Globalization and Health Knowledge Network: Research Papers Towards Health-Equitable Globalisation: Rights, Regulation and Redistribution Final Report to the Commission on Social Determinants of Health Globalization Knowledge Network Final Report to the Commission on Social Determinants of Health 1 Preface The Globalization Knowledge Network (GKN) was formed in 2005 with the purpose of examining how contemporary globalization was infl uencing social determinants of health. It was one of nine Knowledge Networks providing evidence-informed guidance to the work of the World Health Organization’s Commission on Social Determinants of Health (2005-2008): like most of the Knowledge Networks, its operations were fi nanced by an external funder (in this case, the International Affairs Directorate of Health Canada, Canada’s national ministry of health). The GKN conducted two face-to-face meetings to debate, discuss, outline and review its work, and produced thirteen background papers and a Final Report. These papers and the Final Report underwent extensive internal and external peer review to ensure that their fi ndings and policy inferences accurately refl ected available evidence and scholarship. This GKN publication series was prepared under the general editorship of Ronald Labonté, with assistance from Vivien Runnels and copy-editing provided by Wayne Harding. All views expressed are exclusively those of the authors. A complete list of titles in the publication series appears on the inside back cover of this monograph. Acknowledgments and disclaimers This report is the product of some 16 months’ work by a large number of people. The efforts of all writing groups (see pages 81-84); a large number of external reviewers (see page 85); and Corinne Packer, Vivien Runnels, Kirsten Stoebenau, Elizabeth Venditti and Joëlle Walker at the Institute of Population Health Hub have been indispensable. This work was made possible through funding provided by Health Canada and the World Health Organization (WHO), and undertaken as work for the Globalisation Knowledge Network established as part of the WHO Commission on the Social Determinants of Health. The views presented in this fi nal report are those of the authors and do not necessarily represent the decisions, policy or views of WHO or Commissioners. June 2007 Globalization and Health Knowledge Network: Research Papers Towards Health-Equitable Globalisation: Rights, Regulation and Redistribution Final Report to the Commission on Social Determinants of Health Globalization Knowledge Network Ronald Labonté (Chair) Ted Schrecker (Hub coordinator) Final Report Writing Group: Ronald Labonté (Lead author) Chantal Blouin Mickey Chopra Kelley Lee Corinne Packer Mike Rowson Ted Schrecker David Woodward Drafting Assistance: Patrick Bond Giovanni Andrea Cornia Carlos Correa Corinna Hawkes Meri Koivusalo John Lister Vivien Runnels David Sanders Kirsten Stoebenau Sebastian Taylor Zoë Wilson Additional Technical Assistance: Joëlle Walker Elizabeth Venditti Note: UK spelling is used in the Final Report as requested by the Commission on Social Determinants of Health; Layout and Design: Canadian spelling is used in all of the background papers. Rhonda Carscadden: rhocaDESIGNS.com Table of contents Acknowledgements and disclaimers 2 Table of acronyms 6 Executive summary 8 1. Introduction: Globalisation’s challenges to reducing health inequities 16 1.1 Focus on the global marketplace 17 1.2 Globalisation and social determinants of health: Mapping the linkages 18 1.3 The importance of being clear about policy goals 19 1.4 Globalisation’s contested gains: It all depends 20 1.5 What is left out 22 2. Globalisation’s role in increasing health inequalities: An overview 24 3. Globalisation and health (in)equity: Key pathways and policy implications 30 3.1 Globalisation magnifies asymmetries in power and resources 30 3.1.1 Initial endowments and primary commodity traps 32 3.1.2 Global labour markets 32 3.1.3 Global market integration and national policy space 37 3.2 The global marketplace: Trade liberalisation 39 3.2.1 Economic insecurity 40 3.2.2 Declines in public revenues 42 3.2.3 Trade in health services 44 3.2.4 Food insecurity 45 3.3 The global marketplace: Aid and investment 46 3.3.1 Official development assistance (ODA) 49 3.3.2 External debt and debt reduction 52 3.3.3 Old conditionalities in new bottles? The PRSP process and the expenditure ceilings debate 55 3.4 The global marketplace and basic needs 59 3.4.1 Globalisation and health systems change 59 3.4.2 Globalisation and health human resources (HHR) 62 3.4.3 Globalisation of intellectual property rights 64 3.4.4 Globalisation and nutrition transitions 66 3.4.5 Globalisation, safe water and sanitation 68 3.5 Politics matters – or, asymmetry is not destiny 71 4 Globalization and Health Knowledge Network 4. Policy directions: Rights, regulations, redistribution and reformed governance 73 4.1 A general theme: Regulation, rights and redistribution 74 4.2 Global governance for health equity and SDH: Getting there from here 74 4.2.1 Improving institutions of global governance 74 4.3 Linking institutions and principles: Human rights and health equity 79 4.4 Linking institutions and principles: New sources of financing 80 4.5 Coda 81 Globalisation Knowledge Network members 82 Globalisation Knowledge Network papers and writing groups 83 List of reviewers of GKN commissioned papers 86 Appendix 1: Globalisation and social determinants of health: conceptual model 87 and Key research questions Appendix 2: Gains and losses of average LEB by 2000 due to policies introduced in the 1980s and 1990s and to random shocks 89 Appendix 3: Case studies 1. Health decline in the former Soviet Union 90 2. Export-oriented employment in Bangladesh 90 3. The Self-Employed Women’s Association (India) 91 4. Financial markets, implicit conditionality and social policy: The case of Brazil 91 5. Lessons on social protection from the Indian experience 91 6. Expanding trade in health services: Lessons from the Thai experience 92 7. Cuba and the Philippines: A tale of two HHR exporters 93 Appendix 4: Mapping and criteria, global governance for health equity 96 References 98 Final Report to the Commission on Social Determinants of Health 5 Table of Acronyms ADF The African Development Fund AIDS Acquired Immunodeficiency Syndrome ATTAC Association for the Taxation of Financial Transactions for the Aid of Citizens/ Association pour la taxation des transactions financières pour l’aide aux citoyennes et citoyens BMI Body Mass Index CEOs Chief Executive Officers CGD Center for Global Development CIPIH Commission on Intellectual Property Rights, Innovation and Public Health CPIA Country Policy and Institutional Assessment CSDH Commission on Social Determinants of Health CSOs Civil Society Organisations CTDL Currency Transaction Development Levy CVD Cardiovascular Disease DAC Development Assistance Committee DHS Demographic and Health Survey DPT Diphtheria, Pertussis, and Tetanus vaccine DRC Democratic Republic of Congo ECLAC United Nations Economic Commission on Latin America and the Caribbean ECOSOC United Nations Economic and Social Council EEA European Economic Area EFTA European Free Trade Association EPZ Export Processing Zones EQUINET Regional Network on Equity in Health in Southern Africa ESCAP UN Economic and Social Commission for Asia and the Pacific EU European Union FAO Food and Agriculture Organisation of the United Nations FCTC Framework Convention on Tobacco Control FDI Foreign Direct Investment FTAs Free Trade Agreements G10 Group of 10 G7 Group of 7 G8 Group of 8 GATS General Agreement on Trade in Services GATT General Agreement on Tariffs and Trade GAVI Alliance (formerly known as) the Global Alliance for Vaccines and Immunisation GBS General Budget Support GDP Gross Domestic Product GDP/capita Gross Domestic Product per capita GFATM The Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria GKN Globalisation Knowledge Network GNI Gross National Income GNP Gross National Product GPGHs Global Public Goods for Health GPGs Global Public Goods GPPPs Global Public-Private Partnerships HHR Health Human Resources HIPCs Heavily Indebted Poor Countries HIV Human Immunodeficiency Virus HIV/AIDS Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) HRBA Human Rights-Based Approach HSR Health Sector Reform ICT Information and Communications Technologies IDA The International Development Association IDPF International Drug Purchase Facility IEO Internal Evaluation Office IFF International Finance Facility 6 Globalization and Health Knowledge Network IFIs International Financial Institutions IFPRI International Food Policy Research Institute ILO International Labour Organisation IMF International Monetary Fund IMR Infant Mortality Rate IPRs Intellectual Property Rights IT Information Technologies IUATLD International Union Against Tuberculosis and Lung Disease IWRM Integrated Water Resources Management, Integrated Water Resource Management LDCs Least Developed Countries LEB Life Expectancy at Birth MAI Multilateral Agreement on Investment MDGs Millennium Development Goals MDRI Multilateral Debt Relief Initiative M-EGS Maharashtra Employment Guarantee Scheme MENA Middle East and North Africa NAMA Non-Agricultural Market Access NPV debt Net Present Value of Debt ODA Official Development Assistance OECD Organisation for Economic Co-operation and Development OPEC Organisation of the Petroleum Exporting Countries PHM People’s Health Movement POEA Philippine Overseas