UNIT 3 Integration of content Nov 2011

1. UNIT 3Integration of content Nov 2011

2. Participation in tutoring sessions (Nov 1, Nov 4) Nygren-Krug. H. A forthcoming guide for policy makers: Diagnostic Tool on Trade & Health Guerrero, E., Auer, A. Godue, C. 4.3 Trade in: Approaching Topics from an International Health Perspective and the Development of a Conceptual Model. Kemm, J. Chapter 10: Health impact assessment in Health in All Policies in: Health in All Policies: prospects and principles. Ministry of Social Affairs and Health, Finland, 2006. Development of an essay 3-page essay that outlines the major trade agreements/ issues that relate to your country topic and how you propose to address these issues. You should describe how you propose to prevent or mitigate the negative impact of trade influences in your country topic. Presentation of essay on Nov 10.

3. From: “A Forthcoming Guide for Policy Makers: Diagnostic Tool on Trade & Health (WHO):The Tool builds on a joint WTO-WHO 2002 publication on WTOagreements and public health, and on current work within WHO and in selected countries to improve the understanding of, and action on, trade and health issues. Trade and Health are increasing intertwined with each other Cross-border are affecting health through an increasing number of channels: Health professionals are emigrating from resource-poor settings in search of better economic opportunities elsewhere Food price rises have increased worldwide malnutrition Prevalence of NCDs in developed and developing countries alike Infectious disease outbreaks are causing economic instability Consumers are travelling away from their home nations to receive care elsewhere In every nation, in countless ways, trade is impacting the access, quality, and affordability of health care.

4. Trade agreements have implications for health and the health sector, whether they are multilateral, bilateral, linked to the World Trade Organization (WTO), or linked to regional trading systems, such as the EC, ASEAN, SADC or NAFTA For instance, the General Agreement on Trade in Services (GATS) aims to liberalize trade in various services, including health Similarly, the Agreement on Trade-Related Intellectual Property Rights (TRIPS) affects patent protection for pharmaceutical drugs In this complex milieu of trading policies and practices, health must be protected. Member states have asked WHO for assistance in this endeavor.

5. Member states call for WHO support to analyze the impact of trade on health WHA Resolution 59.26 on international trade and health calls upon WHO: to provide assistance to Member States to frame coherent policies to address the relationship between trade and health to respond to Member States’ requests for support in their efforts to build the capacity to understand the implications of international trade and trade agreements for health and to address relevant issues through policies and legislation It also requests WHO to work with other international organizations to generate and share evidence on the relationship between trade and health.

6. To implement this resolution, WHO is developing a diagnostic tool (“Tool”) in trade and health that will guide national policymakers in: developing national policies and strategies related to trade and health; and structuring their requests for capacity building in issues related to trade and health. The Tool seeks to provide those engaged in health policy with a means to ensure that economic integration, international trade, and trade agreements contribute to improved population health and health systems. Specifically, the current draft of the Tool: • Maps the linkages between health and trade at population and individual levels; • Provides frameworks to guide policymakers seeking to achieve health and trade policy coherence; • Contains a workbook allowing readers to individually assess the means by which national health systems are impacted by trade policies; and • Provides sector-specific overviews on the impact of trade in medicines, health services, hazardous products, and foodstuffs.

8. Based on “Approaching Topics from an International Health Perspective and the Development of a Conceptual Model Organizers “ Guerrero, Auer, & Godue

9. Conceptual Model of International Health

10. Evolution of Thought on IPH Public Health International Health Global Health

11. Public Health vs International health The modern conceptualization of public health had its boom in the 50’s with the development of workshops and meetings dedicated to its analysis by PAHO/WHO academic groups. It was during this time that Departments of Public Health were created in some universities in Latin America. A significant milestone in 1970 was social medicine, with a great deal of theoretical works produced at this time.

