A new generation of trade policy: potential risks to diet-related health from the trans pacific partnership agreement

Health in Food Systems Policies in India: A Document Review

BACKGROUND

Food systems affect nutritional and other health outcomes. Recent literature from India has described policy aspects addressing nutritional implications of specific foods (eg, fruits, vegetables, and trans-fats), and identified opportunities to tackle the double burden of malnutrition. This paper attempts to deepen the understanding on how health concerns and the role of the health sector are addressed across food systems policies in India.

METHODS

This qualitative study used two approaches; namely (i) the framework method and (ii) manifest content analysis, to investigate national-level policy documents from relevant sectors (ie, food security, agriculture, biodiversity, food processing, trade, and waste management, besides health and nutrition). The documents were selected purposively. The textual data were coded and compared, from which themes were identified, described, and interpreted. Additionally, mentions of various health concerns and of the health ministry in the included documents were recorded and collated.

RESULTS

A total of 35 policy documents were included in the analysis. A variety of health concerns spanning nutritional, communicable and non-communicable diseases (NCDs) were mentioned. Undernutrition received specific attention even beyond nutrition policies. Only few policies mentioned NCDs, infectious diseases, and injuries. Governing and advisory bodies were instituted by 17 of the analysed policies (eg, food safety, agriculture, and food processing), and often included representation from the health ministry (9 of the 17 identified inter-ministerial bodies).

CONCLUSION

We found some evidence of concern for health, and inclusion of health ministry in food policy documents in India. The ongoing and planned intersectoral coordination to tackle undernutrition could inform actions to address other relevant but currently underappreciated concerns such as NCDs. Our study demonstrated a method for analysis of health consideration and intersectoral coordination in food policy documents, which could be applied to studies in other settings and policy domains.

Does international trade and investment liberalization facilitate corporate power in nutrition and alcohol policymaking? Applying an integrated political economy and power analysis approach to a case study of South Africa

Background

While there is a growing body of legally-focused analyses exploring the potential restrictions on public health policy space due to international trade rules, few studies have adopted a more politically-informed approach. This paper applies an integrated political economy and power analysis approach to understand how power relations and dynamics emerging as a result of the international trade and investment regime influence nutrition and alcohol regulatory development in a case study of South Africa.

Methods

We interviewed 36 key stakeholders involved in nutrition, alcohol and/or trade/investment policymaking in South Africa. Interview transcripts and notes were imported into NVivo and analyzed using thematic analysis. We used a conceptual framework for analyzing power in health policymaking to guide the analysis.

Results

Under the neoliberal paradigm that promotes trade liberalization and market extension, corporate power in nutrition and alcohol policymaking has been entrenched in South Africa via various mechanisms. These include via close relationships between economic policymakers and industry; institutional structures that codify industry involvement in all policy development but restrict health input in economic and trade policy decisions; limited stakeholder knowledge of the broader linkages between trade/investment and food/alcohol environments; high evidentiary requirements to prove public health policy effectiveness; both deliberate use of neoliberal frames/narratives as well as processes of socialization and internalization of neoliberal ideas/values shaping perceptions and policy preferences and ultimately generating policy norms prioritizing economic/trade over health objectives.

Conclusions

Exposing power in policymaking can expand our own ideational boundaries of what is required to promote transformative policy change. This work points to a number of potential strategies for challenging corporate power in nutrition and alcohol policymaking in the context of international trade and investment liberalization in South Africa.

Global health diplomacy in Mexico: insights from key actors in the field

BACKGROUND

Global health diplomacy (GHD) focuses on the actions taken by diverse stakeholders from different nations -governments, multilateral agents, and civil society- to phenomena that can affect population health and its determinants beyond national borders. Although the literature on conceptual advancements of GHD exists, empirical studies about how health becomes an issue of relevance for foreign policy are scarce. We present an analysis of the entry processes of health into the foreign policy and diplomatic domains in Mexico from the perspective of key informants of three different sectors.

METHODS

A purposive sample of high-rank representatives of three sectors involved in GHD was designed: Two from Health Sector (HS), four from Foreign Affairs Sector (FAS), and three from Non-governmental organizations (NGOs). Nine semi-structured interviews were conducted exploring the topics of: (1) Health concerns entering diplomatic and foreign policy; (2) Processes that allow actors to influence foreign policy and negotiation and; (3) Impact of multilateral negotiations on decision-making at the national level.

RESULTS

Our analysis suggests that GHD in Mexico is hierarchically driven by the FAS and health concerns only enter foreign policy when they are relevant to national priorities (such as trade or security). HS possesses a lesser degree of influence in GHD, serving as an instance of consultation for the FAS when deciding on health-related issues at global meetings (i.e., World Health Assembly). NGOs resort to lobbying, advocacy, networking, and coalition-working practices with other sectors (academy, think-tanks) to prevent harmful impacts on local health from multilateral decisions and as a mean to compensate its power asymmetry for influencing GHD processes in relation to the government.

