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Paina L, Young R, Oladapo O, Leandro J, Chen Z, Igusa T. Prospective policy analysis-a critical interpretive synthesis review. Health Policy Plan 2024; 39:429-441. [PMID: 38412286 PMCID: PMC11005837 DOI: 10.1093/heapol/czae009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/24/2024] [Accepted: 01/30/2024] [Indexed: 02/29/2024] Open
Abstract
Most policy analysis methods and approaches are applied retrospectively. As a result, there have been calls for more documentation of the political-economy factors central to health care reforms in real-time. We sought to highlight the methods and previous applications of prospective policy analysis (PPA) in the literature to document purposeful use of PPA and reflect on opportunities and drawbacks. We used a critical interpretive synthesis (CIS) approach as our initial scoping revealed that PPA is inconsistently defined in the literature. While we found several examples of PPA, all were researcher-led, most were published recently and few described mechanisms for engagement in the policy process. In addition, methods used were often summarily described and reported on relatively short prospective time horizons. Most of the studies stemmed from high-income countries and, across our sample, did not always clearly outline the rationale for a PPA and how this analysis was conceptualized. That only about one-fifth of the articles explicitly defined PPA underscores the fact that researchers and practitioners conducting PPA should better document their intent and reflect on key elements essential for PPA. Despite a wide recognition that policy processes are dynamic and ideally require multifaceted and longitudinal examination, the PPA approach is not currently frequently documented in the literature. However, the few articles reported in this paper might overestimate gaps in PPA applications. More likely, researchers are embedded in policy processes prospectively but do not necessarily write their articles from that perspective, and analyses led by non-academics might not make their way into the published literature. Future research should feature examples of testing and refining the proposed framework, as well as designing and reporting on PPA. Even when policy-maker engagement might not be feasible, real-time policy monitoring might have value in and of itself.
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Affiliation(s)
- Ligia Paina
- Health Systems Program, Department of International Health, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - Ruth Young
- Health Systems Program, Department of International Health, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - Oyinkansola Oladapo
- Health Systems Program, Department of International Health, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - Jose Leandro
- Health Systems Program, Department of International Health, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - Zhixi Chen
- Department of Civil and Systems Engineering, Johns Hopkins University Whiting School of Engineering, 3400 N Charles Street, Baltimore, MD 21218, USA
| | - Takeru Igusa
- Department of Civil and Systems Engineering, Johns Hopkins University Whiting School of Engineering, 3400 N Charles Street, Baltimore, MD 21218, USA
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Akselrod S, Collins TE, Berlina D, De Pinho Campos K, Fones G, de Sousa Neves D, Bashir F, Allen LN. Multisectoral action to address noncommunicable diseases: lessons from three country case studies. Front Public Health 2024; 12:1303786. [PMID: 38450149 PMCID: PMC10915276 DOI: 10.3389/fpubh.2024.1303786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 01/22/2024] [Indexed: 03/08/2024] Open
Abstract
Introduction Multisectoral action is a central component of the global response to the rising prevalence of non-communicable diseases (NCDs). In this paper we aimed to unpack the definition of multisectoral action and provide an overview of the historical context, challenges, and recommendations alongside three country case studies: salt reduction in the UK, tobacco legislation in Nigeria, and regulation of edible oils in Iran. Methods We used an iterative review process to select three country case studies from a list of 20 potential cases previously identified by WHO. At our third round of review we unanimously agreed to focus on salt reduction in the UK, tobacco regulation in Nigeria, and edible oil regulation in Iran as these represented rich cases on diverse risk factors from three different world regions that we felt offered important lessons. We conducted literature reviews to identify further data for each case study. Results Across the three studies a number of important themes emerged. We found that multisectoral approaches demand the often difficult reconciliation of competing and conflicting values and priorities. Across our three chosen cases, commercial interests and free trade agreements were the most common obstacles to successful multisectoral strategies. We found that early consultative stakeholder engagement and strong political and bureaucratic leadership were necessary for success. Discussion The complex multi-rooted nature of NCDs requires a multisectoral approach, but the inevitable conflicts that this entails requires careful navigation.
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Affiliation(s)
| | | | | | | | - Guy Fones
- World Health Organization, Geneva, Switzerland
| | | | | | - Luke N. Allen
- Healthier Systems Ltd., Streatley, United Kingdom
- London School of Hygiene and Tropical Medicine, University of London, London, United Kingdom
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Reeve E, Bell C, Sacks G, Mounsey S, Waqa G, Peeters A, Thow AM. Lessons for strengthening policymaking for obesity and diet-related noncommunicable disease prevention: A narrative synthesis of policy literature from the Western Pacific Region. Obes Rev 2024; 25:e13651. [PMID: 37905309 DOI: 10.1111/obr.13651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 05/28/2023] [Accepted: 09/09/2023] [Indexed: 11/02/2023]
Abstract
Obesity and diet-related noncommunicable diseases (NCDs) have a profound impact on individuals, households, health care systems, and economies in low- and middle- income countries (LMICs), with the Western Pacific Region experiencing some of the highest impacts. Governments have committed to improving population diets; however, implementation challenges limit effective policy action. We undertook meta-narrative synthesis of the academic literature and used theories of policymaking and implementation to synthesize current knowledge of issues affecting the adoption and implementation of policies to prevent obesity and diet-related NCDs in LMICs in the Western Pacific Region. We found that political leadership and management of food and nutrition policies often diluted following policy adoption, and that nutrition and health advocates find it difficult to enforce policy compliance from actors outside their sectors. Opportunities for strengthening implementation of food and nutrition policies in the Western Pacific include (1) improved and earlier engagement between health policymakers and implementing agencies; (2) focusing on the need for increased accountability from governments, including through effective engagement and organization of actor networks, knowledge sharing, and in highlighting where stronger action is required; and (3) identifying and building the strategic capacities of policy actors in framing, advocacy, coalition-building, knowledge translation, and leadership.
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Affiliation(s)
- Erica Reeve
- Global Centre for Preventive Health and Nutrition (GLOBE), Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
| | - Colin Bell
- School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Gary Sacks
- Global Centre for Preventive Health and Nutrition (GLOBE), Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
| | - Sarah Mounsey
- Menzies Centre for Health Policy, School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Gade Waqa
- Pacific Research Centre for Prevention of Obesity and Non-Communicable Disease (C-POND), Fiji National University, Suva, Fiji
| | - Anna Peeters
- Institute for Health Transformation, Faculty of Health, Deakin University, Geelong, Victoria, Australia
| | - Anne Marie Thow
- Menzies Centre for Health Policy, School of Public Health, University of Sydney, Sydney, New South Wales, Australia
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Gilmore AB, Fabbri A, Baum F, Bertscher A, Bondy K, Chang HJ, Demaio S, Erzse A, Freudenberg N, Friel S, Hofman KJ, Johns P, Abdool Karim S, Lacy-Nichols J, de Carvalho CMP, Marten R, McKee M, Petticrew M, Robertson L, Tangcharoensathien V, Thow AM. Defining and conceptualising the commercial determinants of health. Lancet 2023; 401:1194-1213. [PMID: 36966782 DOI: 10.1016/s0140-6736(23)00013-2] [Citation(s) in RCA: 103] [Impact Index Per Article: 103.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 10/13/2022] [Accepted: 12/23/2022] [Indexed: 04/07/2023]
Abstract
Although commercial entities can contribute positively to health and society there is growing evidence that the products and practices of some commercial actors-notably the largest transnational corporations-are responsible for escalating rates of avoidable ill health, planetary damage, and social and health inequity; these problems are increasingly referred to as the commercial determinants of health. The climate emergency, the non-communicable disease epidemic, and that just four industry sectors (ie, tobacco, ultra-processed food, fossil fuel, and alcohol) already account for at least a third of global deaths illustrate the scale and huge economic cost of the problem. This paper, the first in a Series on the commercial determinants of health, explains how the shift towards market fundamentalism and increasingly powerful transnational corporations has created a pathological system in which commercial actors are increasingly enabled to cause harm and externalise the costs of doing so. Consequently, as harms to human and planetary health increase, commercial sector wealth and power increase, whereas the countervailing forces having to meet these costs (notably individuals, governments, and civil society organisations) become correspondingly impoverished and disempowered or captured by commercial interests. This power imbalance leads to policy inertia; although many policy solutions are available, they are not being implemented. Health harms are escalating, leaving health-care systems increasingly unable to cope. Governments can and must act to improve, rather than continue to threaten, the wellbeing of future generations, development, and economic growth.
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Affiliation(s)
| | - Alice Fabbri
- Department for Health, University of Bath, Bath, UK
| | - Fran Baum
- Stretton Health Institute, University of Adelaide, Adelaide, SA, Australia
| | | | - Krista Bondy
- Stirling Management School, University of Stirling, Stirling, UK
| | - Ha-Joon Chang
- Department of Economics, School of Oriental and African Studies University of London, London, UK
| | - Sandro Demaio
- Victorian Health Promotion Foundation, Melbourne, VIC, Australia
| | - Agnes Erzse
- South African Medical Research Council/Wits Centre for Health Economics and Decision Science, Wits School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Nicholas Freudenberg
- Graduate School of Public Health and Health Policy, City University of New York, New York, NY, USA
| | - Sharon Friel
- Menzies Centre for Health Governance, School of Regulation and Global Governance, The Australian National University, Acton, ACT, Australia
| | - Karen J Hofman
- South African Medical Research Council/Wits Centre for Health Economics and Decision Science, Wits School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Paula Johns
- ACT Health Promotion, Rio de Janeiro, Brazil
| | - Safura Abdool Karim
- South African Medical Research Council/Wits Centre for Health Economics and Decision Science, Wits School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Jennifer Lacy-Nichols
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, VIC, Australia
| | | | - Robert Marten
- Alliance for Health Policy and Systems Research, World Health Organization, Geneva, Switzerland
| | - Martin McKee
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Mark Petticrew
- Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, UK
| | - Lindsay Robertson
- Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
| | | | - Anne Marie Thow
- Menzies Centre for Health Policy and Economics, University of Sydney, NSW, Australia
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Pickering K, Pearce T, Manuel L, Doran B, Smith TF. Socio-ecological challenges and food security in the 'salad bowl' of Fiji, Sigatoka Valley. Reg Environ Change 2023; 23:61. [PMID: 37033698 PMCID: PMC10074355 DOI: 10.1007/s10113-023-02059-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 03/18/2023] [Indexed: 06/09/2023]
Abstract
This article examines food security in the Sigatoka Valley, one of the most productive food regions in Fiji, in the context of recent socio-ecological challenges through a case study of Narewa village. Data were collected using semi-structured interviews (n = 25), a fixed question food insecurity experience survey (n = 25), and a free listing exercise about preferred and consumed foods (n = 24). Results revealed that while most households had access to sufficient food, the increased frequency and intensity of droughts, tropical cyclones, and flooding caused almost half to worry about meeting their future food needs. To date, a culture of sharing within the village has helped most households access food but this will likely be inadequate to meet future needs as climate change is projected to impact food production. Given that the foundation of food production in Narewa, like other villages in the valley, relies on the long-term viability of agricultural systems, better focus needs to be placed on the natural resources that form the backbone of these systems such as water availability, soil health, and slope stability and their resilience to anthropogenic and natural stressors. Efforts that focus on protecting and enhancing local ecosystems in light of expected future climate change, combined with greater attention on food storage and the use of resilient crops, and enhancing social cohesion and sharing networks are needed to avoid breaching tipping points in the food system.
