Holly Jarman

Attack on Australia: Tobacco industry challenges to plain packaging

In 2011, the Australian Government passed landmark legislation requiring tobacco manufacturers to adopt ‘plain packaging’, a government-mandated design standardized across all brands of tobacco products. In response, plain packaging policy in Australia has faced multiple, simultaneous challenges from a global, well-resourced industry able to use all available fora to seek redress. Generalizing from the Australian experience, we analyze four types of challenges to plain packaging from the tobacco industry. We characterize three ways in which industry questions public health policies through international trade and investment law, on: (i) the intent or purpose of the policy; (ii) the economic consequences of it; and (iii) the regulatory authority behind it. We make recommendations and suggest that public health policymakers can know with some precision what attacks will be launched on tobacco control policies, and prepare their strategies and legislation accordingly.

Crossborder trade in health services: Lessons from the European laboratory

We find four key lessons that health policymakers and practitioners should be aware of: the potential of services liberalization to incur high transition and transaction costs; the difficulty of reconciling economic and social policy goals and the subsequent high likelihood of backlash; the tendency of rule-based systems to promote policy spillover; and the importance (and difficulty) of early monitoring in order to avoid unwanted policy outcomes. We conclude that continued awareness of new policy developments, coordination of expertise on health and trade and preemptive regulation are vital in order to deal with the expansion of crossborder trade in health services.

Public health and the Transatlantic trade and investment partnership

What would you do for an extra €120 billion a year? That’s an extra 0.5 % GDP across the European Union (EU), or an extra €545 per household per year.1 If you are a European politician facing poor economic conditions, you might be tempted by an international agreement that promises growth, political capital and campaign finance contributions—all with minimal pain. The EU is currently negotiating such an agreement with the United States: the Transatlantic Trade and Investment Partnership (TTIP). Public health advocates should be wary of TTIP, which carries the risk that important public health protections and principles—from access to essential medicines and medical procedures to tobacco control, food and medical device regulation—could be hampered in exchange for the promise of economic gains. To call TTIP a ‘trade deal’ is to ignore some of its most important features with big consequences for health: regulatory convergence, measures allowing foreign investors to sue governments and strong intellectual …

How will Brexit affect health and health services in the UK? Evaluating three possible scenarios

The process of leaving the European Union (EU) will have profound consequences for health and the National Health Service (NHS) in the UK. In this paper, we use the WHO health system building blocks framework to assess the likely effects of three scenarios we term soft Brexit, hard Brexit, and failed Brexit. We conclude that each scenario poses substantial threats. The workforce of the NHS is heavily reliant on EU staff. Financing of health care for UK citizens in the EU and vice versa is threatened, as is access to some capital funds, while Brexit threatens overall economic performance. Access to pharmaceuticals, technology, blood, and organs for transplant is jeopardised. Information used for international comparisons is threatened, as is service delivery, especially in Northern Ireland. Governance concerns relate to public health, competition and trade law, and research. However, we identified a few potential opportunities for improvement in areas such as competition law and flexibility of training, should the UK Government take them. Overall, a soft version of Brexit would minimise health threats whereas failed Brexit would be the riskiest outcome. Effective parliamentary scrutiny of policy and legal changes will be essential, but the scale of the task risks overwhelming parliament and the civil service.

What Whitehall? Definitions, Demographics and the Changing Home Civil Service

This article asks who works in Whitehall today. We argue that there are points of consensus about the nature of ‘Whitehall’, including generalism, internal labour markets, Oxbridge education, and lifetime careers. An analysis of 306 biographies of the top team of the UK civil service, which goes beyond existing published use of biographical data on the topic, allows us to compare the civil service with this model. We find that in every respect the descriptive usefulness of a Whitehall model is weak. Whitehall is no longer marked by internal labour markets, Oxbridge dominance, or lifetime careers, and there are signs of reduced generalism. Furthermore, many of the most politically salient departments appear to be leading the way towards a different public sector model premised on managerial, policy expertise rather than civil service generalism and loyalty.

When trade law meets public health evidence: the World Trade Organization and clove cigarettes

A recent trade dispute between the USA and Indonesia, overseen by the World Trade Organization, challenges piecemeal approaches to tobacco regulation.

Healthcare, borders, and boundaries: Crossborder health markets and the entrepreneurial state

Abstract Responding to arguments that states are strongly constrained by global capital, this article uses the concept of the entrepreneurial state to analyze the ways states create crossborder health markets. The article, combined with the others in this special issue, provide three key findings. First, we find that the territorially bound nature of much domestic health policy is being challenged by international integration in a growing number of sectors. Second, we find that crossborder legal frameworks in place to govern markets are extensive but not sufficient to decide questions of global health. Finally, we conclude that states matter in crossborder health because they shape rules that govern markets. Although states are challenged by global capital mobility and global regulatory frameworks, they are still capable of shaping crossborder health markets and should be held accountable for protecting the public from the risks that to health that these markets can create.

Managing risks in EU health services policy: Spot markets, legal certainty and bureaucratic resistance

European Union (EU) healthcare services policy has been largely driven by the European Court of Justice (ECJ) applying the law of the internal market to the previously separate area of healthcare systems. We argue that it opened up two major risks: that health service planning would be disrupted by cross-border flows of patients and professionals, including ostensibly interchangeable professionals or procedures that actually vary in quality; and that health systems would be disrupted by the application of liberalizing EU regulatory frameworks. The threats have largely been managed by four developments. Cross-border flows have largely appeared as spot markets rather than broad competition. States, meanwhile, have managed both regulatory and planning risks by debating and then legislating, which increases legal certainty, and the ECJ has taken the hint and become more cautious in its rulings. Meanwhile, states and health systems alike have implemented a strategy of ‘bureaucratic resistance’ upon discovering how easy it is to comply in only the narrowest ways, thereby limiting affects on systems and regulations alike. The experience testifies to the difficulty of creating and sustaining health markets, but also to the risks of international trade in health services and the amount of effort it takes to manage such risks.

Collaboration and Consultation: Functional Representation in EU Stakeholder Dialogues

Abstract In the past decade, the EU has experimented with various types of consultation mechanisms intended to address perceived deficits in policy knowledge and decision-making legitimacy within the European system. I examine attempts by the European Commission to build up its decision-making legitimacy and inform policy via various formal mechanisms, focusing on the extent to which the relationship between the Commission and its civil society groups is collaborative or consultative. In particular, I examine two such experiments: The DG Trade Civil Society Dialogue (CSD) and the DG SANCO platform on Diet, Physical Activity and Health. DG Trade, a strong and relatively autonomous DG, developed a consultative model of engagement, gaining legitimation by consulting with advocacy groups. DG SANCO, working in areas where the EU competencies are weak, adopts a collaborative model in which it can set the agenda and structure debates but fundamentally depends on industry association partners, rather than its own legal powers, to achieve its goals.

The New Political Economy of Health Care in the European Union The Impact of Fiscal Governance

We argue that the political economy of health care in the European Union is being changed by the creation of a substantial new apparatus of European fiscal governance. A series of treaties and legal changes since 2008 have given the European Union new powers and duties to enforce budgetary austerity in the member states, and this apparatus of fiscal governance has already extended to include detailed and sometimes coercive policy recommendations to member states about the governance of their health care systems. We map the structures of this new fiscal governance and the way it purports to affect health care decision making.