1. International Trade and Health Towards Policy Coherence
Nick Drager M.D., Ph.D.
Senior Adviser
World Health Organization

2. International Trade and Health Towards Policy Coherence
Overview of trade and health ; WHO's work
Policy Coherence : national /global
Policy coherence and the future global health architecture

3. Public Health in a Globalizing World
Health issues are central to the global policy agenda
Improving health outcomes are critical to achieving the MDGs
Countries must take into account cross border spill-ins and spill- overs when crafting health policies
Domestic action alone - no longer sufficient to protect population health - collective action essential
New context (rules, actors, markets, tools) requires new responses
Context for our work in trade and health
Doha round and public health - agreement on public health and TRIPS was key to agreeing to a new trade round

4. rules and institutions health-related sectors
Globalization
goods, services,
capital, people,
ideas, information
economic opening
cross-border flows
international
rules and institutions
national economy and
health-related sectors
Globalisation: the growing integration of economies and societies around the world
Happening across a wide range of spheres-(and driven by events and current thinking in these spheres) political, social , technological environmental and – illustrated here- economic
Context for trade and health
our concern remains improving health outcome
illustrates the increased complexity globalization brings- now important to understand and act upon distal determinants - such as new trade rules
interaction between trade rules and heath sovereignty
what do they do to domestic policy and regulatory space to protect and promote public health
risk
factors
health
services
household
economy
HEALTH

5. Specific Health Issues & most relevant WTO Agreements
WHO
Specific Health Issues & most relevant WTO Agreements
ETH/SDE
WTO RULES
SPS
TBT
TRIPS
GATS
HEALTH ISSUES
Infectious disease control *
Food safety
Tobacco control
Environment
Access to drugs
Health services
Food security
Emerging issues
Biotechnology
Information Technology
Traditional knowledge

6. WTO accession negotiations and health
Health Issue
WTO Rule
Action required
Health services
GATS
Law on Medicine- create clear regulatory environment for trade in services
In hospital and medical and dental services - legally binding with no restrictions on e-health; movement of consumers ; open to foreign service suppliers (limits on MA; no limits on NT)
Food safety
SPS
11 obligations: regulations governing animal and plant health and food safety shall be based on scientific evidence; risk assessment to ensure measures based on science;  follow international standards
Access to drugs
TRIPS
New patent law being drafted - ensure TRIPS compliance

7. Health Rules and Trade Rights of IHR and obligations of MTAs(SPS)
Issuance of WHO under IHR - temporary or standing recommendations
Gives states the authority to implement trade affecting measures
May conflict with obligations under MTAs depending on the recommendations content
Obligations in the SPS agreement impose science based and trade related disciplines
Would be unlikely that WHO would recommend to states to implement measures that are significantly more trade restrictive then necessary and that recommendations would be based on risk assessment or best available evidence

8. Overlapping African agreements…
Nile River Basin
ECCAS
COMESA
IGAD
AMU
CEMAC
Algeria
Libya
Morocco Mauritania
Tunisia
Somalia
Sao Tomé & Principe
Egypt
Cameroon
Central African Rep.
Gabon
Equat. Guinea
Rep.Congo
ECOWAS
Djibouti
Ethiopia
Eritrea
Sudan
Conseil de
L’Entente
Burundi*
Rwanda*
Ghana
Nigeria
Cape Verde
Gambia
Chad
DR Congo
Kenya*
Uganda*
Benin Niger
Togo Burkina Faso
Cote d’Ivoire
Angola
Guinea-Bissau Mali
Senegal
EAC
Liberia
Sierra Leaone Guinea
Tanzania*
Mauritius*
Syechelles*
Malawi*
Zambia*
Zimbabwe*
WAEMU
SACU
Mano River Union
Comoros*
Madagascar*
CLISS
AMU: Arab Maghreb Union
CBI: Cross Border Initiative
CEMAC: Economic & Monetary Community of Central Africa
CILSS: Permanent Interstate Committee on Drought Control in the Sahel
COMESA: Common Market for Eastern and Southern Africa
EAC: East African Cooperation
ECOWAS: Economic Community of Western African Studies
IGAD: Inter-Governmental Authority for Government
IOC: Indian Ocean Commission
SACU: Southern African Customs Union
SADC: Southern African Development Community
WAEMU: West African Economic & Monetary Union
South Africa
Botswana
Lesotho
Namibia*
Swaziland*
Reunion
*CBI
Mozambique
SADC
IOC

9. Much common ground between trade and health
Health concerns can take precedence over trade issues

10. Trade in Health Services
Opportunity
Risk
Mode 1
Cross border supply of services
Increased care to remote and under served areas
Diversion of resources from other health services
Mode 2
Consumption abroad
Generates foreign exchange earnings for health services of importing country
Crowding out of local population and diversion of resources to service foreign nationals
Mode 3
Commercial presence
Creates opportunities for new employment and access to new technologies
Development of two tiered health system with an internal brain drain
Mode 4
Presence of natural persons
Economic gains from remittances of health care personnel working overseas
Permanent outflows of health personnel, with loss investment in educating and training such personnel

11. Interest of ASEAN countries on regional trade in health services
Mode
Export
Import
1 cross border
supply
No real interest
2 consumption
abroad
Singapore,
Malaysia,
Thailand
Indonesia, Cambodia,
Laos, Brunei, Myanmar,
Brunei
3 commercial
presence
Thailand, Indonesia,
Philippines, Vietnam,
Laos, Cambodia,
Myanmar
4 movement of
natural person
Philippines,
Indonesia
Singapore, Brunei,

