Raphael Lencucha

Philip Morris versus Uruguay: health governance challenged

One prominent feature of the challenges in global health governance is the ability of nations to protect health through legislation within a global market economy that is governed by bilateral and multilateral trade regimens. Although nations have a right to regulate imported products, such as tobacco, this right is constrained by World Trade Organization rules and other bilateral and multilateral agreements. In principle, health considerations are protected by Article XX (b) of the World Trade Organization’s General Agreement on Tariff s and Trade, which states that trade agreements must not have a negative impact on human health. However, in 2005, the Framework Convention on Tobacco Control (FCTC) became the fi rst global health governance tool to become international law. The FCTC seeks to facilitate and legitimise the implementation of national tobaccocontrol legislation. The relation between health protection and trade facilitation was salient in the negotiation of the FCTC. FCTC negotiations sought to clarify the relation between health governance and trade or investment regimes. The relation eventually remained implicit; but with what consequence? The answer to this question might occur sooner than we thought. The following correspondence highlights a recent case that could bear on the health-trade dialogue. On Feb 19, 2010, Philip Morris presented a case against Uruguay under a Switzerland–Uruguay Bilateral Investment Treaty. Philip Morris is challenging Uruguay’s decision—a party to the FCTC—to increase the coverage on tobacco packs of tobacco-warning labels to 80% and to require the use of coloured or plain packaging. According to Investment Arbitration Reporter, Philip Morris argues that these measures infringe on their intellectual property rights and hamper their competitiveness in the Uruguayan market. The company investigated the case against plain packaging well before the Uruguay case was fi led. Legal consultants for the company issued a report on July 23, 2009, stating that “A plain packaging measure would...create a two-tier should include questions about emotional abuse, as well as physical and sexual abuse. Prevention of all forms of intimate partner violence is very important for improving women’s health, particularly their mental health.

Evolving Norms at the Intersection of Health and Trade

There has been growing tension at the intersection of health and economic policy making as global governance has increased across sectors. This tension has been particularly evident between tobacco control and trade policy, as the international norms that frame them -- particularly the Framework Convention on Tobacco Control and the World Trade Organization (WTO) -- have continued to institutionalize. Using five case studies of major tobacco-related trade disputes from the principal multilateral system of trade governance -- the WTO/General Agreement on Tariffs and Trade -- we trace the evolution of these interacting norms over nearly twenty-five years. Our analytic framework focuses on the actors that advance, defend, and challenge these norms. We find that an increasingly broad network, which includes governments, intergovernmental organizations, nongovernmental organizations, and members of the epistemic community, is playing a more active role in seeking to resolve these tensions. Moreover, key economic actors are beginning to incorporate health more actively into their messaging and activities. We also demonstrate that the most recent resonant messages reflect a more nuanced integration of the two norms. The tobacco control example has direct relevance to related policy areas, including environment, safety, access to medicines, diet, and alcohol.

Balancing Challenges and Facilitating Factors when Implementing Client-Centred Collaboration in a Mental Health Setting:

This study undertook a replication of the work conducted by Sumsion in 2004 in the United Kingdom regarding the application of a definition of client-centred practice. Twelve occupational therapists employed by a local mental health facility and working with adult outpatients participated in semi-structured interviews. Template analysis and open coding were used to analyse the data. The resulting concept map indicated that collaboration and meaningful goals were at the centre of client-centred practice and formed the two main categories of data. The therapist and the client were the protagonists in these categories, but the family, team and system also played major roles. A table within this paper outlines all the categories and themes that arose from the data. However, space limitations required a focus on only the category of collaboration and the therapist and client facilitators and challenges within this category. The therapists used both attitudes and actions to facilitate the client-centred process and the clients brought strengths to this relationship. Nevertheless, both groups faced many challenges that had to be overcome to enable the successful implementation of client-centred practice.

Investment incentives and the implementation of the Framework Convention on Tobacco Control: evidence from Zambia

Purpose Policy misalignment across different sectors of government serves as one of the pivotal barriers to WHO Framework Convention on Tobacco Control (FCTC) implementation. This paper examines the logic used by government officials to justify investment incentives to increase tobacco processing and manufacturing in the context of FCTC implementation in Zambia. Methods We conducted qualitative semistructured interviews with key informants from government, civil society and intergovernmental economic organisations (n=23). We supplemented the interview data with an analysis of public documents pertaining to the policy of economic development in Zambia. Results We found gross misalignments between the policies of the economic sector and efforts to implement the provisions of the FCTC. Our interviews uncovered the rationale used by officials in the economic sector to justify providing economic incentives to bolster tobacco processing and manufacturing in Zambia: (1) tobacco is not consumed by Zambians/tobacco is an export commodity, (2) economic benefits outweigh health costs and (3) tobacco consumption is a personal choice. Conclusions Much of the struggle Zambia has experienced in implementing the FCTC can be attributed to misalignments between the economic and health sectors. Zambias development agenda seeks to bolster agricultural processing and manufacturing. Tobacco control proponents must recognise and work within this context in order to foster productive strategies with those working on tobacco supply issues. These findings are broadly applicable to the global context. It is important that the Ministry of Health monitors the tobacco policy of and engages with these sectors to find ways of harmonising FCTC implementation.