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Affiliation(s)
- Kerrie Pickering
- Sustainability Research Centre, University of the Sunshine Coast, 90 Sippy Downs Drive, Sippy Downs, QLD 4556 Australia
- Environmental Sustainability Research Centre, Brock University, St. Catharines, Canada
| | - Tristan Pearce
- Sustainability Research Centre, University of the Sunshine Coast, 90 Sippy Downs Drive, Sippy Downs, QLD 4556 Australia
- Department of Geography, Earth, and Environmental Sciences, University of Northern British Columbia, 3333 University Way, Prince George, BC 42N 4Z9 Canada
| | - Lui Manuel
- Department of Environment, Nadroga-Navosa Provincial Council, Talenavuruvuru, Lawaqa, P.O. Box 267, Sigatoka, Fiji
| | - Brendan Doran
- Sustainability Research Centre, University of the Sunshine Coast, 90 Sippy Downs Drive, Sippy Downs, QLD 4556 Australia
| | - Timothy F. Smith
- Sustainability Research Centre, University of the Sunshine Coast, 90 Sippy Downs Drive, Sippy Downs, QLD 4556 Australia
- Environmental Sustainability Research Centre, Brock University, St. Catharines, Canada
- SWEDESD, Department of Children and Women’s Health, Uppsala University, Uppsala, Sweden
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Friel S, Collin J, Daube M, Depoux A, Freudenberg N, Gilmore AB, Johns P, Laar A, Marten R, McKee M, Mialon M. Commercial determinants of health: future directions. Lancet 2023; 401:1229-1240. [PMID: 36966784 DOI: 10.1016/s0140-6736(23)00011-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 09/06/2022] [Accepted: 12/23/2022] [Indexed: 04/07/2023]
Abstract
This paper is about the future role of the commercial sector in global health and health equity. The discussion is not about the overthrow of capitalism nor a full-throated embrace of corporate partnerships. No single solution can eradicate the harms from the commercial determinants of health-the business models, practices, and products of market actors that damage health equity and human and planetary health and wellbeing. But evidence shows that progressive economic models, international frameworks, government regulation, compliance mechanisms for commercial entities, regenerative business types and models that incorporate health, social, and environmental goals, and strategic civil society mobilisation together offer possibilities of systemic, transformative change, reduce those harms arising from commercial forces, and foster human and planetary wellbeing. In our view, the most basic public health question is not whether the world has the resources or will to take such actions, but whether humanity can survive if society fails to make this effort.
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Affiliation(s)
- Sharon Friel
- Menzies Centre for Health Governance, School of Regulation and Global Governance, The Australian National University, Acton, ACT, Australia.
| | - Jeff Collin
- School of Political and Social Science, University of Edinburgh, Edinburgh, UK
| | - Mike Daube
- Faculty of Health Sciences, Curtin University, Perth, WA, Australia
| | - Anneliese Depoux
- Virchow-Villermé Public Health Centre, University of Paris, Paris, France
| | - Nicholas Freudenberg
- School of Public Health and Health Policy, City University of New York, New York, NY, USA
| | - Anna B Gilmore
- Tobacco Control Research Group, Department for Health, University of Bath, Bath, UK
| | - Paula Johns
- ACT Health Promotion, Rio de Janeiro, Brazil
| | - Amos Laar
- School of Public Health, University of Ghana, Legon, Ghana
| | - Robert Marten
- Alliance for Health Policy and Systems Research, World Health Organization, Geneva, Switzerland
| | - Martin McKee
- London School of Hygiene & Tropical Medicine, London, UK
| | - Melissa Mialon
- Trinity Business School, Trinity College Dublin, Dublin, Ireland
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Brewer T, Andrew N, Abbott D, Detenamo R, Faaola E, Gounder P, Lal N, Lui K, Ravuvu A, Sapalojang D, Sharp M, Sulu R, Suvulo S, Tamate J, Thow A, Wells A. The role of trade in pacific food security and nutrition. Global Food Security 2023; 36:100670. [DOI: 10.1016/j.gfs.2022.100670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Barlow P, Allen LN. US and EU Free Trade Agreements and implementation of policies to control tobacco, alcohol, and unhealthy food and drinks: A quasi-experimental analysis. PLoS Med 2023; 20:e1004147. [PMID: 36602976 PMCID: PMC9815641 DOI: 10.1371/journal.pmed.1004147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 11/22/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Identifying and tackling the factors that undermine regulation of unhealthy commodities is an essential component of effective noncommunicable disease (NCD) prevention. Unhealthy commodity producers may use rules in US and EU Free Trade Agreements (FTAs) to challenge policies targeting their products. We aimed to test whether there was a statistical relationship between US and EU FTA participation and reduced implementation of WHO-recommended policies. METHODS AND FINDINGS We performed a statistical analysis assessing the probability of at least partially implementing 10 tobacco, alcohol, and unhealthy food and drink policies in 127 countries in 2014, 2016, and 2019. We assessed differences in implementation of these policies in countries with and without US/EU FTAs. We used matching to conduct 48 covariate-adjusted quasi-experimental comparisons across 27 matched US/EU FTA members (87 country-years) and performed additional analyses and robustness checks to assess alternative explanations for our results. Out of our 48 tests, 19% (9/48) identified a statistically significant decrease in the predicted probability of at least partially implementing the unhealthy commodity policy in question, while 2% (1/48) showed an increase. However, there was marked heterogeneity across policies. At the level of individual policies, US FTA participation was associated with a 37% reduction (95%CI: -0.51 to -0.22) in the probability of fully implementing graphic tobacco warning policies, and a 53% reduction (95%CI: -0.63 to -0.43) in the probability of at least partially implementing smoke-free place policies. EU FTA participation was associated with a 28% reduction (95%CI: -0.45 to -0.10) in the probability of fully implementing graphic tobacco warning policies, and a 25% reduction (95%CI: -0.47 to -0.03) in the probability of fully implementing restrictions on child marketing of unhealthy food and drinks. There was a positive association with implementing fat limits and bans, but this was not robust. Associations with other outcomes were not significant. The main limitations included residual confounding, limited ability to discern precise mechanisms of influence, and potentially limited generalisability to other FTAs. CONCLUSIONS US and EU FTA participation may reduce the probability of implementing WHO-recommended tobacco and child food marketing policies by between a quarter and a half-depending on the FTA and outcome in question. Governments negotiating or participating in US/EU FTAs may need to establish robust health protections and mitigation strategies to achieve their NCD mortality reduction targets.
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Affiliation(s)
- Pepita Barlow
- Department of Health Policy, London School of Economics and Political Science, London, United Kingdom
- * E-mail:
| | - Luke N. Allen
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Thow AM, Garde A, Winters LA, Johnson E, Mabhala A, Kingston P, Barlow P. Protecting noncommunicable disease prevention policy in trade and investment agreements. Bull World Health Organ 2022; 100:268-275. [PMID: 35386551 PMCID: PMC8958824 DOI: 10.2471/blt.21.287395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 01/13/2022] [Accepted: 01/17/2022] [Indexed: 11/27/2022] Open
Abstract
Preventing noncommunicable diseases is a global priority, for which the World Health Organization has recommended policies to reduce the consumption of tobacco products, alcohol and unhealthy foods. However, regulation has been strongly opposed by affected industries, who have invoked the provisions of legally binding trade and investment agreements. The aim of this analysis of the legal, economic and public health literature was to present a short primer on the relationship between noncommunicable disease prevention policy and trade and investment agreements to help public health policy-makers safeguard public health policies. The analysis identified opportunities for protecting, and even promoting, public health in trade and investment agreements, including: (i) ensuring exceptions for public health measures are included in agreements; (ii) committing to good regulatory practice that balances transparency and cooperation with the need for governments to limit the influence of vested interests; (iii) ensuring trade and investment agreement preambles acknowledge the importance of public health; (iv) excluding investor-state dispute settlement mechanisms from agreements; and (v) limiting the scope and definition of key provisions on investor protection to reduce the risk of investment disputes. This synthesis of the multidisciplinary literature also provides support for greater strategic and informed engagement between the health and trade policy sectors. In addition, ensuring a high level of health protection in trade and investment agreements requires cooperation between disciplines, engagement with experts in law, economics and public health policy, and fully transparent policy processes and governance structures.
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Affiliation(s)
- Anne Marie Thow
- Menzies Centre for Health Policy and Economics, Level 2, Charles Perkins Centre (D17), University of Sydney, Sydney, NSW 2006, Australia
| | - Amandine Garde
- School of Law and Social Justice, University of Liverpool, Liverpool, England
| | - L Alan Winters
- Department of Economics, University of Sussex, Sussex, England
| | - Ellen Johnson
- Menzies Centre for Health Policy and Economics, Level 2, Charles Perkins Centre (D17), University of Sydney, Sydney, NSW 2006, Australia
| | - Andi Mabhala
- Faculty of Health and Social Care, University of Chester, Chester, England
| | - Paul Kingston
- Faculty of Health and Social Care, University of Chester, Chester, England
| | - Pepita Barlow
- Department of Health Policy, London School of Economics and Political Science, London, England
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Barlow P. COVID-19, Trade, and Health: This Changes Everything? Comment on "What Generates Attention to Health in Trade Policy-Making? Lessons From Success in Tobacco Control and Access to Medicines: A Qualitative Study of Australia and the (Comprehensive and Progressive) Trans-Pacific Partnership". Int J Health Policy Manag 2022; 11:525-528. [PMID: 33233035 PMCID: PMC9309943 DOI: 10.34172/ijhpm.2020.220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 10/24/2020] [Indexed: 11/24/2022] Open
Abstract
Townsend and colleagues highlighted the myriad political forces which fostered attention to health issues during negotiations to establish a new trans-pacific trade deal in Australia (the CP-TPP [Comprehensive and Progressive Agreement for Trans-Pacific Partnership], formerly known as TPP). Among the factors they identify, exporter interests and exogenous events helped to generate attention to trade-related concerns about tobacco and access medicines, and limited attention to nutrition and alcohol. These are important considerations as the United Kingdom negotiates a trade deal with the United States in haste, whilst at the same time attempting to manage the ongoing coronavirus disease 2019 (COVID-19) pandemic. In this commentary, I reflect on changing attention to trade and nutrition during the COVID-19 pandemic in light of Townsend and colleagues' analysis. I explore scope for greater attention to nutrition in US-UK trade negotiations, and the challenges created by the vested interests of major UK and US processed food exporters. I further discuss the utility of the theoretical tools employed by Townsend and colleagues for wider debates in the political economy of health.