12. In the decades of the 60’s, 70’s and 80’s, some of the most important health proposals for the 20th century were presented: primary care and health promotion. During this period, the debate was around the functionalist current of thought surrounding medical sociology. “Public health is a young social practice/discipline/social action that attempts to interpret and act on the human public or collective with the purpose of promoting their health, preventing disease and supporting the treatment and rehabilitation of their diseases by utilizing available knowledge, practices and technologies”

13. At present, public health is considered a practice whose purpose is to have an effect on the health of the people. Due to this, the public health actions that emerge from PAHO/WHO’s technical cooperation with its member countries, have been operationalized into eleven (11) essential public health functions (EPHF) The foundation for the EPHF comes from the health system competencies and these functions constitute a central point on which the States may develop their national plans, fulfilling in this manner their role as health authority.

14. Others recognize that public health is a scientific discipline that, by seeking the best health conditions for the collective, requires social collaboration and solidarity. Furthermore, health supersedes the individual by considering the responsibility of the State in intervening on the determinants of health. This view: exposes the established limits between public health and the government’s role; mentions that society is central within public health actions (which means accepting health as a social right); considers that globalization processes should define theoretical approaches that address the conditioning factors of the health and disease process, in a comprehensive manner without being limited to a focus on risk and by taking into account structural variables. highlights that health should be considered a means for social development.

15. These EPHF functions refer to: Monitoring, evaluation, and analysis of health status Surveillance, research, and control of the risks and threats to public heath Health promotion Social participation in health Development of policies and institutional capacity for public health planning and management Strengthening of public health regulation and enforcement capacity Evaluation and promotion of equitable access to necessary health services Human resources development and training in public health Quality assurance in personal and population-based health services Research in public health Reduction of the impact of emergencies and disasters on health

16. Foundations of “International Health” The concept of international health was proposed in the 80’s, bringing with it new approaches and redefinitions of public health and leading to the development of new educational models. In the year 2000, the People’s Charter for Health explicitly stated the concept of International health and highlighted the impact of the International determinants and the repercussions of trade in health on issues such as medicines and human security. The Pan-American Health Organization (PAHO/WHO) has contributed to the conceptual development of international health for more than two decades, beginning formally in 1985 with the creation of the Training Program in International Health. One important milestone was the 1992 publication of the book “International Health: A North-South Debate”: highlighted the differences in thinking between countries of the “North” and “South”, and stressed the need to move from an assistance model to one of collaboration and cooperation

17. Nation States adopted and assumed International commitments such as the Declaration of Alma-Ata (1978), The Ottawa Charter for Health Promotion (1986), the Millennium Development Goals (2000), the Social Determinants of Health (2005)13, Primary Health Care Renewal in the Americas (2007) and the Health Agenda for the Americas 2008-2017 Dr Roses at Health Agenda: The Agenda is an expression of the needs of the States to combine their efforts to decrease inequalities in health, reduce risks and guarantee social protection, all collective actions that should highlight the steering role of the States. If one were to review the goals of other declarations, they would coincide in the call to establish alliances to attain internationally agreed upon goals”. This implies that governments, economic actors (producers and sellers) and consumers establish the necessary and acceptable international regulatory mechanisms to avoid financial, technological, ethical, environmental and other risks that can affect access to health services and life conditions. Similarly, the 48th Directing Council, 60th Session of the Regional Committee of the World Health Organization for the Americas declared its interest in the area of health and International relations, in support of strengthening national capacity to improve foreign policy actions related to health and to promote the exercise of International cooperation and health diplomacy, as well as international cooperation management .

18. As such, international health is understood as the set of health interactions that take place on a global scale, the actions of which are defined based on the space in which two or more States operate (bilateral, subregional, regional or global). The concept of global health and its differences with international health is another relevant point; Although in recent years, the term “global health” is used in many cases as synonymous with “international health”, for the LIHP the terms are not equal. International health has as its main focus the Nation-State and health issues are viewed through that prism, taking into account national interests, the role and projection of the Nation-State within the international community, and the relations and balances (or imbalances) of power between countries.

