Context: Regional international organizations, from the South African Development Community (SADC) to the European Union (EU), are organizations that promote cooperation among countries in a specific region of the world. Asking what RIOs do to health and health policy by looking only at their formal health policies can understate their effects (e.g., a free trade agreement with no stated health goals can affect health policy) and overstate their effects (as with agreements full of ambition that did not deliver much).

Methods: We adopt a "three faces" framework that identifies their direct health policies, the effects of their trade and market policies, and their effects on health via fiscal governance of their member states in order to better capture their health impact. We tested the usefulness of the framework by examining the Association of Southeast Asian Nations (ASEAN), EU, North American Free Trade Agreement (NAFTA/USMCA), SADC, and the Union of South American Nations (UNASUR).

Findings: All RIOs had some impact on health systems and policies; and, in many cases, the principal policies were not identified as health policy.

Conclusions: Such a framework will be useful in understanding their effects on health systems and policies because it captures indirect and even unintended health effects in a way that permits development of explanatory theories.

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