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Affiliation(s)
- Pepita Barlow
- Department of Health Policy, London School of Economics and Political Science, London, UK
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Elliott LM, Dalglish SL, Topp SM. Health Taxes on Tobacco, Alcohol, Food and Drinks in Low- and Middle-Income Countries: A Scoping Review of Policy Content, Actors, Process and Context. Int J Health Policy Manag 2022; 11:414-428. [PMID: 32945639 PMCID: PMC9309941 DOI: 10.34172/ijhpm.2020.170] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 08/25/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Taxation of tobacco, food, alcohol and other beverages has gained renewed attention in responding to non-communicable diseases (NCDs). While largely built on evidence from high-income countries (HICs), the projected economic and health benefits of these measures have increased calls for their use in price-sensitive low- and middle-income countries (LMICs). However, uptake has been sporadic and there remains little research on why and how LMICs utilise fiscal measures in response to NCDs. METHODS This scoping review analyses factors influencing the design and implementation of health-related fiscal measures in LMICs. Utilising Arksey and O'Malley's scoping review methodology and Walt and Gilson's policy triangle, we considered the contextual, procedural, content and stakeholder-related factors that influenced measures. RESULTS We identified 75 papers focussing on health-related fiscal measures, with 47 (63%) focused on tobacco, 5 on alcohol, 6 on soft drink and 4 studies on food-related fiscal regulation. Thirteen papers analysed multiple measures and most papers (n = 66, 88%) were less than a decade old. Key factors enabling the design and implementation of measures included localised health and economic evidence, policy championing, inter-ministerial support, and global or regional momentum. Impeding factors encompassed negative framing and retaliation by industry, vested interests and governmental policy disjuncture. Aligning with theoretic insights from the policy triangle, findings consistently demonstrated that the interplay between factors - rather than the presence or absence of particular factors - has the most profound impact on policy implementation. CONCLUSION Given the growing urgency to address NCDs in LMICs, this review highlights the need for recognition and rigorous exploration of political economy factors influencing the design and implementation of fiscal measures. Broader LMIC-specific empirical research is needed to overcome an implication noted in much of the literature: that mechanisms used to enact tobacco taxation are universally applicable to measures targeting foods, alcohol and other beverages.
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Affiliation(s)
- Lana M. Elliott
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD, Australia
- School of Public Health & Social Work, Queensland University of Technology, Brisbane, QLD, Australia
| | - Sarah L. Dalglish
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, MD, USA
- Institute for Global Health, University College London, London, UK
| | - Stephanie M. Topp
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD, Australia
- Nossal Institute for Global Health, University of Melbourne, Melbourne, Australia
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Harris J, Hrynick T, Thien MTM, Huynh T, Huynh P, Nguyen P, Thow A. Tensions and coalitions: A new trade agreement affects the policy space for nutrition in Vietnam. Food Secur. [DOI: 10.1007/s12571-022-01264-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
AbstractGlobal trade has shaped food systems over centuries, but modern trade agreements are hastening these changes and making them more complex, with implications for public health and nutrition transition. This study aimed to understand the impact of the 2018 Comprehensive and Progressive Agreement for Trans-Pacific Partnership (CPTPP) on the policy space for public health nutrition in Vietnam. We conducted comparative document review and key informant interviews, and our analysis drew on a framework of policy space and the theory of advocacy coalitions. We identified 10 CPTPP sections with potential public health nutrition implications; and 50 Vietnamese policies relevant to nutrition having one or more tensions with one or more CPTPP sections. A majority of policy tensions were in sections of the CPTPP relating to technical barriers to trade and government procurement; most tensions related to protecting policy-making from vested interests. Different groups of policy actors hold different beliefs and interests on these issues, and therefore promote different framings and policy approaches. We identified two advocacy coalitions working very separately on issues affecting nutrition policy space: a trade coalition holding the policy position that free trade improves nutrition by default; and a nutrition coalition holding the policy position that nutrition should be explicitly considered in trade policy. The policy space for nutrition in Vietnam has important potential constraints through written policy, and the trade and nutrition coalitions will need to interact more regularly and constructively in order to foresee where these tensions will arise in practice, and create plans for their mitigation. This study adds to global evidence of free trade agreement impacts on nutrition policy space, and we extend previous work by explaining these actor groupings in the policy space through the theory of advocacy coalitions.
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Allen LN, Wild CEK, Loffreda G, Kak M, Aghilla M, Emahbes T, Bonyani A, Hatefi A, Herbst C, El Saeh HM. Non-communicable disease policy implementation in Libya: A mixed methods assessment. PLOS Glob Public Health 2022; 2:e0000615. [PMID: 36962549 PMCID: PMC10021530 DOI: 10.1371/journal.pgph.0000615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 10/09/2022] [Indexed: 11/12/2022]
Abstract
The Libyan Ministry of Health is keen to understand how it can introduce policies to protect its population from non-communicable diseases (NCDs). We aimed to perform an implementation research assessment of the current situation, including challenges and opportunities. We used an explanatory sequential mixed methods design. We started with a quantitative assessment of NCD policy performance based on review of the WHO NCD Progress Monitor Reports. Once we had identified Libya's NCD policy gaps we performed a systematic review to identify international lessons around barriers and successful strategies for the policies Libya has not yet implemented. Finally, we performed a series of key stakeholder interviews with senior policymakers to explore their perspectives around promising policy actions. We used a realist paradigm, methods triangulation, and a joint display to synthesise the interpretation of our findings and develop recommendations. Libya has not fully implemented any of the recommended policies for diet, physical activity, primary care guidelines & therapeutics, or data collection, targets & surveillance. It does not have robust tobacco policies in place. Evidence from the international literature and policymaker interviews emphasised the centrality of according strong political leadership, governance structures, multisectoral engagement, and adequate financing to policy development activities. Libya's complex political and security situation are major barriers for policy implementation. Whilst some policies will be very challenging to develop and deploy, there are a number of simple policy actions that could be implemented with minimum effort; from inviting WHO to conduct a second STEPS survey, to signing the international code on breast-milk substitutes. Like many other fragile and conflict-affected states, Libya has not accorded NCDs the policy attention they demand. Whilst strong high-level leadership is the ultimate key to providing adequate protections, there are a range of simple measures that can be implemented with relative ease.
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Affiliation(s)
- Luke N Allen
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Cervantée E K Wild
- Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Giulia Loffreda
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, Scotland
| | - Mohini Kak
- World Bank Middle East and North Africa, Tunisia
| | | | | | | | - Arian Hatefi
- World Bank Middle East and North Africa, Washington, DC, United States of America
| | | | - Haider M El Saeh
- Libya National Centre for Disease Control, Tajoura, Libya
- University of Tripoli, Tripoli, Libya
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Milsom P, Smith R, Baker P, Walls H. International investment liberalization, transnational corporations and NCD prevention policy non-decisions: a realist review on the political economy of tobacco, alcohol and ultra-processed food. Global Health 2021; 17:134. [PMID: 34819083 PMCID: PMC8611909 DOI: 10.1186/s12992-021-00784-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 11/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Public health concerns relating to international investment liberalization have centred on the potential for investor-state dispute settlement (ISDS)-related regulatory chill. However, the broader political and economic dimensions that shape the relationship between the international investment regime and non-communicable disease (NCD) policy development have been less well explored. This review aimed to synthesise the available evidence using a political economy approach, to understand why, how and under what conditions transnational corporations may use the international investment regime to promote NCD prevention policy non-decisions. MAIN BODY Methods: Mechanisms explaining why/how the international investment regime may be used by transnational health-harmful commodity corporations (THCCs) to encourage NCD prevention policy non-decisions, including regulatory chill, were iteratively developed. Six databases and relevant grey literature was searched, and evidence was extracted, synthesized and mapped against the various proposed explanatory mechanisms. FINDINGS Eighty-nine sources were included. THCCs may be incentivised to use the ISDS mechanism since the costs may be outweighed by the benefits of even just delaying regulatory adoption, particularly since the chilling effect tends to ripple out across jurisdictions. Drivers of regulatory chill may include ambiguity in treaty terms, inconsistency in arbitral rulings, potential arbitrator bias and the high cost of arbitration. Evidence indicates ISDS can delay policy adoption both within the country directly involved but also in other jurisdictions. Additionally, governments are adopting standard assessments of public health regulatory proposals for trade and ISDS risk. Various economic, political and industry-related factors likely interact to increase (or decrease) the ultimate risk of regulatory chill. Some evidence indicates that THCCs take advantage of governments' prioritization of foreign investment over NCD prevention objectives to influence the NCD prevention regulatory environment. CONCLUSIONS While ISDS-related regulatory chill is a real risk under certain conditions, international investment-related NCD prevention policy non-decisions driven by broader political economy dynamics may well be more widespread and impactful on NCD regulatory environments. There is therefore a clear need to expand the research agenda on investment liberalization and NCD policy beyond regulatory chill and engage with theories and approaches from international relations and political science, including political economy and power analyses.
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Affiliation(s)
- Penelope Milsom
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, Kings Cross, London, WC1H 9SH UK
| | - Richard Smith
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Phillip Baker
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC Australia
| | - Helen Walls
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, Kings Cross, London, WC1H 9SH UK
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15
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Abstract
Introduction Rapid increases in the trade of global red and processed meat impede international efforts toward sustainable diets by increasing meat consumption. However, little research has examined cross-country variations in diet-related non-communicable diseases (NCDs) because of meat trade. We aimed to examine the impact of red and processed meat trade on diet-related NCDs and to identify which countries are particularly vulnerable to diet-related NCDs due to red and processed meat trade. Methods By selecting 14 red meat and six processed meat items, we investigated bilateral meat trade flows across 154 countries. Then, we integrated health data and information on red and processed meat trade to quantify the country-specific burden of diet-related NCDs attributable to the meat trade using a comparative risk assessment framework. Results Results show that global increases in red and processed meat trade contributed to the abrupt increase of diet-related NCDs, and the attributable burden of diet-related NCDs had large geographical variations among countries. We also identified responsible exporting countries that increase diet-related NCD risks in importing countries. Over the period from 1993 to 2018, island countries in the Caribbean and Oceania were particularly vulnerable to diet-related NCD incidents and mortality due to large meat imports. In addition, countries in Northern and Eastern Europe have exceedingly increased attributable death and disability-adjusted life year rates via meat imports. Conclusion Our findings suggest that both exporters and importers must urgently undertake cross-sectoral actions to reduce the meat trade’s health impacts. To prevent unintended health consequences due to red and processed meat trade, future interventions need to integrate health policies with agricultural and trade policies by cooperating with both responsible exporting and importing countries.
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Affiliation(s)
- Min Gon Chung
- Center for Systems Integration and Sustainability, Michigan State University, East Lansing, Michigan, USA .,Sierra Nevada Research Institute, University of California, Merced, California, USA
| | - Yingjie Li
- Center for Systems Integration and Sustainability, Michigan State University, East Lansing, Michigan, USA.,Advancing Systems Analysis Program, International Institute of Applied Systems Analysis, Laxenburg, Austria
| | - Jianguo Liu
- Center for Systems Integration and Sustainability, Michigan State University, East Lansing, Michigan, USA
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Garton K, Swinburn B, Thow AM. Who influences nutrition policy space using international trade and investment agreements? A global stakeholder analysis. Global Health 2021; 17:118. [PMID: 34600556 PMCID: PMC8487514 DOI: 10.1186/s12992-021-00764-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 09/09/2021] [Indexed: 01/22/2023] Open
Abstract
Background 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. Methods 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. Results 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. Conclusions 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. Supplementary Information The online version contains supplementary material available at 10.1186/s12992-021-00764-7.