12. Export of health tourism services
Export revenues
Number of patients
Origin of patients
Malaysia
(2003)
RM 150 million
($40 million)
More than 100,000
60 percent from Indonesia, 10 percent from other ASEAN countries
Singapore (2002)
$420 million
210,000
45 percent from Indonesia, 20 percent from Malaysia, percent from other ASEAN countries
Thailand
Around 20 billion baht in 2003
($482 million)
470,000 (2001)
630,000 (2002)
42 percent from the Far East (mostly Japan), 7 percent from ASEAN countries

13. The House that GATS Built
Trade Liberalization
Preservation of the Right to Regulate Services
Multilateral Framework
Side Wall:
Market Access
Commitments
Back Wall:
Exceptions
GATS
(Services)
Side Wall:
National Treatment
Commitments
Front Wall:
General
Obligations
and
Disciplines
GATS Council
Floor:
Dispute Settlement

16. Trade in Health Services

17. National Policy Coherence

18. Trade and Health elements of a country analysis
priority trade and health issues: policies, regulatory environment and standards
trade in health goods
trade in health related services
trade agreements and on going negotiations
institutional capacity
domestic policy coordination

19. Global Policy Coherence WHO/WTO collaboration
high level policy consultations
governance meetings
research and analysis
country missions
regional, national meetings
training courses
informal consultations

20. Global Policy Coherence some current global health and trade issues
Avian flu /flu pandemic
IP commission report follow up
TRIPS para 6 implementation
GATS request/offers
Implementation of WHA trade and health resolution

21. International Trade and Health WHA Resolution 59.26
The Fifty-ninth World Health Assembly,
Having considered the report on international trade and health1;
Recalling resolutions WHA52.19, WHA53.14, WHA56.23, WHA56.27, WHA57.14 and WHA57.19;
Recognizing the demand for information about the possible implications of international trade and trade agreements for health and health policy at national, regional and global levels;
Mindful of the need for all relevant ministries, including those of health, trade, commerce, finance and foreign affairs, to work together constructively in order to ensure that the interests of trade and health are appropriately balanced and coordinated,
1 Document A59/15

22. International Trade and Health WHA Resolution 59.26
to promote multi-stakeholder dialogue at national level to consider the interplay between international trade and health;
to adopt, where necessary, policies, laws and regulations that deal with issues identified in that dialogue and take advantage of the potential opportunities, and address the potential challenges that trade and agreements may have for health, considering, where appropriate, using the flexibilities inherent in them;
to apply or establish, where necessary, coordination mechanisms involving ministries of finance, health, and trade, and other relevant institutions, to address public health related aspects of international trade;
to create constructive and interactive relationships across the public and private sectors for the purpose of generating coherence in their trade and health policies
to continue to develop capacity at national level to track and analyse the potential opportunities and challenges of trade and trade agreements for health-sector performance and health outcomes;

23. International Trade and Health WHA Resolution 59.26
to provide support to Member States, at their request and in collaboration with the competent international organizations, in their efforts to frame coherent policies to address the relationship between trade and health;
to respond to Member States' requests for support of 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 that take advantage of the potential opportunities, and address the potential challenges, that trade and trade agreements may have for health;
to continue collaborating with the competent international organizations in order to support policy coherence between trade and health sectors at regional and global levels, including generating and sharing evidence on the relationship between trade and health;
to report to the Sixty-first World Health Assembly, through the Executive Board, on progress made in implementing this resolution.

24. Global Health Governance Mapped
ISSUE
Media
Epistemic communities
Individuals
Social movements
UNFPA
UNICEF
Research institutions
ILO
WTO
Developing countries
Developed countries
Religious groups
TNCs
UNDP
NGOs
IMF
World Bank
WHO
CENTRE

25. Shaping the architecture for GHG: Challenges
Given
rapidly changing global context
shift in patterns of disease
improved understanding of the social and economic determinants of health
diversity of institutional actors
Need
to address factors which cross, and even ignore the geographical boundaries of the state
to define and address the determinants of health from a multi-sectoral perspective
to involve both formally and informally a broader range of actors and interests –bring together state and non-state actors (FCTC. IHR, GPPPs- ? accountability to GHA)

26. Shaping the architecture for GHG: Challenges
Need to agree on the normative framework upon which GHG can be built- consensus on underlying moral and ethical principles that define global health cooperation: universalism; health as a human right, justice and dignity
Define leadership and authority of GHG - willingness of states to pool sovereignty and act collectively
Generate sufficient resources (dual track budgets) for global health cooperation and distribute them appropriately according to agreed priorities – GPGH lens-
Need for effective monitoring, accountability

28. Working Towards Trade and Health Policy Coherence for Human Development institutional challenges
common understanding of the key trade and health policy issues through ongoing dialogue
clear commitment and MOH leadership to work towards trade and health policies that mutually support human development objectives
sustainable institutional mechanisms to enhance coherence and use innovative instruments and appropriate incentives
early and effective stakeholder involvement, building trust , importance of transparency,
get the evidence right, costing and financing options, proposing alternatives
measure, track, and evaluate progress and make course corrections
develop negotiation skills

30. Globalization, Trade and Health
Website
who.int/trade/
Thank-you