CONCLUSIONS

GHD in Mexico occurs in a context of asymmetric power relationships where government actors have the strongest influence. However, NGOs' experience in raising awareness of health risks needs to be weighted by government decision-makers. This situation calls for capacity building on intersectoral communication and coordination to create formal mechanisms of GHD practices, including the professionalization and training on GHD among government agencies.

Global red and processed meat trade and non-communicable diseases

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.

Who influences nutrition policy space using international trade and investment agreements? A global stakeholder analysis

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.

Food environment solutions for childhood obesity in Latin America and among Latinos living in the United States

The food environment is a major contributor to unhealthy diets in children and, therefore, to the increasing rates of obesity. Acclaimed by scholars across the world, Latin American countries have been leaders in implementing policies that target different aspects of the food environment. Evidence on the nature and to what extent children are exposed and respond to unhealthy food environments in the region and among Latinos in the United States is, however, deficient. The objective of this review is to use the integrated International Network for Food and Obesity/noncommunicable diseases (NCDs) Research, Monitoring and Action Support (INFORMAS) framework to create healthy food environment to (i) compare the key elements of childhood obesity-related food environments in Latin America and for Latinos living in the United States; (ii) describe the evidence on solutions to improve childhood obesity-related food environments; and (iii) identify research priorities to inform solutions to fight childhood obesity in these populations. We found that an integrated body of evidence is needed to inform an optimal package of policies to improve food environments to which children in Latin America and Latino children in the United States are exposed and more efficiently translate policy solutions to help curb growing childhood obesity levels across borders.

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

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.

Glossary on free trade agreements and health part 1: the shift from multilateralism and the rise of 'WTO-Plus' provisions

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.

Shaping Physical, Economic, and Policy Components of the Food Environment to Create Sustainable Healthy Diets

Background:

Sustainable healthy diets are those dietary patterns that promote all dimensions of individuals’ health and well-being; have low environmental pressure and impact; are accessible, affordable, safe, and equitable; and are culturally acceptable. The food environment, defined as the interface between the wider food system and consumer’s food acquisition and consumption, is critical for ensuring equitable access to foods that are healthy, safe, affordable, and appealing.

Discussion:

Current food environments are creating inequities, and sustainable healthy foods are generally more accessible for those of higher socioeconomic status. The physical, economic, and policy components of the food environment can all be acted on to promote sustainable healthy diets. Physical spaces can be modified to improve relative availability (ie, proximity) of food outlets that carry nutritious foods in low-income communities; to address economic access certain actions may improve affordability, such as fortification, preventing food loss through supply chain improvements; and commodity specific vouchers for fruits, vegetables, and legumes. Other policy actions that address accessibility to sustainable healthy foods are comprehensive marketing restrictions and easy-to-understand front-of-pack nutrition labels. While shaping food environments will require concerted action from all stakeholders, governments and private sector bear significant responsibility for ensuring equitable access to sustainable healthy diets.

The spatial and temporal dynamics of global meat trade networks

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.

Oral Health Inequalities and the Corporate Determinants of Health: A Commentary

Empirical research critically examining the role of the corporate determinants of health has gained traction in the past few years. Many of these reports have received strong, sometimes litigious, backlash from the corporations exposed. The aim of this paper is to provide a critical commentary on existing literature, policies, procedures and observations of issues, especially regarding the use of the corporate determinants of health as a research construct, in the persistence and flourishing of oral health inequalities at a global level. We discuss theoretical frameworks that underpin the power constructs of the corporate determinants of health, including Lukes “three faces of power” theory. This theory posits that power is exercised in three ways: through decision-making, through non-decision-making and ideologically. We will demonstrate, using examples of corporate determinants of health and oral health inequalities from several countries, how intervening at key leverage points is a crucial strategy for improving oral health inequalities at a global level.

Towards Critical Analysis of the Political Determinants of Health Comment on "How Neoliberalism Is Shaping the Supply of Unhealthy Commodities and What This Means for NCD Prevention"

The recent perspective article "How Neoliberalism Is Shaping the Supply of Unhealthy Commodities and What This Means for NCD Prevention," by Lencucha and Throw, interrogates how the dominant neoliberal paradigm restricts meaningful policy action to prevent non-communicable diseases (NCDs). It contributes an NCD perspective to the existing literature on neoliberalism and health, which to date has been dominated by a focus on HIV, gender and trade agreements. It further advances the emerging commercial determinants of health (CDoH) scholarship by calling for more nuanced analysis of how the governance of both health and the economy facilitates corporate influence in policy-making. In political science terms, Lencucha and Throw are calling for greater structural analysis. However, their focus on the pragmatic, as opposed to political, aspects of neoliberalism reflects a hesitancy within health scholarship to engage in political analysis. This depoliticization of health serves neoliberal interests by delegitimizing critical questions about who sustains and benefits from current institutional norms. Lencucha and Throw’s call for greater interrogation of the structures of neoliberalism forms a basis from which to advance analysis of the political determinants of health.