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Affiliation(s)
- Kelly Garton
- School of Population Health, The University of Auckland, Auckland, New Zealand.
| | - Boyd Swinburn
- School of Population Health, The University of Auckland, Auckland, New Zealand
| | - Anne Marie Thow
- Menzies Centre for Health Policy, The University of Sydney, Sydney, NSW, Australia
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Townsend B, Friel S, Schram A, Baum F, Labonté R. What Generates Attention to Health in Trade Policy-Making? Lessons From Success in Tobacco Control and Access to Medicines: A Qualitative Study of Australia and the (Comprehensive and Progressive) Trans-Pacific Partnership. Int J Health Policy Manag 2021; 10:613-624. [PMID: 32610761 PMCID: PMC9278530 DOI: 10.34172/ijhpm.2020.80] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 05/27/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Despite greater attention to the nexus between trade and investment agreements and their potential impacts on public health, less is known regarding the political and governance conditions that enable or constrain attention to health issues on government trade agendas. Drawing on interviews with key stakeholders in the Australian trade domain, this article provides novel insights from policy actors into the range of factors that can enable or constrain attention to health in trade negotiations. METHODS A qualitative case study was chosen focused on Australia's participation in the Trans-Pacific Partnership (TPP) negotiations and the domestic agenda-setting processes that shaped the government's negotiating mandate. Process tracing via document analysis of media reporting, parliamentary records and government inquiries identified key events during Australia's participation in the TPP negotiations. Semi-structured interviews were undertaken with 25 key government and non-government policy actors including Federal politicians, public servants, representatives from public interest nongovernment organisations and industry associations, and academic experts. RESULTS Interviews revealed that domestic concerns for protecting regulatory space for access to generic medicines and tobacco control emerged onto the Australian government's trade agenda. This contrasted with other health issues like alcohol control and nutrition and food systems that did not appear to receive attention. The analysis suggests sixteen key factors that shaped attention to these different health issues, including the strength of exporter interests; extent of political will of Trade and Health Ministers; framing of health issues; support within the major political parties; exogenous influencing events; public support; the strength of available evidence and the presence of existing domestic legislation and international treaties, among others. CONCLUSION These findings aid understanding of the factors that can enable or constrain attention to health issues on government trade agendas, and offer insights for potential pathways to elevate greater attention to health in future. They provide a suite of conditions that appear to shape attention to health outside the biomedical health domain for further research in the commercial determinants of health.
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Affiliation(s)
- Belinda Townsend
- School of Regulation and Global Governance, College of Asia and the Pacific, Australian National University, Canberra, ACT, Australia
| | - Sharon Friel
- School of Regulation and Global Governance, College of Asia and the Pacific, Australian National University, Canberra, ACT, Australia
| | - Ashley Schram
- School of Regulation and Global Governance, College of Asia and the Pacific, Australian National University, Canberra, ACT, Australia
| | - Fran Baum
- Southgate Institute for Health, Society and Equity, Department of Public Health, Flinders University, Adelaide, SA, Australia
| | - Ronald Labonté
- Institute of Population Health, University of Ottawa, Ottawa, ON, Canada
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Garton K, Swinburn B, Thow AM. Implications of international trade and investment agreements on policy space for restricting marketing of unhealthy food and beverages to children: lessons from inter-disciplinary expert interviews. Public Health Nutr 2021;:1-15. [PMID: 33972007 DOI: 10.1017/S1368980021001993] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To determine the implications of international trade and investment agreements (TIA) for national governments' policy space to restrict the marketing of unhealthy food and beverages to children. DESIGN In-depth interviews based on a series of policy scenario 'vignettes,' guided by an adapted scenario analysis methodology. SETTING Global. PARTICIPANTS Nine key informants from relevant sectors, with expertise regarding the intersection of public health nutrition policy, international trade law and international investment law. RESULTS Participants consistently identified the relevance of several principles, common to many TIA: non-discrimination, necessity and justification, market access requirements and quantitative restrictions, intellectual property rights and trademark protections and fair and equitable treatment of investors. Two main policy design factors that interact heavily with TIA-related policy space were the framing of objectives and regulatory distinctions drawn. Contextual factors may shape the analysis of TIA-related policy space on a case-by-case basis, while the relative power of the actors and institutions involved in both domestic and international policy spheres may influence whether and how such legal constraints to policy space are activated. CONCLUSIONS Regulatory marketing restrictions run the risk of incurring challenges under World Trade Organization agreements and other free TIA. However, concerned policymakers should be aware of the difference between theoretical risk, threat of a challenge and realistic initiation and/or loss of a formal dispute. Our findings indicate that there is policy space to adopt significant marketing restrictions, though an understanding of these legal risks and strategic policy design are important.
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McNamara CL, Labonte R, Schram A, Townsend B. Glossary on free trade agreements and health part 2: new trade rules and new urgencies in the context of COVID-19. J Epidemiol Community Health 2021; 75:jech-2020-215105. [PMID: 33408164 DOI: 10.1136/jech-2020-215105] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 10/19/2020] [Accepted: 11/29/2020] [Indexed: 11/03/2022]
Abstract
Part 1 of this glossary provided a brief background on the rise of regional/bilateral free trade agreements (FTAs) and described the health implications of new trade obligations that figure prominently in current and recent trade negotiations, focusing on those provisions that build on previous agreements of the World Trade Organization (WTO). This approach continues into part 2 of the glossary, which also considers components of FTAs that have no precedent within WTO treaties. Following a broader discussion of how the current political context and the COVID-19 pandemic shape the contemporary trade environment, part 2 considers the main areas of trade and health policy incoherence as well as recommendations to address them.
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Affiliation(s)
- Courtney L McNamara
- Department of Sociology and Political Science, Centre for Global Health Inequalities Research (CHAIN), Norwegian University of Science and Technology, Trondheim, Norway
| | - Ronald Labonte
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Ashley Schram
- Menzies Centre for Health Governance, School of Regulation and Global Governance, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Belinda Townsend
- Menzies Centre for Health Governance, School of Regulation and Global Governance, Australian National University, Canberra, Australian Capital Territory, Australia
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20
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McNamara CL, Labonte R, Schram A, Townsend B. Glossary on free trade agreements and health part 1: the shift from multilateralism and the rise of 'WTO-Plus' provisions. J Epidemiol Community Health 2021; 75:jech-2020-215104. [PMID: 33402393 DOI: 10.1136/jech-2020-215104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 10/19/2020] [Accepted: 11/29/2020] [Indexed: 11/03/2022]
Abstract
The global trading system has undergone a shift away from multilateral trade negotiations to a 'spaghetti-bowl' of regional and bilateral free trade agreements (FTAs). In this two-part glossary, we discuss why this shift has occurred, focusing on how it poses new challenges for public health. Specifically, we introduce key terms that shape this new trading environment and explain them through a public health lens. Part 1 of this glossary focuses on provisions in FTAs that build on previous agreements of the World Trade Organization (WTO). These provisions are commonly designated as 'WTO-Plus'. This approach continues into part 2 of the glossary, which also considers components of FTAs that have no precedent within WTO treaties. Following a broader discussion of how the current political context and the COVID-19 pandemic shape the contemporary trade environment, part 2 considers the main areas of trade and health policy incoherence as well as recommendations to address them.
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Affiliation(s)
- Courtney L McNamara
- Department of Sociology and Political Science, Centre for Global Health Inequalities Research (CHAIN), Norwegian University of Science and Technology, Trondheim, Norway
| | - Ronald Labonte
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Ashley Schram
- Menzies Centre for Health Governance, School of Regulation and Global Governance, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Belinda Townsend
- Menzies Centre for Health Governance, School of Regulation and Global Governance, Australian National University, Canberra, Australian Capital Territory, Australia
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Abstract
BACKGROUND Since the 1980s, markets have turned increasingly to intangible goods - healthcare, education, the arts, and justice. Over 40 years, the authors investigated healthcare commoditisation to produce policy knowledge relevant to patients, physicians, health professionals, and taxpayers. This paper revisits their objectives, methods, and results to enlighten healthcare policy design and research. MAIN TEXT This paper meta-analyses the authors' research that evaluated the markets impact on healthcare and professional culture and investigated how they influenced patients' timely access to quality care and physicians' working conditions. Based on these findings, they explored the political economic of healthcare. In low-income countries the analysed research showed that, through loans and cooperation, multilateral agencies restricted the function of public services to disease control, with subsequent catastrophic reductions in access to care, health de-medicalisation, increased avoidable mortality, and failure to attain the narrow MDGs in Africa. The pro-market reforms enacted in middle-income countries entailed the purchaser-provider split, privatisation of healthcare pre-financing, and government contracting of health finance management to private insurance companies. To establish the materiality of a cause-and-effect relationship, the authors compared the efficiency of Latin American national health systems according to whether or not they were pro-market and complied with international policy standards. While pro-market health economists acknowledge that no market can offer equitable access to healthcare without effective regulation and control, the authors showed that both regulation and control were severely constrained in Asia by governance and medical secrecy issues. In high-income countries they questioned the interest for population health of healthcare insurance companies, whilst comparing access to care and health expenditures in the European Union vs. the U.S., the Netherlands, and Switzerland. They demonstrated that commoditising healthcare increases mortality and suffering amenable to care considerably and carries professional, cultural, and ethical risks for doctors and health professionals. Pro-market policies systems cause health systems inefficiency, inequity in access to care and strain professionals' ethics. CONCLUSION Policy research methodologies benefit from being inductive, as health services and systems evaluations, and population health studies are prerequisites to challenge official discourse and to explore the historical, economic, sociocultural, and political determinants of public policies.
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Affiliation(s)
- Jean-Pierre Unger
- Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, B-2000, Antwerp, Belgium.
| | - Ingrid Morales
- Medical Director, Office de la Naissance et de l'Enfance, French Community of Belgium, Chaussée de Charleroi 95, B-1060, Brussels, Belgium
| | - Pierre De Paepe
- Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, B-2000, Antwerp, Belgium
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Miller M, Wilkinson C, Room R, O'Brien P, Townsend B, Schram A, Gleeson D. Industry submissions on alcohol in the context of Australia's trade and investment agreements: A content and thematic analysis of publicly available documents. Drug Alcohol Rev 2020; 40:22-30. [PMID: 33230913 DOI: 10.1111/dar.13219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 10/03/2020] [Accepted: 10/07/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION AND AIMS Alcohol use is a leading risk factor for death and disability, responsible for 3 million deaths in 2016. The alcohol industry is a powerful player in shaping trade and investment rules in ways that can constrain the ability of governments to regulate alcoholic beverages to reduce harm. This paper analyses publicly available submissions about alcohol in the context of Australia's free trade agreements to determine the key themes put forward by industry. DESIGN AND METHODS We searched for submissions made to the Department of Foreign Affairs and Trade by alcohol industry trade associations, alcohol manufacturers, distributors and retailers, general industry association, and government agencies with responsibilities for alcohol trade, about specific free trade agreements involving Australia. Thirty-one submissions in relation to eight trade agreements were included for analysis. The analysis involved both descriptive content analysis and thematic analysis. RESULTS Findings suggest that industry is actively seeking to shape trade negotiations around alcohol. Priority issues for the industry include improving market access, harmonising regulation, improving clarity and transparency, reducing the burden of regulation and preventing monopolies on product names. DISCUSSION AND CONCLUSION The alcohol industry and associated business and government organisations are actively working to influence trade agreement negotiations for industry economic gain, arguing for rules which may undermine public health goals. The analysis suggests that public health experts should pay attention to trade and investment agreements and develop counter frames to ensure agreements do not create barriers for coherent health policies.
