Nick Drager

Globalization and health: a framework for analysis and action

Globalization is a key challenge to public health, especially in developing countries, but the linkages between globalization and health are complex. Although a growing amount of literature has appeared on the subject, it is piecemeal, and suffers from a lack of an agreed framework for assessing the direct and indirect health effects of different aspects of globalization. This paper presents a conceptual framework for the linkages between economic globalization and health, with the intention that it will serve as a basis for synthesizing existing relevant literature, identifying gaps in knowledge, and ultimately developing national and international policies more favourable to health. The framework encompasses both the indirect effects on health, operating through the national economy, household economies and health-related sectors such as water, sanitation and education, as well as more direct effects on population-level and individual risk factors for health and on the health care system. Proposed also is a set of broad objectives for a programme of action to optimize the health effects of economic globalization. The paper concludes by identifying priorities for research corresponding with the five linkages identified as critical to the effects of globalization on health.

Trade and health: an agenda for action

The processes of contemporary globalisation are creating ever-closer ties between individuals and populations across different countries. The health of a population, and the systems in place to deliver health care, are affected increasingly by factors beyond the population and health system. The Lancets Series on trade and health has provided an overview of these links between international trade, trade liberalisation, and health, and raised the key issues that face the health community. In this final paper in the Series, we call for a substantial and sustained effort by those within the health profession to engage with issues of trade, to strengthen institutional capacity in this area, and to place health higher on the agenda of trade negotiations. The rapid rise of trade agreements and treaties, as well as trade that occurs beyond these institutional boundaries, means that further action is required by a range of actors, including WHO, the World Bank, the World Trade Organization (WTO), regional agencies, foundations, national governments, civil society, non-governmental organisations, and academics. The stewardship of a domestic health system in the 21st century requires a sophisticated understanding of how trade affects, and will affect, a countrys health system and policy, to optimise opportunities to benefit health and health care while minimising the risks posed though the assertion of health goals in trade policy. To acheive this will place a premium on all those engaged in health to understand the importance of trade and to engage with their counterparts involved in trade and trade policy. We hope that this Series has prompted the reader to become involved in these efforts.

Managing the pursuit of health and wealth: the key challenges

This article forms part of a six-part Series on trade and health, and sets the stage for this Series by analysing key aspects of the relationship between trade and health. The Series takes stock of this relation and provides timely analysis of the key challenges facing efforts to achieve an appropriate balance between trade and health across a diverse range of issues. This introductory article reviews how trade and health have risen and expanded on global policy agendas in the past decade in unprecedented ways, describes how trade and health issues are respectively governed in international relations, examines the ongoing search for policy coherence between the two policy spheres, and highlights the topics of the remaining articles in the Series.

International Trade in Health Services and the GATS: Current Issues and Debates

Health ministries around the world face a new challenge: to assess the risks and respond to the opportunities of the increasing openness in health services under the World Trade Organizations (WTO) General Agreement on Trade in Services (GATS). This publication addresses this challenge head-on by providing analytical tools to policymakers in health and trade ministries alike who are involved in the liberalization agenda and, specifically, in the GATS negotiations. This book informs and assists policymakers in formulating trade policy and negotiating internationally. There is ongoing and animated international debate about the impact of GATS on public services in general and health in particular. In response, the book offers different perspectives from more than 15 leading experts. Some of the authors stress opportunities linked to trade in health services, others focus more on the risks. The book offers: Detailed legal analysis of the impact of the agreement on health policy; an overview of trade commitments in health-related services; new empirical evidence from nine country studies; and a simple 10-step explanation on how to deal with GATS negotiations.

