprehensive food environment regulation; and 2) an industry and economic growth coalition, which places a higher priority on deregulation and is overall not supportive of comprehensive food environment regulation. The industry and economic growth coalition appears to be dominant, based on its relative power, resources and coordination. However, the public health nutrition coalition maintains influence through individual activism, collective lobbying and government pressure (e.g. by CSOs), and expert knowledge generation.Our analysis suggests that the industry and economic growth coalition is highly capable of leveraging networks and institutional structures to its advantage, as well as promoting and entrenching a set of pervasive beliefs within the policy subsystem, and is a formidable source of opposition acting to constrain nutrition policy space, including through TIAs.There are opportunities for the public health nutrition coalition to strengthen its influence in the support of nutrition policy space.These findings are consistent with emerging literature on the roles, activities and power of stakeholders in policy change within the food environment policy subsystem. In particular, this study follows a growing body of research applying the ACF to nutrition policy change questions in global contexts, noting tensions between public health/nutrition coalitions, industry/economic coalitions, and in some cases food security coalitions –67. As pIn terms of solutions, some experts propose targeting formal structures, for instance revising some of the language in TIAs, reforming ISDS processes, and establishing limits on private sector participation in TIA negotiations to avoid conflicts of interest . Other pLencucha and Thow (2020) point out that in recent years, some governments and international economic agencies have begun to re-evaluate the status-quo of narrow economic rationality that places economic growth above health, environment or other social goals, providing ‘windows of opportunity’ for transforming how governments approach health-harmful industries such as unhealthy food, alcohol and tobacco . This emThis analysis suggests potential entry points for the public health nutrition coalition to focus efforts, leverage support and build capacity for preserved/increased policy space.Vavrasovsky and Brugha (2000) recommend different strategies  for ‘optimally’ managing different stakeholders, according to their positions on the issue in question . This alIn the simplest terms, this suggests that public health nutrition coalitions should involve more groups who are, or could be, supportive of food environment regulation. Some of these groups may be non-mobilised. As indicated by the data, this could include the mainstream media (as an enabling force), and a wider scope of CSOs i.e. public interest groups with an interest in food systems transformation. Swinburn (2019) suggests, for example, that “for some countries and regions, narratives around food security, food sovereignty or malnutrition may have greater currency, but whatever the narrative, it needs to be inclusive of the many groups and people who care about food in different ways.” ( p6) ThisVarvasovsky and Brugha (2000) suggest collaboration with the diverse-position groups . Here, srefrain from undermining them” (emphasis ours).(67 p8) On the other hand, there may be opportunities for a public health nutrition coalition to build bridges with the economic sector in new and constructive ways that explicitly remove support from unhealthy commodity-producing industries in favour of industries, consumer products and modes of production that are sustainable, health-promoting, and contribute to the economy [Some critical public health experts argue that food and beverage companies, under the current business-as-usual conditions, can only go as far as their customers and shareholders  will allow, and carrying front-of-pack nutrition warning labels, increasing prices to dissuade consumption, or internalising the negative externalities of their unhealthy commodities based on ‘public-spiritedness’ alone is not conceivable . In that economy . In thisWe can also consider strategic action in terms of what kind of change is within our realm of influence. For example, the Lancet Commission on Obesity report (2019) explains that policy inertia in obesity prevention is contributed to in large part by power asymmetries in food systems, including corporate-captured or inept government, food industry opposition, and weak civil society . UnfortuA number of strategic actions may be worth pursuing by public health nutrition advocacy coalition actors to preserve nutrition policy space, at both the international (IGO)-level, and domestic levels, which we briefly discuss below.nutrition labelling. Third, in light of the opportunities for health policy space preservation gained from obtaining access to secret negotiation texts, there may be opportunities for the public health nutrition advocacy coalition to push for transparency in investment arbitration.This analysis suggests three avenues for action at the international level. First, the legitimacy associated with scientific expertise in the TIA interpretation space indicates that the production of robust evidence by public health nutrition researchers and credible IGOs with a public health nutrition mandate  will enable justification of food