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Affiliation(s)
- Mia Miller
- Centre for Alcohol Policy Research, La Trobe University, Melbourne, Australia
| | - Claire Wilkinson
- Centre for Alcohol Policy Research, La Trobe University, Melbourne, Australia.,Drug Policy Modelling Program, Social Policy Research Centre, UNSW Sydney, Sydney, Australia
| | - Robin Room
- Centre for Alcohol Policy Research, La Trobe University, Melbourne, Australia.,Centre for Social Research on Alcohol and Drugs, Department of Public Health Sciences, Stockholm University, Stockholm, Sweden
| | - Paula O'Brien
- Melbourne Law School, The University of Melbourne, Melbourne, Australia
| | - Belinda Townsend
- Menzies Centre for Health Governance, School of Regulation and Global Governance, Australian National University, Canberra, Australia
| | - Ashley Schram
- Menzies Centre for Health Governance, School of Regulation and Global Governance, Australian National University, Canberra, Australia
| | - Deborah Gleeson
- School of Psychology and Public Health, La Trobe University, Melbourne, Australia
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Chung MG, Kapsar K, Frank KA, Liu J. The spatial and temporal dynamics of global meat trade networks. Sci Rep 2020; 10:16657. [PMID: 33028857 DOI: 10.1038/s41598-020-73591-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 09/10/2020] [Indexed: 01/02/2023] Open
Abstract
Rapid increases in meat trade generate complex global networks across countries. However, there has been little research quantifying the dynamics of meat trade networks and the underlying forces that structure them. Using longitudinal network data for 134 countries from 1995 to 2015, we combined network modeling and cluster analysis to simultaneously identify the structural changes in meat trade networks and the factors that influence the networks themselves. The integrated network approach uncovers a general consolidation of global meat trade networks over time, although some global events may have weakened this consolidation both regionally and globally. In consolidated networks, the presence of trade agreements and short geographic distances between pairs of countries are associated with increases in meat trade. Countries with rapid population and income growth greatly depend on meat imports. Furthermore, countries with high food availability import large quantities of meat products to satisfy their various meat preferences. The findings from this network approach provide key insights that can be used to better understand the social and environmental consequences of increasing global meat trade.
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Harris J, Nguyen PH, Tran LM, Huynh PN. Nutrition transition in Vietnam: changing food supply, food prices, household expenditure, diet and nutrition outcomes. Food Secur 2020. [DOI: 10.1007/s12571-020-01096-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
AbstractWhile literature has noted the presence of a nutrition transition in terms of changing nutrition outcomes in Vietnam, very limited evidence linking changes in upstream food system factors to downstream diet and nutrition changes exists. Combining available data from different sources and analyzing it through a conceptual food systems framework, our study examines different pathways of nutrition transition through food supply, food prices, household food expenditures, diets, and nutrition outcomes in Vietnam. Our findings show that while Vietnam is at the start of its nutrition transition, change is happening rapidly. Undernutrition is falling, obesity is rising, and nutrition-related chronic diseases account for a significant burden of diseases and death. In terms of changes in healthful foods, the supply of vegetables and fruits is plentiful, and expenditure on vegetables remains consistent and small. Notably however, vegetable consumption has dropped, and increasing meat and milk consumption have been double-edged swords for nutrition. In terms of foods associated with the negative sides of the nutrition transition, the availability of sweets and sweetened beverages has risen in recent years, with oils and fats rising less. The expenditure share on food eaten away from home, in many contexts a marker for less healthful diets, has increased over time. While these changes are typical of a nutrition transition, Vietnam is also somewhat of an outlier in some respects: wet markets and daily fresh food purchases continue to dominate food purchasing behaviour, and food eaten away from home means a different thing in a country renowned for its diverse and healthy street food and roadside restaurant culture. While this study brings together important data on the food system drivers of a nutrition transition in Vietnam, it cannot link each of these issues into a standard statistical model of change due to data gaps at different levels, calling for data collection improvement in future diet and food systems research. Vietnamese health policy explicitly acknowledges nutrition transition issues, with targets for obesity reduction. This work on the food system drivers of the nutrition transition points to the need to further adapt policy in other sectors beyond health, however. At the same time as making nutrient-rich foods more accessible, nutrient-poor or ultra-processed foods need to be made less accessible and desirable if additional income is to contribute to a healthy diet in limiting Vietnam’s emerging nutrition transition.
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Abstract
This paper analyses the significance and methods of foreign trade export forecasting. The index system of foreign trade export forecasting is determined based on the analysis of foreign trade export forecasting research results. The concepts and principles of artificial neural network and fuzzy system theory are expounded, and their respective advantages and disadvantages as well as their complementarities are analyzed. This paper introduces the types and training algorithms of evolutionary morphological neural network, combines the neural network with the fuzzy system theory, and establishes the prediction model. Finally, the evolutionary morphological neural network model is applied to the prediction of foreign trade export in view of the characteristics of export and considering the influence of various factors, the whole process of establishing evolutionary morphological neural network forecasting model is introduced in detail, and the change range of export is predicted, and the ideal forecasting results are obtained.
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Affiliation(s)
- Jiang Bin
- College of International Business and Economics, Jiangxi University of Finance and Economics, China
| | - Xiong Tianli
- School of Economics, Chongqing Technology and Business University, China
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Kidgell D, Hills D, Griffiths D, Endacott R. Trade agreements and the risks for the nursing workforce, nursing practice and public health: A scoping review. Int J Nurs Stud 2020; 109:103676. [PMID: 32603925 DOI: 10.1016/j.ijnurstu.2020.103676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 05/31/2020] [Accepted: 05/31/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Trade agreements in the 21st century have evolved to include provisions that affect domestic public policy and public health in signatory countries. There are growing calls for health professionals and public health advocates to pursue an active advisory role in trade negotiations in order to anticipate and prevent negative outcomes for health services and public health. AIM This scoping review explored current literature to identify existing knowledge of the implications of trade agreements for the nursing workforce, nursing practice and public health using as an example the 2018 'Comprehensive and Progressive Agreement for Trans-Pacific Partnership'. DESIGN Scoping review DATA SOURCES: Emerald Insight, Informit, Ovid MEDLINE, PubMed, ProQuest, Scopus, and a number of specialist Economics, International Trade and Business, and International Relations databases. Grey literature included national and international policy documents. REVIEW METHOD Literature was selected according to extraction field criteria, supplemented by hand searching of relevant grey literature and snowballing references from the selected literature reference lists. Analysis was undertaken to identify key themes emerging from the literature. REVIEW RESULTS Six key themes relevant to nursing workforce, nursing practice or public health were 1. Lack of consultation with public health and health professionals in trade negotiations; 2. Implications of strengthened intellectual property provisions for equitable access to medicines (including biologics) and medical devices; 3. Threats to government capacity to regulate domestic policy for public health and health services through 'Investor State Dispute Settlement' provisions 4. Threats to government capacity to regulate domestic policy for public health and health services through 'Regulatory Coherence' 5. Potential limited benefits to communities and increased health inequities 6. Potential implications of increased temporary migration. Gaps were identified in the literature for implications for nursing practice and the nursing workforce from regulatory and labour provisions of trade agreements. CONCLUSIONS The analysis of the literature reviewed is of international importance for the nursing workforce, nursing practice and public health. Policymakers must anticipate and respond to how the inclusion of labour or regulatory provisions in trade agreements will affect nursing practice and the nursing workforce, and how this may subsequently impact on the health of communities globally.
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Affiliation(s)
- Dianna Kidgell
- School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Road, Clayton, Victoria 3800, Australia.
| | - Danny Hills
- School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Road, Clayton, Victoria 3800, Australia; School of Nursing and Healthcare Professions, Federation University Australia, P.O. Box 663, Ballarat, Victoria 3353, Australia
| | - Debra Griffiths
- School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Road, Clayton, Victoria 3800, Australia
| | - Ruth Endacott
- School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Road, Clayton, Victoria 3800, Australia; School of Nursing and Midwifery, University of Plymouth, Drake Circus, Plymouth PL48AA, United Kingdom
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Affiliation(s)
- Eric Crosbie
- School of Community Health Sciences, University of Nevada, 1664 N. Virginia Street, Reno, NV, USA.,Ozmen Institute for Global Studies, University of Nevada, 1664 N. Virginia Street, Reno, NV, USA
| | - Arian Hatefi
- Department of Medicine, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA, USA.,Institute for Global Health Sciences, University of California San Francisco, 550 16th Street, Third Floor, San Francisco, CA, USA
| | - Laura Schmidt
- Institute for Global Health Sciences, University of California San Francisco, 550 16th Street, Third Floor, San Francisco, CA, USA.,Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, 3333 California Street, Ste 265, San Francisco, CA, USA.,Department of Anthropology, History and Social Medicine, University of California San Francisco, 3333 California Street, Ste 485, San Francisco, CA, USA
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Thow AM, Jones A, Huckel Schneider C, Labonté R. Increasing the public health voice in global decision-making on nutrition labelling. Global Health 2020; 16:3. [PMID: 31900178 PMCID: PMC6942308 DOI: 10.1186/s12992-019-0533-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 12/06/2019] [Indexed: 11/10/2022] Open
Abstract
To respond to the global noncommunicable disease (NCD) crisis, the Codex Alimentarius Commission (Codex), a multilateral United Nations body responsible for work on food standards, is developing global guidance for front of pack (FoP) nutrition labelling. Guidance from Codex regarding FoP nutrition labelling at the global level will almost certainly influence national policy making. This shift in Codex’s activities towards standards to address NCDs presents new risks for achievement of public health goals, as a result of the high level of industry involvement in this forum; there is a potential commercial conflict of interest held by manufacturers of products whose consumption could be discouraged by such guidance. In this Commentary, we examine the implications of Codex processes for developing robust global guidance on FoP nutrition labelling and identify opportunities to increase consideration of public health objectives. To date, there has been significantly higher representation of food industry compared to public health actors in Codex discussions on FoP nutrition labelling. Without a strong public health voice in Codex, the industry voice could dominate discussions on FoP nutrition labelling, such that subsequent global guidance prioritises future trade and profits over potential risks to public health. There is currently a critical window of opportunity for public health interests to be prioritised in this multisectoral international forum. The key public health priority for global guidance on FoP nutrition labelling is to ensure protection of policy space for national governments to implement strong and effective regulation, and allow scope for innovation. Public health actors can engage directly with Codex processes, at both the national and global level, and also need to raise awareness among domestic policy makers – including with Ministries of Agriculture and Industry, which often represent countries at Codex – regarding the importance and effectiveness of FoP labelling in NCD prevention. Increased engagement with Codex processes represents a tangible new opportunity to strengthen global governance for public health, and move towards improved coherence between trade policy and health protection goals.