Foreign policy, trade and health: at the cutting edge of global health diplomacy

Under its Constitution, the World Health Organization (WHO) works with its members towards the attainment by all peoples of the highest possible level of health. The context in which WHO and its Members pursue this goal has radically changed since 1946. The interdependence produced by globalization has broken down traditional ways of conceptualizing and organizing the medical, economic, political and technological means to improve health. Nowhere is this transformation more apparent than in the rise of health as a foreign policy concern. As the papers in this issue of the Bulletin demonstrate, the relationship between health and foreign policy is vital, complex and contested. To craft health policy today, governments, international institutions and nongovernmental organizations must find mechanisms to manage health risks that spill into and out of every country. These endeavours create the new world of global health diplomacy. Critical to global health diplomacy is the relationship between health and foreign policy. Even though much of what affects health today is transnational in nature, countries remain core actors that must reorient their health and foreign policies in ways that align their national interests with the diplomatic, epidemiological and ethical realities of a globalized world. This alignment involves governments adjusting to globalization by overcoming fragmented policy competencies in national governance systems. The trade and health relationship unfolds on the cutting edge of global health diplomacy and offers lessons for the health and foreign policy nexus. The World Heath Assembly recognized this significance in a May 2006 resolution on International Trade and Health, in which the Assembly called for foreign, trade and health ministries to move towards coherency in formulating national policies on trade and health. The Assembly tasked WHO to collaborate with other international organizations to generate and share evidence on ways to align trade and health. This trade and health linkage highlights the new prominence of health within foreign policy; however, the linkage itself is not new. These enquiries allow us to see how countries historically dealt with health in their trade and foreign policies, particularly with respect to ensuring that health measures did not unnecessarily restrict international commerce. The trade and health relationship is also at the centre of international lawmaking, particularly in the World Trade Organization. International trade law allows us to analyse how countries calibrate their national interests regarding economic growth and protection of health. The trade and health arena has also seen involvement by nongovernmental entities promoting trade and health interests; these actions provide avenues for understanding how countries adjust their foreign policy strategies when non-state actors intervene. The window into global health diplomacy provided by the trade and health relationship reveals controversy, but also increasing efforts between those in trade and health ministries towards coherent policies within and among countries. WHO’s work on trade and health policy coherence reveals increasing country-level commitment to, and sophistication about, strategies to promote trade and protect health in ways that are politically feasible, economically attractive, epidemiologically informed and ethically sound. Through these efforts, health ministries are identifying how they can best inform pre-negotiation trade positions, provide input during negotiations, analyse the health costs and benefits of proposed compromises and monitor the health impacts of trade agreements. WHO is collaborating with its members and other international organizations to advance this integrated approach to foreign policy by developing a new trade and health diagnostic tool. This tool is being designed to help health and trade ministries more systematically assess trade and health issues, to empower health ministries to give better advice to their trade counterparts and to enhance health policy input into the trade community’s pursuit of integrated frameworks, trade policy reviews and aid initiatives to bolster trade capacities in developing countries. The cutting edge of global health diplomacy raises certain cautions regarding health’s role in trade and foreign policies. Competition among countries’ national interests sometimes impedes policy coherence, which makes attainment of health goals more difficult. As the trade and health relationship makes clear, health ministries, experts and advocates can affect this competition constructively by combining their epidemiological skills and ethical principles with sharpened political and economic sensibilities about global politics. Securing health’s fullest participation in foreign policy does not ensure health for all, but it supports the principle that foreign policy achievements by any country in promoting and protecting health will be of value to all. ■