Understanding Australian policies on public health using social and political science theories: reflections from an Academy of the Social Sciences in Australia Workshop

There is strong, and growing, evidence documenting health inequities across the world. However, most governments do not prioritize policies to encourage action on the social determinants of health and health equity. Furthermore, despite evidence concerning the benefits of joined-up, intersectoral policy to promote health and health equity, it is rare for such policy approaches to be applied systematically. To examine the usefulness of political and social science theory in understanding the reasons for this disjuncture between evidence and practice, researchers and public servants gathered in Adelaide for an Academy of the Social Sciences in Australia (ASSA) Workshop. This paper draws together the learnings that emerged from the Workshop, including key messages about the usefulness of various theories as well as insights drawn from policy practice. Discussions during the Workshop highlighted that applying multiple theories is particularly helpful in directing attention to, and understanding, the influence of all stages of the policy process; from the construction and framing of policy problems, to the implementation of policy and evaluation of outcomes, including those outcomes that may be unintended. In addition, the Workshop emphasized the value of collaborations among public health researchers, political and social scientists and public servants to open up critical discussion about the intersections between theory, research evidence and practice. Such critique is vital to render visible the processes through which particular sources of knowledge may be privileged over others and to examine how political and bureaucratic environments shape policy proposals and implementation action.

Australia's sugar tale

OBJECTIVE

To establish high intake of free sugars and its related disease burden as a significant public health challenge in Australia.

DESIGN

We discuss five key actions to reduce intake of free sugars tailored to the Australian context. These strategies are informed by reviewing the global scientific evidence on the effectiveness of a range of policy responses to reduce intake of free sugars at the population level.

SETTING

Australia.

PARTICIPANTS

Australian population.

RESULTS

The five key actions to reduce population levels for intake of free sugars tailored to the Australian context include prioritising health in trade agreements and policy; introducing a fiscal policy supporting health and promoting food reformulation; regulating advertising and improving labelling; strengthening the current dietary guidelines; and encouraging healthy choices.

CONCLUSIONS

The adoption and implementation of the strategies discussed in the current commentary would aid in tackling the rising health burden from the intake of free sugars in Australia.

Trade and nutrition policy coherence: a framing analysis and Australian case study

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.

What is driving global obesity trends? Globalization or "modernization"?

BACKGROUND

Worldwide obesity has more than doubled since 1980. Researchers have attributed rising obesity rates to factors related to globalization processes, which are believed to contribute to obesity by flooding low-income country markets with inexpensive but obesogenic foods and diffusing Western-style fast food outlets (dependency/world systems theory). However, alternative explanations include domestic factors such as increases in unhealthy food consumption in response to rising income and higher women's labor force participation as countries develop economically ("modernization" theory). To what extent are processes of globalization driving rising global overweight/obesity rates versus domestic economic and social development processes? This study evaluates the influence of economic globalization versus economic development and associated processes on global weight gain.

RESULTS

Using two-way fixed-effects OLS regression with a panel dataset of mean body weight for 190-countries over a 30-year period (1980-2008), we find that domestic factors associated with "modernization" including increasing GDP per capita, urbanization and women's empowerment were associated with increases in mean BMI over time. There was also evidence of a curvilinear relationship between GDP per capita and BMI: among low income countries, economic growth predicted increases in BMI whereas among high-income countries, higher GDP predicted lower BMI. By contrast, economic globalization (dependency/world systems theory) did not significantly predict increases in mean BMI and cultural globalization had mixed effects. These results were robust to different model specifications, imputation approaches and variable transformations.

DISCUSSION

Global increases in overweight/obesity appear to be driven more by domestic processes including economic development, urbanization and women's empowerment, and are less clearly negatively impacted by external globalization processes suggesting that the harms to health from global trade regimes may be overstated.

Agricultural trade policies and child nutrition in low- and middle-income countries: a cross-national analysis

BACKGROUND

There has been growing interest in understanding the role of agricultural trade policies in diet and nutrition. This cross-country study examines associations between government policies on agricultural trade prices and child nutrition outcomes, particularly undernutrition.

METHODS

This study links panel data on government distortions to agricultural incentives to data from 212,258 children aged 6 to 35 months participating in Demographic and Health Surveys from 22 countries between 1991 and 2010. Country fixed-effects regression models were used to examine the association between within-country changes in nominal rates of assistance to tradable agriculture (government price distortions as a percentage of original prices) and child nutritional outcomes (height-for-age, weight-for-age, and weight-for-height Z-scores) while controlling for a range of time-varying country covariates.