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Affiliation(s)
- Anne Marie Thow
- Menzies Centre for Health Policy, School of Public Health, Charles Perkins Centre, The University of Sydney, Sydney, Australia.
| | | | - Carmen Huckel Schneider
- Menzies Centre for Health Policy, School of Public Health, Charles Perkins Centre, The University of Sydney, Sydney, Australia
| | - Ronald Labonté
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
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Friel S, Baker P, Thow AM, Gleeson D, Townsend B, Schram A. An exposé of the realpolitik of trade negotiations: implications for population nutrition. Public Health Nutr 2019; 22:3083-91. [PMID: 31439059 DOI: 10.1017/S1368980019001642] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To explore the formal and informal ways in which different actors involved in shaping trade agreements pursue their interests and understand the interactions with nutrition, in order to improve coherence between trade and nutrition policy goals. DESIGN The paper draws on empirical evidence from Australian key informant interviews that explore the underlying political dimensions of trade agreements that act as barriers or facilitators to getting nutrition objectives on trade agendas. SETTING Countries experiencing greater availability and access to diets full of energy-dense and nutrient-poor foods through increased imports, greater foreign direct investment and increasing constraints on national health policy space as a result of trade agreements. PARTICIPANTS Interviews took place with Australian government officials, industry, public-interest non-government organizations and academics. RESULTS The analysis reveals the formal and informal mechanisms and structures that different policy actors use both inside and outside trade negotiations to pursue their interests. The analysis also identifies the discourses used by the different actors, as they attempt to influence trade agreements in ways that support or undermine nutrition-related goals. CONCLUSIONS Moving forward requires policy makers, researchers and health advocates to use various strategies including: reframing the role of trade agreements to include health outcomes; reforming the process to allow greater access and voice to health arguments and stakeholders; establishing cross-government partners through accountable committees; and building circles of consensus and coalitions of sympathetic public-interest actors.
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Reeve B, Gostin LO. "Big" Food, Tobacco, and Alcohol: Reducing Industry Influence on Noncommunicable Disease Prevention Laws and Policies Comment on "Addressing NCDs: Challenges From Industry Market Promotion and Interferences". Int J Health Policy Manag 2019; 8:450-454. [PMID: 31441282 PMCID: PMC6706978 DOI: 10.15171/ijhpm.2019.30] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 05/11/2019] [Indexed: 01/08/2023] Open
Abstract
The food, tobacco and alcohol industries have penetrated markets in low- and middle-income countries (LMICs), with a significant impact on these countries' burden of noncommunicable diseases (NCDs). Tangcharoensathien and colleagues describe the aggressive marketing of unhealthy food, alcohol and tobacco in LMICs, as well as key tactics used by these industries to resist laws and policies designed to reduce behavioural risk factors for NCDs. This commentary expands on the recommendations made by Tangcharoensathien and colleagues for preventing or managing conflicts of interest and reducing undue industry influence on NCD prevention policies and laws, focusing on the needs of LMICs. A growing body of research proposes ways to design voluntary industry initiatives to make them more effective, transparent and accountable, but governments should also consider whether collaboration with health-harming industries is ever appropriate. More fundamentally, mechanisms for identifying, managing and mitigating conflicts of interest and reducing industry influence must be woven into - and supported by - broader governance and regulatory structures at both national and international levels.
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Affiliation(s)
- Belinda Reeve
- The University of Sydney Law School, Sydney, NSW, Australia
| | - Lawrence O. Gostin
- O’Neill Institute for National and Global Health Law, Georgetown University Law Center, Washington, DC, USA
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Baker P, Friel S, Gleeson D, Thow AM, Labonte R. Trade and nutrition policy coherence: a framing analysis and Australian case study. Public Health Nutr 2019; 22:2329-37. [PMID: 31111806 DOI: 10.1017/S1368980019000752] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Maximising synergies and minimising conflicts (i.e. building policy coherence) between trade and nutrition policy is an important objective. One understudied driver of policy coherence is the alignment in the frames, discourses and values of actors involved in the respective sectors. In the present analysis, we aim to understand how such actors interpret (i.e. 'frame') nutrition and the implications for building trade-nutrition policy coherence. DESIGN We adopted a qualitative single case study design, drawing on key informant interviews with those involved in trade policy. SETTING We focused on the Australian trade policy sub-system, which has historically emphasised achieving market growth and export opportunities for Australian food producers. PARTICIPANTS Nineteen key informants involved in trade policy spanning the government, civil society, business and academic sectors. RESULTS Nutrition had low 'salience' in Australian trade policy for several reasons. First, it was not a domestic political priority in Australia nor among its trading partners; few advocacy groups were advocating for nutrition in trade policy. Second, a 'productivist' policy paradigm in the food and trade policy sectors strongly emphasised market growth, export opportunities and deregulation over nutrition and other social objectives. Third, few opportunities existed for health advocates to influence trade policy, largely because of limited consultation processes. Fourth, the complexity of nutrition and its inter-linkages with trade presented difficulties for developing a 'broader discourse' for engaging the public and political leaders on the topic. CONCLUSIONS Overcoming these 'ideational challenges' is likely to be important to building greater coherence between trade and nutrition policy going forward.
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Cuevas García-Dorado S, Cornselsen L, Smith R, Walls H. Economic globalization, nutrition and health: a review of quantitative evidence. Global Health 2019; 15:15. [PMID: 30786909 PMCID: PMC6381642 DOI: 10.1186/s12992-019-0456-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 02/04/2019] [Indexed: 12/31/2022] Open
Abstract
Background Unhealthy dietary patterns have in recent decades contributed to an endemic-level burden from non-communicable disease (NCDs) in high-income countries. In low- and middle-income countries rapid changes in diets are also increasingly linked to malnutrition in all its forms as persistent undernutrition and micronutrient deficiencies continue to coexist with a rising prevalence of obesity and associated NCDs. Economic globalization and trade liberalization have been identified as potentially important factors driving these trends, but the mechanisms, pathways and actual impact are subject to continued debate. Methods We use a ‘rigorous review’ to synthesize evidence from empirical quantitative studies analysing the links between economic globalization processes and nutritional outcomes, with a focus on impact as well as improving the understanding of the main underlying mechanisms and their interactions. Findings While the literature remains mixed regarding the impacts of overall globalization, trade liberalization or economic globalization on nutritional outcomes, it is possible to identify different patterns of association and impact across specific sub-components of globalization processes. Although results depend on the context and methods of analysis, foreign direct investment (FDI) appears to be more clearly associated with increases in overnutrition and NCD prevalence than to changes in undernutrition. Existing evidence does not clearly show associations between trade liberalization and NCD prevalence, but there is some evidence of a broad association with improved dietary quality and reductions in undernutrition. Socio-cultural aspects of globalization appear to play an important yet under-studied role, with potential associations with increased prevalence of overweight and obesity. The limited evidence available also suggests that the association between trade liberalization or globalization and nutritional outcomes might differ substantially across population sub-groups. Overall, our findings suggest that policymakers do not necessarily face a trade-off when considering the implications of trade or economic liberalization for malnutrition in all its forms. On the contrary, a combination of nutrition-sensitive trade policy and adequate regulation of FDI could help reduce all forms of malnutrition. In the context of trade negotiations and agreements it is fundamental, therefore, to protect the policy space for governments to adopt nutrition-sensitive interventions. Electronic supplementary material The online version of this article (10.1186/s12992-019-0456-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Soledad Cuevas García-Dorado
- Leverhulme Centre for Integrate Research on Agriculture and Health, 36 Gordon Square, London, WC1H 0PD, UK. .,SOAS, University of London, Bloomsbury, London, WC1H 0XG, UK.
| | - Laura Cornselsen
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Tavistock Place, London, WC1H 9SH, UK.,Leverhulme Centre for Integrate Research on Agriculture and Health, 36 Gordon Square, London, WC1H 0PD, UK
| | - Richard Smith
- University of Exeter, Stocker Rd, Exeter, EX4 4PY, UK
| | - Helen Walls
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Tavistock Place, London, WC1H 9SH, UK.,Leverhulme Centre for Integrate Research on Agriculture and Health, 36 Gordon Square, London, WC1H 0PD, UK
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Townsend B, Schram A, Baum F, Labonté R, Friel S. How does policy framing enable or constrain inclusion of social determinants of health and health equity on trade policy agendas? Critical Public Health 2018. [DOI: 10.1080/09581596.2018.1509059] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Belinda Townsend
- School of Regulation and Global Governance, Australian National University, Canberra, Australia
| | - Ashley Schram
- School of Regulation and Global Governance, Australian National University, Canberra, Australia
| | - Fran Baum
- Department of Public Health, Flinders University of South Australia, Adelaide, Australia
| | - Ronald Labonté
- Institute of Population Health, University of Ottawa, Ottawa, Canada
| | - Sharon Friel
- School of Regulation and Global Governance, Australian National University, Canberra, Australia
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Schram A, Ruckert A, VanDuzer JA, Friel S, Gleeson D, Thow AM, Stuckler D, Labonte R. A conceptual framework for investigating the impacts of international trade and investment agreements on noncommunicable disease risk factors. Health Policy Plan 2018; 33:123-136. [PMID: 29106574 DOI: 10.1093/heapol/czx133] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2017] [Indexed: 01/18/2023] Open
Abstract
We developed a conceptual framework exploring pathways between trade and investment and noncommunicable disease (NCD) outcomes. Despite increased knowledge of the relevance of social and structural determinants of health, the discourse on NCD prevention has been dominated by individualizing paradigms targeted at lifestyle interventions. We situate individual risk factors, alongside key social determinants of health, as being conditioned and constrained by trade and investment policy, with the aim of creating a more comprehensive approach to investigations of the health impacts of trade and investment agreements, and to encourage upstream approaches to combating rising rates of NCDs. To develop the framework we employed causal chain analysis, a technique which sequences the immediate causes, underlying causes, and root causes of an outcome; and realist review, a type of literature review focussed on explaining the underlying mechanisms connecting two events. The results explore how facilitating trade in goods can increase flows of affordable unhealthy imports; while potentially altering revenues for public service provision and reshaping domestic economies and labour markets-both of which distribute and redistribute resources for healthy lifestyles. The facilitation of cross-border trade in services and investment can drive foreign investment in unhealthy commodities, which in turn, influences consumption of these products; while altering accessibility to pharmaceuticals that may mediate NCDs outcomes that result from increased consumption. Furthermore, trade and investment provisions that influence the policy-making process, set international standards, and restrict policy-space, may alter a state's propensity for regulating unhealthy commodities and the efficacy of those regulations. It is the hope that the development of this conceptual framework will encourage capacity and inclination among a greater number of researchers to investigate a more comprehensive range of potential health impacts of trade and investment agreements to generate an extensive and robust evidence-base to guide future policy actions in this area.
