Introduction

An important feature of the modern global trading environment has been the establishment of a comprehensive legal and institutional foundation to regulate international trade in the context of a general desire to enhance political and economic stability. Since 1947, the General Agreement on Tariffs and Trade (GATT) has provided a rules-based regime to govern world trade, but has had limited powers of enforcement. In recognition of the expanding network and volume of world trade, the GATT evolved in 1995 into the World Trade Organization (WTO), an international organisation with the mandate to reduce trade barriers to goods and services and to mediate trade disputes between countries. Under the WTO, the rules and regulations that guide world trade are entrenched in multilateral trade agreements (MTAs) that are enforceable through a binding dispute resolution mechanism. The underlying assumption of the WTO system is that human welfare will increase through economic growth based on trade liberalisation in the context of non-discriminatory rules and transparency. From a public health perspective, this desirable goal requires linking the benefits of the global trading system to sound social policies (Drager 1999)

This chapter explores from a public health perspective the impact, actual and potential, of selected WTO MTAs on health policy, especially in low- and middle-income countries (LMICs). The purpose of this analysis is to suggest policy options for ensuring that existing, and any future, MTAs are more sensitive to public health issues.

Globalisation is among the most discussed, and is undoubtedly one of the most disputed, terms to have come into common parlance in recent years. Scholarly and popular writing about globalisation has grown exponentially over the past decade or so, spurred by often heated debates over whether or not the process is actually occurring, to what extent, for what reasons, in what forms and with what consequences. Economic globalisation has initially received the lion's share of attention, but recognition of the political, social, cultural, technological, environmental and other aspects of globalisation has rapidly grown in more recent years.

It is in the latter context that this book, which explores how health policy-making is being affected by forces broadly defined as globalisation, was conceived. Health is an important sector of most economies and a core area of social policy. For example, total expenditure on health as a proportion of Gross Domestic Product (GDP) is as high as 14 per cent in the US and is over 10 per cent in a number of additional OECD (Organization for Economic Co-operation and Development) member countries. Public expenditure on health as a proportion of total public expenditure varies widely between countries, with India and Indonesia spending 3.9 and 3.0 per cent respectively, and Andorra and Argentina spending 38.5 and 21.6 per cent respectively (WHO 2000a).

Introduction

In this concluding chapter, we focus on key lessons from the preceding chapters concerning the potential impacts of globalisation on the making of health policy, particularly policy affecting the health of populations in low- and middle-income countries (LMICs). The contested nature of the globalisation and health policy debate was touched upon in the introductory chapter. The political left and right, as well as groups in the North and South, among others, advance divergent claims, counter-claims and speculation regarding the impact of globalisation on health policy. Regrettably, these claims are too rarely based on empirical analysis. This book represents an attempt to infuse into the debate analysis on a selected range of health policy issues.

In light of our understanding of globalisation, as a set of processes that are transforming the nature of human interaction across a wide range of spheres (e.g. social, political, economic and technological) and along three dimensions of change (spatial, cognitive and temporal), we begin with the assumption that globalisation has altered the world of policy-making in tangible ways. Evidence of this is manifest in the answers to a range of questions that this concluding chapter seeks to explore. In what ways, and to what extent, can health issues be considered global? How is globalisation changing the nature of the challenges faced by policy-makers? How do determinants of health that are transnational in nature affect the type of issues on the health agenda?

Introduction

Other chapters in this book demonstrate the profound changes accompanying globalisation, which are altering the manner and the ability of nation-states (particularly in low-income countries) to formulate and implement health policy. More specifically, later chapters expose how a variety of challenges cannot be met efficiently at the national level, but require additional collective international, if not global, approaches. Moreover, the ascendancy of organised capital over the power of the nation-state adds impetus to intergovernmental co-operation. Indeed, it has been argued that: ‘short of a backlash against globalisation, states will have little choice but to pool their sovereignty to exercise public power in a global environment now mostly shaped by private actors’ (Reinicke and Witte 1999). Consequently, new multilateral institutions and instruments are being established, others reformed and some given hitherto unprecedented powers (e.g. the binding nature of the World Trade Organization Agreements), and a number of new forms of global governance are emerging. As globalisation forces a shift from state-centric politics to more complex forms of multicentred governance, and makes the desirability of global level mechanisms for the governance of global problems more apparent, a new set of challenges to the existing multilateral system comes into play.

In relation to the United Nations (UN), two trends in the nature of the emerging global governance architecture are observable, although the notion of the emergence of any system of global governance remains contested (Dodgson et al. 2000).