RESULTS

Five-year average nominal rates of assistance to tradable agriculture ranged from - 72.0 to 45.5% with a mean of - 5.0% and standard deviation of 18.9 percentage points. A 10-percentage point increase in five-year average rates of assistance to tradable agriculture was associated with improved height-for-age (0.02, 95% CI: 0.00-0.05) and weight-for-age (0.05, 95% CI: 0.02-0.09) Z-scores. Improvements in nutritional status were greatest among children who had at least one parent earning wages in agriculture, and effects decreased as a country's proportion of tradable agriculture increased, particularly for weight-for-age Z-scores.

CONCLUSIONS

Government assistance to tradable agriculture, such as through reduced taxation, was associated with small but significant improvements in child nutritional status, especially for children with a parent earning wages in agriculture when the share of tradable agriculture was not high.

Protocol to monitor trade agreement food-related aspects: the Fiji case study

Despite the growing rates of obesity and diet-related non-communicable diseases, globally, public health attention has only relatively recently turned to the links between trade agreements and the nutritional risks associated with it. Specific trade agreements appear to have played an influential role in the volume and types of foods entering different countries, yet there is currently no systematic and objective monitoring of trade agreements for their impacts on food environments. Recently, INFORMAS was set up to monitor and benchmark food environments, government policies and private sector actions within countries and globally. One of its projects/modules focuses on trade policy and in particular the food-related aspects of trade agreements. This paper describes the INFORMAS trade protocol, an approach to collecting food-related information about four domains of trade: trade in goods; trade in services and foreign direct investment; domestic supports, and policy space. Specifically, the protocol is tested in Fiji. The development and testing of this protocol in Fiji represents the first effort to set out a framework and process for objectively monitoring trade agreements and their impacts on national food supply and the wider food environment. It has shown that entry into WTO trade agreements contributed to the nutrition transition in Fiji through the increased availability of imported foods with varying nutritional quality. We observed an increase in imports of both healthy and less healthy foods. The application of the monitoring protocol also highlights challenges for data collection associated with each trade domain that should be considered for future data collection and analysis in other low and middle income countries.

Economic globalization, nutrition and health: a review of quantitative evidence

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.

Trade, investment and public health: compiling the evidence, assembling the arguments

Trade has long been an axiomatic characteristic of globalization, although international rules governing trade are of more recent vintage. Notably in the post-World War II period, an ever increasing number of countries began negotiating treaties to reduce, first, tariff barriers and, later, non-tariff barriers (government measures of any sort) that could impede the cross-border flow of goods. The rationale, in part, was that countries that became more entwined economically would be less likely to go to war with each other. It wouldn't be in their own economic interests to do so, or at least that of the firms based within their borders but engaged in transnational trade and dependent upon global supply chains. At first primarily an undertaking of developed (high-income) countries, developing (low and middle-income countries) slowly enjoined in what, in 1995, became the World Trade Organization. The WTO locked in scheduled declines in tariffs (border taxes), albeit with lesser obligations on developing country members (a problematic nomenclature given the vast geographic, economic, and development differences between such countries, but which nonetheless persists within the WTO). Importantly, a slew of new agreements that coincided with the establishment of the WTO also sought to liberalize trade in services (not just goods) (The General Agreement on Trade in Services), create new rules for agricultural trade (Agreement on Agriculture), expand intellectual property rights protections (The Agreement on Trade-Related Aspects of Intellectual Property Rights), limit trade-distorting government subsidies (Agreement on Subsidies and Countervailing Measures), and ensure that government food, health, or environmental regulations would not pose an unnecessary barrier to trade (the Technical Barriers to Trade and the Sanitary and Phytosanitary Measures Agreements). Outside of the WTO system, bilateral or regional investment treaties granting special rights to foreign investors to sue governments for actions perceived to affect the value of their investment (such as direct expropriation or passage of new laws and regulations considered 'tantamount to expropriation') similarly exploded in number, dispute frequency, and the size of monetary claims. The breadth and depth of these post-1995 Agreements meant that few areas of general public health concern are potentially untouched.

Something Borrowed, Something New: A Governance and Social Construction Framework to Investigate Power Relations and Responses of Diverse Stakeholders to Policies Addressing Antimicrobial Resistance

While antimicrobial resistance (AMR) has rapidly ascended the political agenda in numerous high-income countries, developing effective and sustainable policy responses in low- and middle-income countries (LMIC) is far from straightforward, as AMR could be described as a classic ‘wicked problem’. Effective policy responses to combat AMR in LMIC will require a deeper knowledge of the policy process and its actors at all levels—global, regional and national—and their motivations for supporting or opposing policies to combat AMR. The influence of personal interests and connections between for-profit organisations—such as pharmaceutical companies and food producers—and policy actors in these settings is complex and very rarely addressed. In this paper, the authors describe the role of policy analysis focusing on social constructions, governance and power relations in soliciting a better understanding of support and opposition by key stakeholders for alternative AMR mitigation policies. Owing to the lack of conceptual frameworks on the policy process addressing AMR, we propose an approach to researching policy processes relating to AMR currently tested through our empirical programme of research in Cambodia, Pakistan, Indonesia and Tanzania. This new conceptualisation is based on theories of governance and a social construction framework and describes how the framework is being operationalised in several settings.