19. Global health, on the other hand, is generally associated with global interdependence and collective action “The focus of global health is the impact of global interdependence on the determinants of health, the transfer of health risks and the policy response of countries, international organizations and the many other actors in the global health arena. Its goal is the equitable access to health in all regions of the globe.” It is important to note that both perspectives take into account the role of the different global actors and reaching agreements between countries. The difference is seen in the approach to the topic and the perspective from which it is analyzed It is in this context that the LIHP hopes to contribute by proposing a conceptual model that establishes a framework for studying highly complex topics that entail an increasing diversity of foci and responses due to multiple actors and interests.

20. Conceptual Model of the LIHP 2009-2010

21. The conceptual model of the LIHP is guided by the search for health as a right and the reduction of social inequalities; where political stances are integrated into a hierarchical structure that represents the defined interrelations between the center, two cross-cutting forces and four driving forces. • The center of the model is health, defined by WHO as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. In this structure, the model also implies a guarantee of the right to health, whose ultimate objective is equity in health. • The cross-cutting forces, which should be seen as a conditioning factor, are those elements that should be considered from an international health perspective when analyzing public health issues. • In this case, the two crosscutting factors are the tensions, conflicts and agreements that occur within and between States (which impede or facilitate their relationships), and international relations, defined as the space where States satisfy their interests and agree upon actions based on common interests and their populations’ wellbeing. • The driving forces are composed of those elements that could have a greater impact in ensuring the right to health and attaining health equity, viz., models of : • Development • trade, • International cooperation and health diplomacy.

22. Trade as a Driving Force Impacting on Health • Between trade and health it is important to understand those negotiations that favor health so as to improve them and the access to services, medicines and technology. Similarly, it is important to demonstrate the impact of free trade treaties, other agreements and modes of production and trade that are employed as well as the impact of illegal trade on governance and specific population groups. Definition • Trade is the practice of exchange of products, goods and services to meet the needs of human groups. This exchange and the conditions under which it is carried out have been evolving, from simple exchanges to globalized financial movements, with unequal developments in humanity.

23. Trade agreements or exchanges and their impact at every level can generate economic growth or inequalities that affect or benefit the parties involved • In the last decades, the relationship between trade and health has taken on greater relevance due to its implications for health, the environment and the quality of life of human populations • Trade can be categorized from different perspectives: its • Conceptualization—classified as production of goods or services • legal aspects—legal and illegal trade • Fairness

24. Legal Aspects • In addition to the International Health Regulations (2005), there are 4 multi-lateral multilateral trade agreements defined by the World Trade Organization (WTO) that are especially important for the area of health: • The General Agreement on Trade in Services (GATS) • The agreements on the Application of Sanitary and Phytosanitary Measures (SPS) • The agreements on Technical Barriers to Trade (TBT) • The agreements on the Trade-Related aspects of Intellectual Property Rights (TRIPS) NOTE: The International Health Regulations (IHR) are an international legal instrument that is binding on 194 countries across the globe, including all the Member States of WHO. Their aim is to help the international community prevent and respond to acute public health risks that have the potential to cross borders and threaten people worldwide.

25. Illegal Trade • The illegal market, illegal trade, black market or underground economies are terms utilized to describe the clandestine and illegal sale of goods, products or services, and violations in terms of price fixing or of legislation or ethical standards imposed by the governments. • The black market does not consist exclusively of necessary products: • countries that prohibit, restrict or allow their sale increase their prices, as has occurred with tobacco and alcohol, leading to the emergence of people that introduce these products illegally. This also includes trade of children and women, and the sale and purchase of drugs, arms and other illegal substances.