environment regulations in international trade and investment forums. Generation of this evidence will be enabled by strategic planning in terms of allocating resources to strengthening the evidence base where it is most needed. Second, the uneven influence observed between coalitions in international standard-setting indicates that public health nutrition policy makers and CSOs could work to bring greater/stronger public health presence within Codex, specifically in standard development for Based on this analysis, we also propose the following avenues for action at the domestic level to preserve nutrition policy space with respect to TIAs:First, this research demonstrates the importance of positive public opinion. There is an opportunity for public health nutrition researchers and CSOs to foster this through broad public engagement , to include more potentially supportive actors. For example, if media is non-mobilised (i.e. uninterested), reporters could be engaged (and trained) to ensure balanced and factual reporting on the public health nutrition implications of TIAs and the trade implications of nutrition regulations. In addition, there may be opportunities to collaborate with trade analysts and activists not yet considering the food systems and nutrition angle.Second, the imbalance of power between sectors of government indicates that public health nutrition advocacy coalition members within government could build capacity within Ministries of Health to more effectively engage with trade Ministries on questions of TIA negotiation (or RIAs), and to translate to them the public health importance of policy proposals. Researchers, CSOs and policy makers could advocate for publicly-accessible Health Impact Assessments to be carried out as part of any TIA negotiation process, which include an examination of potential constraints on policy space for regulating food environments .Third, this research highlights the potential conflict of interest arising from institutional arrangements that favour private sector input within the policy subsystem. Researchers and CSOs should advocate that their governments commit to setting clear guidelines for the type and scope of industry engagement in domestic policy making processes (including trade and investment agreement negotiations), in accordance with whatever normal legislative consultation procedures are required under national law . By the Finally, there appear to be a number of opportunities to strengthen civil society. CSOs could identify ‘passive ally’ groups at the domestic level who could be brought on board to the public health nutrition advocacy coalition’s cause of food environment regulation . Interested CSOs could build their inter-sectoral capacity to better understand the implications of increased trade and investment liberalisation on nutrition policy space. CSOs working toward nutrition regulations for NCD prevention could coordinate their advocacy agendas, for instance focussing on a few key ‘asks.’ New and/or unconventional sources of funding and resources could be channelled to their activities. Bloomberg Philanthropies’ Food Policy Program, for example, has funded CSOs working toward obesity prevention in Mexico, the Caribbean, Colombia, Brazil, South Africa, and the US . FinallyThis study presents a comprehensive and systematic analysis of the stakeholders within the policy subsystem of food environment regulation that potentially influence policy space with respect to TIAs, and the connections between them, guided by established theoretical frameworks. This analysis is the first to comprehensively collate this information to answer the specific question of how actors and institutions play a role in the constraint or preservation of government policy space for food environment regulation, through TIAs.Due to the nature of the data collected , we have had to make broad generalisations for groups of stakeholders, though one could expect some heterogeneity within stakeholder categories, and for whole groups in different contexts. Finally, it is analytically challenging to determine the ‘true’ interests of actors and to disentangle ties of influence as this is inherently a matter of perception, and often these are concealed. As such, the analysis presented in this article serves best as a guide to help make sense of the agency of various stakeholders within the global nutrition policy sphere with respect to TIAs. A more in-depth analysis would need to be applied in order to answer specific policy space questions in specific contexts.Our analysis identified two primary competing advocacy coalitions engaged in either constricting or supporting policy space for food environment regulation globally. Our findings suggest that the economic growth coalition is dominant, highly capable of leveraging networks, institutional structures and dominant ideologies to its advantage, and is a formidable source of opposition acting to constrain nutrition policy space, including through TIAs. Opportunities for the public health nutrition coalition to strengthen its influence in the support of nutrition policy space include strategic evidence generation, and coalition-building through broader engagement and capacity-building.Additional file 1: Table S1. Characteristics of stakeholder types relevant to the food environment policy subsystem with respect to international trade and investment agreements.