Revisiting the Corporate and Commercial Determinants of Health

We trace the development of the concept of the corporate determinants of health. We argue that these determinants are predicated on the unchecked power of corporations and that the means by which corporations exert power is increasingly unseen. We identify four of the ways corporations influence health: defining the dominant narrative; setting the rules by which society, especially trade, operates; commodifying knowledge; and undermining political, social, and economic rights. We identify how public health professionals can respond to these manifestations of power.

A conceptual framework for investigating the impacts of international trade and investment agreements on noncommunicable disease risk factors

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.

Investigating societal determinants of oral health-Opportunities and challenges in multilevel studies

The high prevalence of oral diseases and the persistent nature of socioeconomic inequalities in oral health outcomes across societies presents a significant challenge for public health globally. A debate exists in epidemiology on the merits of investigating population variations in health and its determinants over studying individual health and its individual risk factors. The choice of analytical unit for health outcomes at the population level has policy implications and consequences for the causal understanding of population-level variations in health/disease. There is a lack of discussion in oral epidemiology on the relevance of studying population variations in oral health. Evidence on the role of societal factors in shaping variations in oral health at both the individual level and the population level is also mounting. Multilevel studies are increasingly applied in social epidemiology to address hypotheses generated at different levels of social organization, but the opportunities offered by multilevel approaches are less applied for studying determinants of oral health at the societal level. Multilevel studies are complex as they aim to examine hypotheses generated at multiple levels of social organization and require attention to a range of theoretical and methodological aspects from the stage of design to analysis and interpretation. This discussion study aimed to highlight the value in studying population variations in oral health. It discusses the opportunities provided by multilevel approaches to study societal determinants of oral health. Finally, it reviews the key methodological aspects related to operationalizing multilevel studies of societal determinants of oral health.

Politics, policies and processes: a multidisciplinary and multimethods research programme on policies on the social determinants of health inequity in Australia

INTRODUCTION

The development and implementation of multisectoral policy to improve health and reduce health inequities has been slow and uneven. Evidence is largely focused on the facts of health inequities rather than understanding the political and policy processes. This 5-year funded programme of research investigates how these processes could function more effectively to improve equitable population health.

METHODS AND ANALYSIS

The programme of work is organised in four work packages using four themes (macroeconomics and infrastructure, land use and urban environments, health systems and racism) related to the structural drivers shaping the distribution of power, money and resources and daily living conditions. Policy case studies will use publicly available documents (policy documents, published evaluations, media coverage) and interviews with informants (policy-makers, former politicians, civil society, private sector) (~25 per case). NVIVO software will be used to analyse the documents to see how 'social and health equity' is included and conceptualised. The interview data will include qualitative descriptive and theory-driven critical discourse analysis. Our quantitative methodological work assessing the impact of public policy on health equity is experimental that is in its infancy but promises to provide the type of evidence demanded by policy-makers.

ETHICS AND DISSEMINATION

Our programme is recognising the inherently political nature of the uptake, formulation and implementation of policy. The early stages of our work indicate its feasibility. Our work is aided by a Critical Policy Reference Group. Multiple ethics approvals have been obtained with the foundation approval from the Social and Behavioural Ethics Committee, Flinders University (Project No: 6786).The theoretical, methodological and policy engagement processes established will provide improved evidence for policy-makers who wish to reduce health inequities and inform a new generation of policy savvy knowledge on social determinants.

Trade is central to achieving the sustainable development goals: a case study of antimicrobial resistance

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

Monitoring the impact of trade agreements on national food environments: trade imports and population nutrition risks in Fiji

BACKGROUND

Trade agreements are increasingly recognised as playing an influential role in shaping national food environments and the availability and nutritional quality of the food supply. Global monitoring of food environments and trade policies can strengthen the evidence base for the impact of trade policy on nutrition, and support improved policy coherence. Using the INFORMAS trade monitoring protocol, we reviewed available food supply data to understand associations between Fiji's commitments under WTO trade agreements and food import volume trends.

METHODS

First, a desk review was conducted to map and record in one place Fiji's commitments to relevant existing trade agreements that have implications for Fiji's national food environment under the domains of the INFORMAS trade monitoring protocol. An excel database was developed to document the agreements and their provisions. The second aspect of the research focused on data extraction. We began with identifying food import volumes into Fiji by country of origin, with a particular focus on a select number of 'healthy and unhealthy' foods. We also developed a detailed listing of transnational food corporations currently operating in Fiji.

RESULTS

The study suggests that Fiji's WTO membership, in conjunction with associated economic and agricultural policy changes have contributed to increased availability of both healthy and less healthy imported foods. In systematically monitoring the import volume trends of these two categories of food, the study highlights an increase in healthy foods such as fresh fruits and vegetables and whole-grain refined cereals. The study also shows that there has been an increase in less healthy foods including fats and oils; meat; processed dairy products; energy-dense beverages; and processed and packaged foods.