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Affiliation(s)
- Ashley Schram
- School of Regulation and Global Governance, Australian National University, 8 Fellows Road, Canberra, ACT 2601, Australia
| | - Arne Ruckert
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - Sharon Friel
- School of Regulation and Global Governance, Australian National University, 8 Fellows Road, Canberra, ACT 2601, Australia
| | - Deborah Gleeson
- School of Psychology and Public Health, La Trobe University, Melbourne, Australia
| | - Anne-Marie Thow
- Menzies Centre for Health Policy, School of Public Health, University of Sydney, Sydney, Australia
| | - David Stuckler
- Carlo F. Dondena Centre for Research on Social Dynamics and Public Policy, Bocconi University, Milan, Italy
| | - Ronald Labonte
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada
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Battams S, Townsend B. Power asymmetries, policy incoherence and noncommunicable disease control - a qualitative study of policy actor views. Critical Public Health 2018. [DOI: 10.1080/09581596.2018.1492093] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Samantha Battams
- Southgate Institute for Health, Society and Equity, Flinders University
| | - Belinda Townsend
- School of Regulation and Global Governance, Australian National University, Canberra, Australia
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Thow AM, Greenberg S, Hara M, Friel S, duToit A, Sanders D. Improving policy coherence for food security and nutrition in South Africa: a qualitative policy analysis. Food Secur 2018. [DOI: 10.1007/s12571-018-0813-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Barlow P, Labonte R, McKee M, Stuckler D. Trade challenges at the World Trade Organization to national noncommunicable disease prevention policies: A thematic document analysis of trade and health policy space. PLoS Med 2018; 15:e1002590. [PMID: 29944652 PMCID: PMC6019096 DOI: 10.1371/journal.pmed.1002590] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 05/17/2018] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND It has long been contested that trade rules and agreements are used to dispute regulations aimed at preventing noncommunicable diseases (NCDs). Yet most analyses of trade rules and agreements focus on trade disputes, potentially overlooking how a challenge to a regulation's consistency with trade rules may lead to 'policy or regulatory chill' effects whereby countries delay, alter, or repeal regulations in order to avoid the costs of a dispute. Systematic empirical analysis of this pathway to impact was previously prevented by a dearth of systematically coded data. METHODS AND FINDINGS Here, we analyse a newly created dataset of trade challenges about food, beverage, and tobacco regulations among 122 World Trade Organization (WTO) members from January 1, 1995 to December 31, 2016. We thematically describe the scope and frequency of trade challenges, analyse economic asymmetries between countries raising and defending them, and summarise 4 cases of their possible influence. Between 1995 and 2016, 93 food, beverage, and tobacco regulations were challenged at the WTO. 'Unnecessary' trade costs were the focus of 16.4% of the challenges. Only one (1.1%) challenge remained unresolved and escalated to a trade dispute. Thirty-nine (41.9%) challenges focussed on labelling regulations, and 18 (19.4%) focussed on quality standards and restrictions on certain products like processed meats and cigarette flavourings. High-income countries raised 77.4% (n = 72) of all challenges raised against low- and lower-middle-income countries. We further identified 4 cases in Indonesia, Chile, Colombia, and Saudi Arabia in which challenges were associated with changes to food and beverage regulations. Data limitations precluded a comprehensive evaluation of policy impact and challenge validity. CONCLUSIONS Policy makers appear to face significant pressure to design food, beverage, and tobacco regulations that other countries will deem consistent with trade rules. Trade-related influence on public health policy is likely to be understated by analyses limited to formal trade disputes.
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Affiliation(s)
- Pepita Barlow
- Department of Sociology, University of Oxford, Oxford, United Kingdom
| | - Ronald Labonte
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Martin McKee
- Department of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - David Stuckler
- Department of Policy Analysis and Public Management, Italy
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Delany L, Signal L, Thomson G. International trade and investment law: a new framework for public health and the common good. BMC Public Health 2018; 18:602. [PMID: 29739460 PMCID: PMC5941687 DOI: 10.1186/s12889-018-5486-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 04/19/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND International trade and investment agreements can have positive outcomes, but also have negative consequences that affect global health and influence fundamental health determinants: poverty, inequality and the environment. This article proposes principles and strategies for designing future international law to attain health and common good objectives. ARGUMENT Basic principles are needed for international trade and investment agreements that are consistent with the common good, public health, and human rights. These principles should reflect the importance of reducing inequalities, along with social and environmental sustainability. Economic growth should be recognised as a means to common good objectives, rather than an end in itself. Our favoured approach is both radical and comprehensive: we describe what this approach would include and outline the strategies for its implementation, the processes and capacity building necessary for its achievement, and related governance and corporate issues. The comprehensive approach includes significant changes to current models for trade and investment agreements, in particular (i) health, social and environmental objectives would be recognised as legitimate in their own right and implemented accordingly; (ii) changes to dispute-resolution processes, both state-to-state and investor-state; (iii) greater deference to international legal frameworks for health, environmental protection, and human rights; (iv) greater coherence across the international law framework; (v) limitations on investor privileges, and (vi) enforceable corporate responsibilities for contributing to health, environmental, human rights and other common good objectives. We also identify some limited changes that could be considered as an alternative to the proposed comprehensive approach. Future research is needed to develop a range of model treaties, and on the means by which such treaties and reforms might be achieved. Such research would focus also on complementary institutional reforms relevant to the United Nations and other international agencies. Advocacy by a range of communities is needed for effective change. Reform will require informed debate, determined engagement with decision-makers and stakeholders, and some agreement across health, social and environmental sectors on alternatives. CONCLUSIONS Current frameworks of international law that govern trade and economic development need radical change, in relation to treaty processes, content, and contexts, to better attain public health objectives.
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Abstract
The Thailand Tobacco Monopoly (TTM) controlled the country’s tobacco industry from its formation in the 1940s, until the government dropped restrictions on imported cigarettes in the late 1980s in response to pressure from the United States. The TTM has since competed with transnational tobacco companies (TTCs) in a semi-monopoly market in which TTCs have steadily increased their market share. Coupled with a decline in national smoking prevalence, the result of Thailand’s stringent tobacco control agenda, the TTM now accounts for a diminishing share of a contracting market. In response, the monopoly has looked to regional trade liberalisation, and proximity to markets with some of the world’s highest smoking rates to expand its operations. Expansion strategies have gone largely unrealised however, and the TTM effectively remains a domestic operation. Using TTM publications, market and trade reports, industry publications, tobacco industry documents and other resources, this paper analyses TTM expansion strategies, and the limited extent to which they have been achieved. This inability to expand its operations has left the monopoly potentially vulnerable to global strategies of its transnational competitors. This article is part of the special issue ‘The Emergence of Asian Tobacco Companies: Implications for Global Health Governance’.
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Affiliation(s)
- Ross MacKenzie
- a Department of Psychology , Macquarie University , Sydney , Australia
| | - Hana Ross
- b Southern Africa Labour and Development Research Unit (SALDRU), School of Economics , University of Cape Town , Cape Town , South Africa
| | - Kelley Lee
- c Faculty of Health Sciences , Simon Fraser University , Burnaby , Canada
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Thow AM, Reeve E, Naseri T, Martyn T, Bollars C. Food supply, nutrition and trade policy: reversal of an import ban on turkey tails. Bull World Health Organ 2017; 95:723-725. [PMID: 29147046 PMCID: PMC5689196 DOI: 10.2471/blt.17.192468] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Revised: 06/12/2017] [Accepted: 07/04/2017] [Indexed: 11/27/2022] Open
Affiliation(s)
- Anne Marie Thow
- Menzies Centre for Health Policy, D17 Charles Perkins Centre, University of Sydney, New South Wales, 2006, Australia
| | - Erica Reeve
- Centre for Population Health Research, Deakin University, Melbourne, Australia
| | | | - Tim Martyn
- Centre for Pacific Island Studies, University of the Sunshine Coast, Queensland, Australia
| | - Caroline Bollars
- Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
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Abstract
Johanna Hanefeld and colleagues highlight the links between trade and health and argue for greater consideration of trade agreements in actions to meet the sustainable development goals
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Affiliation(s)
- Johanna Hanefeld
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine London, London, UK
| | - Mishal Khan
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine London, London, UK
| | - Göran Tomson
- Public Health-Global Health/IHCAR, Karolinska Institutet, Stockholm, Sweden
- Swedish Institute for Global Health Transformation (SIGHT), Stockholm
| | - Richard Smith
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine London, London, UK
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43
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Buse K, Tanaka S, Hawkes S. Healthy people and healthy profits? Elaborating a conceptual framework for governing the commercial determinants of non-communicable diseases and identifying options for reducing risk exposure. Global Health 2017; 13:34. [PMID: 28619031 PMCID: PMC5472958 DOI: 10.1186/s12992-017-0255-3] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 06/02/2017] [Indexed: 11/10/2022] Open
Abstract
Background Non-communicable diseases (NCDs) represent a significant threat to human health and well-being, and carry significant implications for economic development and health care and other costs for governments and business, families and individuals. Risks for many of the major NCDs are associated with the production, marketing and consumption of commercially produced food and drink, particularly those containing sugar, salt and transfats (in ultra-processed products), alcohol and tobacco. The problems inherent in primary prevention of NCDs have received relatively little attention from international organizations, national governments and civil society, especially when compared to the attention paid to secondary and tertiary prevention regimes (i.e. those focused on provision of medical treatment and long-term clinical management). This may in part reflect that until recently the NCDs have not been deemed a priority on the overall global health agenda. Low political priority may also be due in part to the complexity inherent in implementing feasible and acceptable interventions, such as increased taxation or regulation of access, particularly given the need to coordinate action beyond the health sector. More fundamentally, governing determinants of risk frequently brings public health into conflict with the interests of profit-driven food, beverage, alcohol and tobacco industries. Materials We use a conceptual framework to review three models of governance of NCD risk: self-regulation by industry; hybrid models of public-private engagement; and public sector regulation. We analyse the challenges inherent in each model, and review what is known (or not) about their impact on NCD outcomes. Conclusion While piecemeal efforts have been established, we argue that mechanisms to control the commercial determinants of NCDs are inadequate and efforts at remedial action too limited. Our paper sets out an agenda to strengthen each of the three governance models. We identify reforms that will be needed to the global health architecture to govern NCD risks, including to strengthen its ability to consolidate the collective power of diverse stakeholders, its authority to develop and enforce clear measures to address risks, as well as establish monitoring and rights-based accountability systems across all actors to drive measurable, equitable and sustainable progress in reducing the global burden of NCDs.
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Affiliation(s)
| | | | - Sarah Hawkes
- Institute for Global Health, University College London, London, UK.
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Walls HL, Hanefeld J, Smith RD. The Trans-Pacific Partnership: Should We "Fear the Fear"? Comment on "The Trans-Pacific Partnership: Is It Everything We Feared for Health?". Int J Health Policy Manag 2017; 6:353-355. [PMID: 28812829 PMCID: PMC5458798 DOI: 10.15171/ijhpm.2016.140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 10/15/2016] [Indexed: 11/09/2022] Open
Abstract
RLabonté et al entitle their paper in this issue of the International Journal of Health Policy and Management "The Trans-Pacific Partnership: Is It Everything We Feared for Health?" Tantalisingly, they do not directly answer the question they pose, and in this commentary, we suggest that it is the wrong question; we should not 'fear' the Trans-Pacific Partnership (TPP) at all, rather we should ask how we are to respond. The public health community is right to be concerned with the potential implications of trade and investment agreements (TIAs) for health, particularly with shifts from multilateral to regional/bilateral agreements including provisions with greater risk to public health. But it is critical to understand also the potential health benefits, and especially the mitigating policy and governance mechanisms to respond to adverse TIA implications. Given entrenched and divergent sectoral worldviews and perspectives between trade and health communities on these issues, achieving the requisite understanding will also likely require characterisation of these perspectives and identification of areas of common understanding and agreed solutions.