Plain packaging: an opportunity for improved international policy coherence?

This paper highlights two salient challenges at the intersection of tobacco control and macroeconomic policy-making: (i) the use of trade and investment disputes to undermine and/or stall tobacco control legislation and (ii) the inconsistency, and thus unpredictability, of country positions across the two spheres. In the interest of improving international policy coherence, the authors suggest possible solutions to these two challenges at the national and intergovernmental levels.

Tobacco control and trade policy: Proactive strategies for integrating policy norms

Palpable tension continues at the intersection of tobacco control and trade policy. Through consideration of four major tobacco control-related trade disputes, we suggest how to empower public health proponents in the face of entrenched economic policymaking norms. We argue that a more effective pro-tobacco control message should: (a) seek to be broadly consistent with core principles of the world trading system, (b) boldly assert countries’ international commitments to the Framework Convention on Tobacco Control, (c) marshal deep scientific evidence, and (d) come from a broad range of actors, including from low- and middle-income countries as well as from other trade policy community members.

Cosmopolitanism and foreign policy for health: ethics for and beyond the state

BackgroundForeign policy holds great potential to improve the health of a global citizenship. Our contemporary political order is, in part, characterized by sovereign states acting either in opposition or cooperation with other sovereign states. This order is also characterized by transnational efforts to address transnational issues such as those featured so prominently in the area of global health, such as the spread of infectious disease, health worker migration and the movement of health-harming products. These two features of the current order understandably create tension for truly global initiatives.DiscussionNational security has become the dominant ethical frame underlying the health-based foreign policy of many states, despite the transnational nature of many contemporary health challenges. This ethical approach engages global health as a means to achieving national security objectives. Implicit in this ethical frame is the version of humanity that dichotomizes between “us” and “them”. What has been left out of this discourse, for the most part, is the role that foreign policy can play in extending the responsibility of states to protect and promote health of the other, for the sake of the other.SummaryThe principal purpose of this paper is to review arguments for a cosmopolitan ethics of health-based foreign policy. I will argue that health-based foreign policy that is motivated by security interests is lacking both morally and practically to further global health goals. In other words, a cosmopolitan ethic is not only intrinsically superior as a moral ideal, but also has potential to contribute to utilitarian ends. This paper draws on the cosmopolitanism literature to build robust support for foreign policies that contribute to sustainable systems of global health governance.

The political economy of foreign direct investment—Evidence from the Philippines*

Abstract Much of the conventional wisdom about the political economy of foreign direct investment suggests that many developing country governments lower regulatory and/or legislative standards in order to woo potential investors. Using the case of the tobacco industrys efforts to influence excise tax policy reforms in the Philippines, we find a much more complex reality. Over a period of more than 15 years of concerted efforts and significant financial investment, a large multinational tobacco firm was consistently unable to realize its tax policy goals with serious, negative implications for the firm. In the most recent major policy confrontation over excise tax reform that led to one of the largest tax increases on tobacco products ever in a developing country, a number of major variables mitigated the powerful firms influence. These variables included strong support for tax reform from a number of influential political actors and a well-organized civil society movement, which led to broader public support for both public health and fiscal reasons. Global governance around economic policy and the effects of domestic institutional structures also had marked effects on the outcomes.

A snapshot of global health education at North American universities

Global health education is becoming increasingly prominent in North America. It is widely agreed upon that global health is an important aspect of an education in the health sciences and increasingly in other disciplines such as law, economics and political science. There is currently a paucity of studies examining the content of global health courses at the post-secondary level. The purpose of our research is to identify the content areas being covered in global health curricula in North American universities, as a first step in mapping global health curricula across North America. We collected 67 course syllabi from 31 universities and analyzed the topics covered in the course. This snapshot of global health education will aid students searching for global health content, as well as educators and university administrators who are developing or expanding global health programs in Canada and the United States.

Global health diplomacy: A critical review of the literature

Global health diplomacy (GHD) describes the practices by which governments and non-state actors attempt to coordinate and orchestrate global policy solutions to improve global health. As an emerging field of practice, there is little academic work that has comprehensively examined and synthesized the theorization of Global Health Diplomacy (GHD), nor looked at why specific health concerns enter into foreign policy discussion and agendas. With the objective of uncovering the driving forces behind and theoretical explanations of GHD, we conducted a critical literature review. We searched three English-language scholarly databases using standardized search terms which yielded 606 articles. After screening of abstracts based on our inclusion/exclusion criteria, we retained 135 articles for importing into NVivo10 and coding. We found a lack of rigorous theorizing about GHD and fragmentation of the GHD literature which is not clearly structured around key issues and their theoretical explanations. To address this lack of theoretical grounding, we link the findings from the GHD literature to how theoretical concepts used in International Relations (IR) have been, and could be invoked in explaining GHD more effectively. To do this, we develop a theoretical taxonomy to explain GHD outcomes based on a popular categorization in IR, identifying three levels of analysis (individual, domestic/national, and global/international) and the driving forces for the integration of health into foreign policy at each level.