CONCLUSION

By monitoring the trends of imported foods at country level from the perspective of trade agreements, we are able to develop appropriate and targeted interventions to improve diets and health. This would enable national health interventions to both identify areas of concern, and to ensure that interventions take into account the trade context.

Assessing the Health Impact of Trade: A Call for an Expanded Research Agenda Comment on "The Trans-Pacific Partnership: Is It Everything We Feared for Health?"

Labonté et al provide an insightful analysis of the Trans-Pacific Partnership (TPP) and its impact on a selection of important health determinants. Their work confirms concerns raised by previous analyses of leaked drafts and offers governments serious and timely reasons to carefully consider provisions of the agreement prior to moving forward with ratification. It also contributes more generally to a growing literature focused on identifying the health impacts of trade. This commentary uses the authors’ analysis as a starting point to reflect on two interrelated issues relevant both for taking seriously one of the article’s main recommendations and future work in the area of trade and health.

Is It Time to Say Farewell to the ISDS System? Comment on "The Trans-Pacific Partnership: Is It Everything We Feared for Health?"

Investor-state dispute settlement (ISDS) continues to plague health-oriented government regulation. This is particularly reflected in recent challenges to tobacco control measures through bilateral investment agreements. There are numerous reform proposals circulating within the public health community. However, I suggest that perhaps it is time for the community to explore a stronger position on ISDS. I draw from mounting evidence on the problematic uses of the ISDS to explore the proposition that ISDS is no longer justified. I tackle the normative question of should the ISDS system persist and point out that the ISDS system is not justifiable from a development perspective and because of its nefarious use, is of no added value to a system that could rely on domestic courts.

Trade, Labour Markets and Health

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.

Food systems transformations, ultra-processed food markets and the nutrition transition in Asia

BACKGROUND

Attracted by their high economic growth rates, young and growing populations, and increasingly open markets, transnational food and beverage corporations (TFBCs) are targeting Asian markets with vigour. Simultaneously the consumption of ultra-processed foods high in fat, salt and glycaemic load is increasing in the region. Evidence demonstrates that TFBCs can leverage their market power to shape food systems in ways that alter the availability, price, nutritional quality, desirability and ultimately consumption of such foods. This paper describes recent changes in Asian food systems driven by TFBCs in the retail, manufacturing and food service sectors and considers the implications for population nutrition.

METHOD

Market data for each sector was sourced from Euromonitor International for four lower-middle income, three upper-middle income and five high-income Asian countries. Descriptive statistics were used to describe trends in ultra-processed food consumption (2000-2013), packaged food retail distribution channels (1999-2013), 'market transnationalization' defined as the market share held by TFBCs relative to domestic firms (2004-2013), and 'market concentration' defined as the market share and thus market power held by the four leading firms (2004-2013) in each market.

RESULTS

Ultra-processed food sales has increased rapidly in most middle-income countries. Carbonated soft drinks was the leading product category, in which Coca-Cola and PepsiCo had a regional oligopoly. Supermarkets, hypermarkets and convenience stores were becoming increasingly dominant as distribution channels for packaged foods throughout the region. Market concentration was increasing in the grocery retail sector in all countries. Food service sales are increasing in all countries led by McDonalds and Yum! Brands. However, in all three sectors TFBCs face strong competition from Asian firms.

CONCLUSIONS

Overall, the findings suggest that market forces are likely to be significant but variable drivers of Asia's nutrition transition. The carbonated soft drink market is the most highly concentrated and likely to be most harmful to population nutrition. The grocery retail sector is, in terms of increasing market concentration and thus market power, likely to be the most important driver of ongoing food systems change and ultra-processed food sales in the region. Given it's rapid growth, the food service sector will also contribute significantly to ongoing dietary change.

What is policy and where do we look for it when we want to research it?

Public health researchers are increasingly concerned with achieving 'upstream' change to achieve reductions in the global burden of disease and health inequalities. Consequently, understanding policy and how to change it has become a central goal of public health. Yet conceptualisation of what constitutes policy and where it can be found is very limited within this field. Our glossary demonstrates that policy is many headed. It is located in a vast array of documents, discussions dialogues and actions which can be captured variously by formal and informal forms of documentation and observation. Effectively understanding policy and its relevance for public health requires an awareness of the full range of places and contexts in which policy work happens and policy documents are produced.

Is trade liberalisation a vector for the spread of sugar-sweetened beverages? A cross-national longitudinal analysis of 44 low- and middle-income countries

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.

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Higher tariffs on SSBs significantly decreased per capita SSBs imports in LMICs.

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Increased imports of SSBs were significantly associated with greater sales of SSBs.

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Policies that liberalise trade of SSBs can be expected to lead to the spread SSBs.

The Trans-Pacific Partnership: Is It Everything We Feared for Health?