26. Fairness • Fairness refers to fair trade and unfair trade. • Fair trade is an alternative form of trade that promotes a voluntary commercial and just relationship between the parties. This type of trade is encouraged by several non-governmental organizations, the United Nations system and various social and political movements • Unfair trade denotes those commercial strategies where there is an asymmetry and/or subordination between the parties. • A paradigm of unfair trade is the exploitation of primary resources controlled by transnational corporations where most of the benefits from the commercialization of the product do not transfer to the producing country. • Within these 2 classification there are actors that implement actions in one direction or the other: economic blocks; transnational companies; financial sector; criminal organizations; logistics and transportation companies; national governments; regional, subregional, bilateral and multilateral organizations; the WTO; social movements and human rights organizations.

27. Examples of Relationships between Health and Trade 1. Food Trade • Food trade, depending on its quality, quantity and price, enables or not access to populations, resulting in well-nourished or malnourished societies according to their consumption. • Food trade has transformed cultures and subcultures, modifying habits and customs that today are primary sources of obesity, chronic diseases and malnourishment, among others. • In the same way, production methods that use or don’t use agrochemicals or that modify food production in the livestock, poultry or pork industries have generated conditions that can lead to increased risk factors and some pandemics.

28. 2. Trade in alcohol and tobacco • Trade in alcohol and tobacco is an additional factor that causes risk for chronic illnesses, addiction and road-side accidents. 3. The trade of land and housing affects civility and coexistence, and leads to large groups of humans living in substandard conditions. 4. Trade in transportation and the type of fuel used has modified routines, time management and life in urban centers and has increased pollution levels.

29. 5. The illegal drug and arms trade is one of the biggest problems in modern societies. It is a source of corruption and ethical deviances that affects governance in countries. 6. Trade in technology, legal medicines and biotechnology, including patents, generates tension and conflict related to access and the model of health care. 7. Finally, imbalances emerge and inequalities increase with the sale and purchase of stock in the financial market, with implications for the creation and limitation of jobs, fluctuations in currency value and the external debt of nations and its effects of accumulation or deaccumulation.

30. To analyze the impact of trade on health it is necessary to address the following questions: • What is the impact of trade relations on governance, quality of life and the health of populations? • What type of interaction/approximation/alignment should national foreign policy have with regards to trade and health? • How does trade affect access to health services, technology and, particularly, drugs? • How does food trade affect the development of chronic diseases? • How could an increase in "free trade" affect equity in health? • How can developing countries align to obtain greater benefits with regards to health and development?

31. In addressing these questions it is imperative that the following 5 issues are considered: • Power and actors’ interests. It is necessary to identify the stance and interest of the countries in relation to the trade negotiations that are established, who benefits from them, and cite the existing regulation (whether they support the negotiations or not). In the same manner, the role of the WTO should be noted as well as that of other actors that influence trade between States, such as pharmaceutical and food production industries, global funds, partnerships, international organizations and NGOs. • Financial and economic policies of the country or countries. At thenational level we should contextualize the existing policies, taking into account their advantages and disadvantages given the international context and country project topic. For example, in relation to access to medicines, one question might be: What has the government proposed to achieve universal coverage? What guidelines have been implemented following the signature of WTO agreements? What strategies has the government established to mitigate possible limitations?

32. Relevant agreements. In the international arena, countries reach agreements and sign treaties they expect to benefit from. Therefore, these should be analyzed according to the impact they have on the country project. The agreements should be considered as well as the benefits that they expect to produce. • International cooperation. An analysis of cooperation from a trade point of view should take into account technical or financial actions that impact the country project. For example, one might consider donations of medicines or of funds to purchase the same; licenses on the production of medicines; or related agreements and projects within regional or subregional integration bodies. • Health system. The principles or characteristics of the health system can limit or facilitate access of the population to health services. Given that health has a broader and more complex dimension, the analysis of trade should not be limited to access to medicines, despite the recognition that it is an important topic within trade.

33. See pp 54-57 for Applications of this Methodology to Analyzing Country Specific Issues Thank You