Health Impact of Trade and Investment Agreements
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Trade and Investment Agreements (IEAs) have been widely criticized for their potentially negative effects on health. Many governments, particularly those in low- and middle-income countries, are concerned that mega-regional agreements such as the Trans-Pacific Partnership and the Transatlantic Trade and Investment Partnership could undermine governments` room for manoeuvre on health protection and, for example, weaken options still allowed by World Trade Organization rules. In addition, these mega-regional agreements will set standards and rules of the game that even non-signatories must emulate in order to compete in the global marketplace. This article begins with an overview of the changing structure of trade and investment policy, global production, and the relationship between the two. The health effects of BAIs are then analyzed based on some of the most relevant findings. The key power asymmetries within the global trade and investment architecture are described and how they affect how trade rules are created, implemented and evaluated. Section 5 examines a particularly striking and current example of such power asymmetries, investor-state dispute settlement provisions in the AGREEMENTS and their relevance to health. The article concludes with recommendations to mitigate the potential negative externalities of TIAs. Proponents of trade agreements argue that trade liberalization can bring economic benefits that can directly improve health and/or outweigh potential health damage.
At least one model suggests that trade and economic development have had long-term positive effects on the health of the general population in the United States. [52] However, data and models demonstrating the health benefits of trade agreements are limited. Models that assess the overall benefits of trade agreements currently under negotiation are equally controversial. The expected economic benefits of ongoing trade agreement negotiations vary, with some models predicting modest to significant economic growth, while the vast majority indicate limited economic benefits. [22,53–55] Notably, it is not clear how these potential economic benefits would be distributed among the population. Another issue that has emerged in the negotiations on trade agreements is the patenting of diagnostic, therapeutic and surgical techniques that could compromise the availability of these techniques and their use by health professionals. [13,21–23] It is important that an exception for the patenting of diagnostic, therapeutic and surgical techniques be included in all agreements, similar to the wording of the United States Code (35 USC 287(c)), to avoid potential liability for patent infringement among healthcare professionals who perform procedures and care for patients. [24] Transparency of clinical trial data may also be at stake in trade agreement negotiations. Including trade secret protection for clinical trial data in trade agreements could limit independent analysis of data and potentially compromise patient safety. [25] Craig P, Cooper C, Gunnell D, et al. Using Natural Experiments to Assess Population Health Interventions: New Medical Research Council Guidelines.
J Epidemiol Community Health. 2012;66(12):1182–6. We have identified ten types of provisions in our trade agreement dataset that could impact national pharmaceutical policy and regulation: CETA`s Government Procurement Chapter (Ch. 19) contains a similar set of rules. Canada and most European Union Member States have listed their departments or ministries of health and/or other authorities responsible for medicines. Johnson L,Sachs L. The investment chapter of the TPP: anchoring a flawed system instead of reforming it. ISCC Strategy Paper. New York: Columbia Center for Sustainable Investment; 2015. There is no doubt that future trade agreements will continue to represent a wide range of potential overlaps with pharmaceutical policy that negotiating countries will face in efforts to achieve SDG 3.8.
However, the analysis presented here shows that there is no easy progress in deepening commitments from one trade agreement to another. The suspension of certain intellectual property provisions and procedural rules applicable to pharmaceutical reimbursement programs in the CPTPP could be seen as a wake-up signal of the most extreme positions sought by the United States. However, the resurgence of even more extreme provisions in the USMCA makes it clear that if the US has central bargaining power, it will continue to push for ever stricter IPR regulation. The analysis presented here has highlighted the considerable range of provisions and pathways that require further investigation beyond the protection of intellectual property as such, with potential implications for pharmaceutical policy that go beyond issues of access and affordability. Some of these provisions (such as regulatory requirements for safety, efficacy and quality assessment; Rules for state-owned enterprises and regulatory coherence) have only recently appeared in trade agreements and have received little or no analysis and empirical research as they are only beginning to be adopted and implemented. The analytical framework proposed in Table 1 combines these provisions into a comprehensive checklist of potential determinations, pathways and impacts. The latest generations of negotiations include the Trans-Pacific Partnership (TPP), the Transatlantic Trade and Investment Partnership (TTIP), the Comprehensive Economic and Trade Agreement (CETA), the Regional Comprehensive Economic Partnership (RCEP) and the Trade in Services Agreement (TiSA). In total, more than 60 countries are participating in these negotiations, representing about 60% of the world`s gross domestic product (GDP). Given their scale, these agreements have the potential to (re)shape public health and healthcare around the world and have a significant impact on efforts to address health inequalities and the social determinants of health. [1–6] Of the eleven studies in this category, six were bivariate analyses, four were multivariate analyses and one used a natural experimental design.
Overall, the conclusion of trade agreements and the implementation of related policies were correlated with an increase in imports and consumption of edible oils, meat, processed foods and sugar-sweetened beverages. Studies on smoking have yielded mixed results. The provisions of Chapter 15 of the CPTPP/CPTPP apply for the most part only to entities listed in a number of Annexes. For most countries, the rules apply to all goods and services, except those that are expressly excluded. All TPP parties appear to have committed to giving suppliers from other TPP parties the opportunity to bid on drug purchase contracts at the national or sub-national level, or both [59]. However, to determine the amount covered by a particular country`s drug supply, a detailed analysis of all the institutions involved in the procurement of medicines in each country would be required. Commitments have also been made for public procurement by ministries of health, including procurement by public hospitals (Malaysia) and 34 public hospitals (Vietnam) [59]. Vietnam`s liberalisation of public procurement of pharmaceutical products is to be phased in over 16 years and will cover only 50% of the contract value for pharmaceutical products at the end of this period [60]. However, governments also set thresholds below which there is no obligation to liberalize a public procurement. These specifications of the various parties make it difficult to draw general conclusions as to whether a liberal tender, if the contract is large enough to exceed the threshold, will contribute to reducing the cost of medicines (through competitive prices) or, over time, to increasing the cost of medicines (initially pushing less competitive suppliers out of the market and contributing to a possible monopoly) [57]. Seventeen quantitative studies met our inclusion criteria. There was consistent evidence that the implementation of trade agreements was associated with increased consumption of processed foods and sugar-sweetened beverages.
Import licensing of patented medicines has been associated with improved access to medicines. Implementation of trade agreements and related measures was also correlated with a higher incidence of cardiovascular disease and a higher body mass index (BMI), while correlations with smoking, under-five mortality, maternal mortality and life expectancy were inconclusive. Overall, the quality of the studies is low or moderately low, and co-citation analysis revealed a relative isolation of public health from the economy. Walls HL, Smith RD, Drahos P. Improve regulatory capacity to manage risks related to trade agreements. Global health. 2015;11(14). doi.org/10.1186/s12992-015-0099-7.
Thow AM, Hawkes C. The Impact of Trade Liberalization on Food and Health: A Case Study in Central America. Global health. 2009;5(1):5. Bollyky, T. The TPP and Drug Prices: Why U.S. Trade Agreements Have Not Exported Drug Prices to the United States. Foreign Affairs, 2016.
www.foreignaffairs.com/articles/2016-03-23/dose-tpps-medicine. . . .