BACKGROUND

Negotiations surrounding the Trans-Pacific Partnership (TPP) trade and investment agreement have recently concluded. Although trade and investment agreements, part of a broader shift to global economic integration, have been argued to be vital to improved economic growth, health, and general welfare, these agreements have increasingly come under scrutiny for their direct and indirect health impacts.

METHODS

We conducted a prospective health impact analysis to identify and assess a selected array of potential health risks of the TPP. We adapted the standard protocol for Health impact assessments (HIAs) (screening, scoping, and appraisal) to our aim of assessing potential health risks of trade and investment policy, and selected a health impact review methodology. This methodology is used to create a summary estimation of the most significant impacts on health of a broad policy or cluster of policies, such as a comprehensive trade and investment agreement.

RESULTS

Our analysis shows that there are a number of potentially serious health risks associated with the TPP, and details a range of policy implications for the health sector. Of particular focus are the potential implications of changes to intellectual property rights (IPRs), sanitary and phytosanitary measures (SPS), technical barriers to trade (TBT), investor-state dispute settlement (ISDS), and regulatory coherence provisions on a range of issues, including access to medicines and health services, tobacco and alcohol control, diet-related health, and domestic health policy-making.

CONCLUSION

We provide a list of policy recommendations to mitigate potential health risks associated with the TPP, and suggest that broad public consultations, including on the health risks of trade and investment agreements, should be part of all trade negotiations.

The Trans-Pacific Partnership Agreement and health: few gains, some losses, many risks

Background

In early October 2015, 12 nations signed the Trans-Pacific Partnership Agreement (TPPA), promoted as a model ‘21^st century’ trade and investment agreement that other countries would eventually join. There are growing concerns amongst the public health community about the potential health implications of such WTO+ trade and investment agreements, but little existing knowledge on their potential health impacts.

Methods and results

We conducted a health impact review which allows for a summary estimation of the most significant health impacts of a set of policies, in our case the TPPA. Our analysis shows that there are a number of potentially serious health risks, with the following key pathways linking trade to health: access to medicines, reduced regulatory space, investor-state dispute settlement (ISDS), and environmental protection and labor rights. We also note that economic gains that could translate into health benefits will likely be inequitably distributed.

Conclusion

Our analysis demonstrates the need for the public health community to be knowledgeable about trade issues and more engaged in trade negotiations. In the context of the COP21 climate change Agreement, and the UN Sustainable Development Goals, this may be an opportune time for TPPA countries to reject it as drafted, and rethink what should be the purpose of such agreements in light of (still) escalating global wealth inequalities and fragile environmental resources—the two most foundational elements to global health equity.

Trade and investment liberalization, food systems change and highly processed food consumption: a natural experiment contrasting the soft-drink markets of Peru and Bolivia

Background

Free trade agreements (FTAs) can affect food environments and non-communicable disease risks through altering the availability of highly-processed foods. Few studies have quantified such effects. Using a natural experiment this paper quantifies changes in Peru’s soft-drink market before/after entry into the US-Peru FTA, compared with Bolivia, a county with no such agreement.

Methods

Difference-in-difference models were used to test for between country differences in the rate of per capita foreign direct investment (FDI) inflows, soft-drink imports, the volumes of various soft-drinks sold, and the volumes of sugar from soft-drinks before/after FTA ratification (2006) and enforcement (2009).

Results

In Peru average per capita FDI-inflows rose from US$103.11 in the pre-ratification period to US$269.79 post-ratification, with little change in Bolivia. This corresponded with a 122 % increase in Peruvian soft-drink production. There was a significant between-country difference in FDI-inflows pre-/post-ratification (DID:1.07, 95 % CI:0.19–1.96; p = 0.01). Despite little difference in total per capita soft-drink sales volumes there was a significant between-country difference in per capita sugar from soft-drinks pre-/post enforcement (DID:-0.99, 95 % CI: −1.91–0.06; p = 0.03) with stagnated growth in Peru and continued growth in Bolivia. This resulted from stagnated sugar sweetened carbonates growth and increased bottled water, juice and sports & energy drinks growth in Peru, with continued carbonates growth in Bolivia. There was a significant between-country difference in per capita carbonates (DID: −1.44, 95 % CI: −2.52–0.36, p = 0.01) and bottled water (DID:0.63; 95 % CI: −0.01–1.26; p = 0.04) sales volumes.

Conclusions

The FTA may have resulted in increased FDI-inflows and soft-drink production and also contributed to the diversification of soft drinks produced and sold in Peru with some positive (stagnated carbonates and increased bottled water) and some negative (increased juice and sports & energy drinks) implications for nutrition. These changes were not evident in Bolivia. These results should be interpreted cautiously given the study design limitations.