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Affiliation(s)
- Helen L Walls
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Johanna Hanefeld
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Richard D Smith
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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45
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Townsend B, Gleeson D, Lopert R. The Regional Comprehensive Economic Partnership, Intellectual Property Protection, and Access to Medicines. Asia Pac J Public Health 2017; 28:682-693. [PMID: 27920239 DOI: 10.1177/1010539516676338] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The inclusion of elevated standards of intellectual property (IP) protection in the recently negotiated Trans-Pacific Partnership (TPP) agreement has raised serious public health concerns regarding access to medicines. A lesser-known trade agreement under negotiation in the Asia-Pacific region is the Regional Comprehensive Economic Partnership (RCEP). Framed as an attempt to reassert ASEAN's position in response to the United States-led TPP, RCEP includes key players China and India as well as several low- and middle-income countries (LMICs). Leaked drafts of IP provisions proposed by Japan and South Korea raise similar concerns in the Asia-Pacific region. This article identifies TRIPS (Trade Related Aspects of Intellectual Property Rights agreement)-Plus provisions in leaked negotiating texts and examines their implications for LMICs that are not also parties to the TPP: Cambodia, Indonesia, Laos, Myanmar, the Philippines, Thailand, China, and India. We find that higher levels of IP protection delay the market entry of generic medicines, giving rise to increased costs to governments and reduced access to essential medicines. The article concludes that the public health community should recognize risks inherent in trade agreements that promote expansions of IP rights and engage with governments to ensure that public health is adequately and explicitly protected in trade and investment negotiations.
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Affiliation(s)
| | | | - Ruth Lopert
- George Washington University, Washington, DC, USA
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Thow AM, Gleeson D. Advancing Public Health on the Changing Global Trade and Investment Agenda Comment on "The Trans-Pacific Partnership: Is It Everything We Feared for Health?". Int J Health Policy Manag 2017; 6:295-298. [PMID: 28812819 PMCID: PMC5417153 DOI: 10.15171/ijhpm.2016.129] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 09/21/2016] [Indexed: 11/20/2022] Open
Abstract
Concerns regarding the Trans-Pacific Partnership (TPP) have raised awareness about the negative public health impacts of trade and investment agreements. In the past decade, we have learned much about the implications of trade agreements for public health: reduced equity in access to health services; increased flows of unhealthy commodities; limits on access to medicines; and constrained policy space for health. Getting health on the trade agenda continues to prove challenging, despite some progress in moving towards policy coherence. Recent changes in trade and investment agendas highlight an opportunity for public health researchers and practitioners to engage in highly politicized debates about how future economic policy can protect and support equitable public health outcomes. To fulfil this opportunity, public health attention now needs to turn to strengthening policy coherence between trade and health, and identifying how solutions can be implemented. Key strategies include research agendas that address politics and power, and capacity building for both trade and health officials.
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Affiliation(s)
- Anne Marie Thow
- Menzies Centre for Health Policy, University of Sydney, Sydney, NSW, Australia
| | - Deborah Gleeson
- School of Psychology and Public Health, La Trobe University, Bundoora, VIC, Australia
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Affiliation(s)
- Desmond McNeill
- SUM (Centre for Development and the Environment), University of Oslo, Oslo, Norway.
| | - Carolyn Deere Birkbeck
- University of Oxford's Global Economic Governance Programme, Blavatnik School of Government, Oxford, UK
| | | | | | - Ted Schrecker
- Centre for Public Policy and Health, School of Medicine, Pharmacy and Health, Durham University, Durham, UK
| | - David Stuckler
- Political Economy and Sociology, University of Oxford, Oxford, UK
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Cobiac LJ, Tam K, Veerman L, Blakely T. Taxes and Subsidies for Improving Diet and Population Health in Australia: A Cost-Effectiveness Modelling Study. PLoS Med 2017; 14:e1002232. [PMID: 28196089 PMCID: PMC5308803 DOI: 10.1371/journal.pmed.1002232] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 01/06/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND An increasing number of countries are implementing taxes on unhealthy foods and drinks to address the growing burden of dietary-related disease, but the cost-effectiveness of combining taxes on unhealthy foods and subsidies on healthy foods is not well understood. METHODS AND FINDINGS Using a population model of dietary-related diseases and health care costs and food price elasticities, we simulated the effect of taxes on saturated fat, salt, sugar, and sugar-sweetened beverages and a subsidy on fruits and vegetables, over the lifetime of the Australian population. The sizes of the taxes and subsidy were set such that, when combined as a package, there would be a negligible effect on average weekly expenditure on food (<1% change). We evaluated the cost-effectiveness of the interventions individually, then determined the optimal combination based on maximising net monetary benefit at a threshold of AU$50,000 per disability-adjusted life year (DALY). The simulations suggested that the combination of taxes and subsidy might avert as many as 470,000 DALYs (95% uncertainty interval [UI]: 420,000 to 510,000) in the Australian population of 22 million, with a net cost-saving of AU$3.4 billion (95% UI: AU$2.4 billion to AU$4.6 billion; US$2.3 billion) to the health sector. Of the taxes evaluated, the sugar tax produced the biggest estimates of health gain (270,000 [95% UI: 250,000 to 290,000] DALYs averted), followed by the salt tax (130,000 [95% UI: 120,000 to 140,000] DALYs), the saturated fat tax (97,000 [95% UI: 77,000 to 120,000] DALYs), and the sugar-sweetened beverage tax (12,000 [95% UI: 2,100 to 21,000] DALYs). The fruit and vegetable subsidy (-13,000 [95% UI: -44,000 to 18,000] DALYs) was a cost-effective addition to the package of taxes. However, it did not necessarily lead to a net health benefit for the population when modelled as an intervention on its own, because of the possible adverse cross-price elasticity effects on consumption of other foods (e.g., foods high in saturated fat and salt). The study suggests that taxes and subsidies on foods and beverages can potentially be combined to achieve substantial improvements in population health and cost-savings to the health sector. However, the magnitude of health benefits is sensitive to measures of price elasticity, and further work is needed to incorporate potential benefits or harms associated with changes in other foods and nutrients that are not currently modelled, such as red and processed meats and fibre. CONCLUSIONS With potentially large health benefits for the Australian population and large benefits in reducing health sector spending on the treatment of non-communicable diseases, the formulation of a tax and subsidy package should be given a more prominent role in Australia's public health nutrition strategy.
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Affiliation(s)
- Linda J. Cobiac
- Centre for Health Policy, School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
- * E-mail:
| | - King Tam
- School of Public Health, The University of Queensland, Herston, Queensland, Australia
| | - Lennert Veerman
- School of Public Health, The University of Queensland, Herston, Queensland, Australia
| | - Tony Blakely
- Burden of Disease Epidemiology, Equity and Cost-Effectiveness Programme, Department of Public Health, University of Otago, Wellington, Wellington, New Zealand
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Abstract
Previous analyses indicate that there are a number of potentially serious health risks associated with the Trans-Pacific Partnership (TPP). The objective of this work is to provide further insight into the potential health impacts of the TPP by investigating labour market pathways. The impact of the TPP on employment and working conditions is a major point of contention in broader public debates. In public health literature, these factors are considered fundamental determinants of health, yet they are rarely addressed in analyses of trade and investment agreements. We therefore undertake a prospective policy analysis of the TPP through a content analysis of the agreement's Labour Chapter. Provisions of the Chapter are analyzed with reference to the health policy triangle and four main areas through which labour markets influence health: power relations, social policies, employment conditions and working conditions. Findings indicate that implementation of the TPP can have important impacts on health through labour market pathways. While the Labour Chapter is being presented by proponents of the agreement as a vehicle for improvement in labour standards, we find little evidence to support this view. Instead, we find several ways the TPP may weaken employment relations to the detriment of health.
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Affiliation(s)
- Courtney McNamara
- 1 Department of Sociology and Political Science, Norwegian University of Science and Technology, Dragvoll, Trondheim, Norway
| | - Ronald Labonté
- 2 School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Canada
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Mendez Lopez A, Loopstra R, McKee M, Stuckler D. Is trade liberalisation a vector for the spread of sugar-sweetened beverages? A cross-national longitudinal analysis of 44 low- and middle-income countries. Soc Sci Med 2016; 172:21-27. [PMID: 27871042 PMCID: PMC5224188 DOI: 10.1016/j.socscimed.2016.11.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 09/26/2016] [Accepted: 11/01/2016] [Indexed: 11/27/2022]
Abstract
Does trade and investment liberalisation increase the growth in sales of sugar-sweetened beverages (SSBs)? Here, for the first time to our knowledge, we test this hypothesis using a unique data source on SSB-specific trade flows. We test whether lower tariffs effectively increase imports of SSBs, and whether a higher level of imports increase sales of SSBs. Cross-national fixed effects models were used to evaluate the association between SSBs sales and trade liberalisation. SSBs per capita sales data were taken from EuroMonitor, covering 44 low- and middle-income countries from 2001 to 2014, SSBs import data were from TradeMap, Foreign Direct Investment data were from EuroMonitor, and data on applied tariffs on SSB from the World Trade Organisation tariffs database, all 2015 editions. The results show that higher tariffs on SSBs significantly decreased per capita SSB imports. Each one percent increase in tariffs was associated with a 2.9% (95% CI: 0.9%–5%) decrease in imports of SSBs. In turn, increased imports of SSBs were significantly associated with greater sales of SSBs per capita, with each 10 percent increase in imports (in US$) associated with a rise in sales of 0.36 L per person (95% CI: 0.08–0.68). Between 2001 and 2014, this amounted to 9.1 L greater sales per capita, about 40% of the overall rise seen in this period in LMICs. We observed that tariffs were inversely but not significantly associated with sales of SSBs. In conclusion, lower tariffs substantially increased imports of SSBs in LMICs, which translated into greater sales. These findings suggest that trade policies which lower tariff barriers to SSB imports can be expected to lead to increased imports and then increased sales of SSBs in LMICs, with adverse consequences for obesity and the diseases that result from it. Higher tariffs on SSBs significantly decreased per capita SSBs imports in LMICs. Increased imports of SSBs were significantly associated with greater sales of SSBs. Policies that liberalise trade of SSBs can be expected to lead to the spread SSBs.
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Affiliation(s)
- Ana Mendez Lopez
- Department of Sociology, University of Oxford, OX1 3UQ, United Kingdom.
| | - Rachel Loopstra
- Department of Sociology, University of Oxford, OX1 3UQ, United Kingdom
| | - Martin McKee
- ECOHOST, London School of Hygiene & Tropical Medicine, WC1H 9SH, United Kingdom
| | - David Stuckler
- Department of Sociology, University of Oxford, OX1 3UQ, United Kingdom
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