Globalization: changing the public health landscape

In June of this year trade negotiators from developing and industrialized countries met at the World Trade Organization to discuss intellectual property rights and access to essential medicines for the poor. Several delegations included ministry of health officials, and others had been briefed by public health experts. At about the same time, at the World Health Organization, governments, businesses and nongovernmental organizations were discussing plans for a global health fund, launched earlier this year by Kofi Annan, Secretary-General of the United Nations. This fund may become the basis of a new collective approach to controlling diseases of the poor, particularly AIDS, malaria and tuberculosis. These two examples from a growing number of initiatives reflect widespread awareness of the need for domestic action within the health sector to be complemented by cross-sector and cross-border action. Only with complementary strategies of this kind will it be possible to protect and promote the health of poor populations. In a world of increasing interconnection and interdependence there is an urgent need to scale up combined activities to improve the health of those who have been left behind. It requires a new kind public health workforce with the knowledge and skills to maximize the beneficial effects of globalization on population health status, and minimize the adverse ones. This special issue of the Bulletin is another step towards informing public health professionals about the implications of globalization for their work. The articles cover a wide spectrum of points of view, from international to local, from cheerful to gloomy, from broadly generalizing to highly specific. The major unanswered public health question in this field, despite the firm views held by interested parties, is the health consequences of the economic growth engendered by the current phase of globalization. Two contrasting views appear in this issue. Dollar of the World Bank (pp. 827-833) presents evidence that economic globalization has raised the incomes of poor countries, and that this has generally benefited poor people. Cornia of the University of Florence (pp. 834-841), on the other hand, while appreciating the economic growth-promoting potential of globalization, suggests that the benefits have been restricted to a small number of countries. Importantly, he stresses that where there have been successes they have resulted from a combination of outward orientation and strong domestic regulation. He challenges the view that the impact of globalization on income distribution has been neutral. Two local case studies, on Kerala by Thankappan (pp. 892-893) and Thailand by Sitthi-amorn et al. (pp. 889-890), discuss some specific impacts of various aspects of globalization on health, and in a third, Wyn-Owen (pp. 890-891) illustrates the role of an influential nongovernmental organization in putting the issue of globalization and health high on the political agenda. Again at the local level, Evans et al. (pp. 856-862) find that cost considerations are more important than nutritional knowledge, or even personal preferences, when people shop for food. There is agreement that changes to the international architecture are required to ensure that globalization is beneficial to the poor. …

Assessing trade in health services in countries of the Eastern Mediterranean from a public health perspective

SUMMARY Assessing trade in health services (TiHS) in developing countries is challenging since the sources of information are diverse, information is not accessible and professionals lack grasp of issues. A multi-country study was conducted in the Eastern Mediterranean Region (EMR)--Egypt, Jordan, Lebanon, Morocco, Oman, Pakistan, Sudan, Syrian Arab Republic, Tunisia, and Yemen. The objective was to estimate the direction, volume, and value of TiHS; analyze country commitments; and assess the challenges and opportunities for health services.Trade liberalization favored an open trade regime and encouraged foreign direct investment. Consumption abroad and movement of natural persons were the two prevalent modes. Yemen and Sudan are net importers, while Jordan promotes health tourism. In 2002, Yemenis spent US

From policy coherence to 21st century convergence: a whole-of-society paradigm of human and economic development

80 million out of pocket for treatment abroad, while Jordan generated US

Convergent innovation for sustainable economic growth and affordable universal health care: innovating the way we innovate

620 million. Egypt, Pakistan, Sudan and Tunisia export health workers, while Oman relies on import and 40% of its workforce is non-Omani. There is a general lack of coherence between Ministries of Trade and Health in formulating policies on TiHS.This is the first organized attempt to look at TiHS in the EMR. The systematic approach has helped create greater awareness, and a move towards better policy coherence in the area of trade in health services.

Whole-of-society approach for public health policymaking: a case study of polycentric governance from Quebec, Canada

The 20th century saw accelerated human and economic development, with increased convergence in income, wealth, and living standards around the world. For a large part, owing to the well‐entrenched Western‐centric linear and siloed industrialization pattern, this positive transformation has also been associated with complex societal challenges at the nexus of agricultural, industrial, and health sectors. Efforts at cross‐sectoral policy coherence have been deployed with limited success. To go beyond what has been possible thus far, the whole‐of‐society (WoS) paradigm for human and economic development proposes a 21st century convergence where, instead of the rest (of the world) converging with the West, sectoral and cross‐sectoral efforts converge in their single and collective policy and action on a common target of human and economic development. In this paper, we first review and discuss contributions and limitations of policy coherence approaches. We then elaborate the institutional foundation of the WoS paradigm, taking as an anchor the well‐established model of polycentric governance that views individuals, and state, market, and community, forming society as part of the same complex adaptive system. Actors within such systems self‐organize into nested hierarchies that operate at multiple scales and move toward 21st century convergence of human and economic development.