Is health impact assessment useful in the context of trade negotiations? A case study of the Trans Pacific Partnership Agreement

OBJECTIVE

The Trans Pacific Partnership Agreement (TPP) is a recently concluded free trade agreement involving Australia and 11 other Pacific-rim nations, which has the potential for far-reaching impacts on public health. A health impact assessment (HIA) was carried out during the negotiations to determine the potential future public health impact in Australia and to provide recommendations to mitigate potential harms. This paper explores the findings and outcomes of the HIA, and how this approach can be used to provide evidence for public health advocacy.

DESIGN

A modified version of the standard HIA process was followed. The HIA was led by technical experts in HIA, trade policy, and health policy, in collaboration with advocacy organisations concerned with the TPP and health. The HIA reviewed the provisions in leaked TPP text in order to determine their potential impact on future health policy. As part of this process, researchers developed policy scenarios in order to examine how TPP provisions may affect health policies and their subsequent impact to health for both the general and vulnerable populations. The four policy areas assessed were the cost of medicines, tobacco control, alcohol control and food labelling.

RESULTS

In all areas assessed, the HIA found that proposed TPP provisions were likely to adversely affect health. These provisions are also likely to more adversely affect the health of vulnerable populations.

CONCLUSIONS

The HIA produced relevant evidence that was useful in advocacy efforts by stakeholders, and engaging the public through various media platforms.

Conceptual and institutional gaps: understanding how the WHO can become a more effective cross-sectoral collaborator

BACKGROUND

Two themes consistently emerge from the broad range of academics, policymakers and opinion leaders who have proposed changes to the World Health Organization (WHO): that reform efforts are too slow, and that they do too little to strengthen WHO's capacity to facilitate cross-sectoral collaboration. This study seeks to identify possible explanations for the challenges WHO faces in addressing the broader determinants of health, and the potential opportunities for working across sectors.

METHODS

This qualitative study used a mixed methods approach of semi-structured interviews and document review. Five interviewees were selected by stratified purposive sampling within a sampling frame of approximately 45 potential interviewees, and a targeted document review was conducted. All interviewees were senior WHO staff at the department director level or above. Thematic analysis was used to analyze data from interview transcripts, field notes, and the document review, and data coded during the analysis was analyzed against three central research questions. First, how does WHO conceptualize its mandate in global health? Second, what are the barriers and enablers to enhancing cross-sectoral collaboration between WHO and other intergovernmental organizations? Third, how do the dominant conceptual frames and the identified barriers and enablers to cross-sectoral collaboration interact?

RESULTS

Analysis of the interviews and documents revealed three main themes: 1) WHO's role must evolve to meet the global challenges and societal changes of the 21st century; 2) WHO's cross-sectoral engagement is hampered internally by a dominant biomedical view of health, and the prevailing institutions and incentives that entrench this view; and 3) WHO's cross-sectoral engagement is hampered externally by siloed areas of focus for each intergovernmental organization, and the lack of adequate conceptual frameworks and institutional mechanisms to facilitate engagement across siloes.

CONCLUSION

There are a number of external and internal pressures on WHO which have created an organizational culture and operational structure that focuses on a narrow, technical approach to global health, prioritizing disease-based, siloed interventions over more complex approaches that span sectors. The broader approach to promoting human health and wellbeing, which is conceptualized in WHO's constitution, requires cultural and institutional changes for it to be fully implemented.

The role of trade and investment liberalization in the sugar-sweetened carbonated beverages market: a natural experiment contrasting Vietnam and the Philippines

Background

Trade and investment liberalization may facilitate the spread of sugar-sweetened carbonated beverages (SSCBs), products associated with increased risk factors for obesity, type II diabetes, and cardiovascular diseases (Circulation 121:1356–1364, 2010). Apart from a limited set of comparative cross-national studies, the majority of analyses linking liberalization and the food environment have drawn on case studies and descriptive accounts. The current failure of many countries to reverse the obesity epidemic calls for investigation into both individual and systemic factors, including trade and investment policies.

Methods

Using a natural experimental design we tested whether Vietnam’s removal of restrictions on foreign direct investment (FDI) subsequent to its accession to the World Trade Organization in 2007 increased sales of SSCBs compared with a matched country, the Philippines, which acceded in 1995. Difference-in-difference (DID) models were used to test pre/post differences in total SSCB sales and foreign company penetration covering the years 1999–2013.

Results

Following Vietnam’s removal of restrictions on FDI, the growth rate of SSCB sales increased to 12.1 % per capita per year from a prior growth rate of 3.3 %. SSCB sales per capita rose significantly faster pre- and post-intervention in Vietnam compared with the control country the Philippines (DID: 4.6 L per annum, 95 % CI: 3.8 to 5.4 L, p < 0.008). Vietnam’s increase in SSCBs was primarily attributable to products manufactured by foreign companies, whose annual sales growth rates rose from 6.7 to 23.1 %, again unmatched within the Philippines over this period (DID: 12.3 %, 95 % CI: 8.6 to 16.0 %, p < 0.049).

Conclusions

Growth of SSCB sales in Vietnam, led by foreign-owned companies, significantly accelerated after trade and investment liberalization.