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Trade and Health andTrade and Health andthe Bretton Woods Familythe Bretton Woods Family
David LeggeDavid Legge
International People’s Health UniversityInternational People’s Health University
November 2007November 2007
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The Bretton Woods family (1944)The Bretton Woods family (1944)
International Monetary Fund (IMF)International Monetary Fund (IMF) World Bank (WB)World Bank (WB) World Trade Organisation (from 1995)World Trade Organisation (from 1995)
replacing the General Agreement on Tariffs and replacing the General Agreement on Tariffs and Trade (GATT)Trade (GATT)
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International Monetary FundInternational Monetary Fund
1944+: created in order to lend to countries to prevent 1944+: created in order to lend to countries to prevent currency fluctuations due to short term imbalances in trade currency fluctuations due to short term imbalances in trade flowsflows
1950s - 1980s: private sector international financial 1950s - 1980s: private sector international financial institutions take over short term trade financing (a fund institutions take over short term trade financing (a fund without a function?)without a function?)
1970s - 1980s: Third World Debt Crisis 1970s - 1980s: Third World Debt Crisis new role for IMF as lender of last resort and world new role for IMF as lender of last resort and world
economic policemaneconomic policeman
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The debt crisis and ‘structural The debt crisis and ‘structural adjustment’adjustment’
1973 OPEC oil price rises1973 OPEC oil price rises 1973 - 1980 Loan salesmen on the loose (negative 1973 - 1980 Loan salesmen on the loose (negative
interest rates!)interest rates!) 1981 Reagan, monetarism and interest rates1981 Reagan, monetarism and interest rates IMF ‘structural adjustment packages’IMF ‘structural adjustment packages’ The World Bank joins the Fund in policing the debtThe World Bank joins the Fund in policing the debt 1999 Structural adjustment replaced by ‘Poverty 1999 Structural adjustment replaced by ‘Poverty
reduction strategy papers’reduction strategy papers’
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Structural adjustmentStructural adjustment Cuts in public spendingCuts in public spending Removal of price controlsRemoval of price controls Freezing of wagesFreezing of wages Emphasis on production for exportEmphasis on production for export Import liberalisation Import liberalisation Incentives for foreign investmentIncentives for foreign investment Privatisation of public sector servicesPrivatisation of public sector services Devaluation (to make exports cheaper)Devaluation (to make exports cheaper)
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Impacts of structural adjustmentImpacts of structural adjustment Widening of inequalitiesWidening of inequalities Reduced purchasing power for the poor (increased prices, Reduced purchasing power for the poor (increased prices,
withdrawal of subsidies, freezing of wages)withdrawal of subsidies, freezing of wages) Downsizing of public sectorDownsizing of public sector Lowering the safety netLowering the safety net User pays in health careUser pays in health care Reduced support for subsistence agricultureReduced support for subsistence agriculture Economic growth (in some cases)Economic growth (in some cases)
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Criticism of the impact of SAPs on health in Criticism of the impact of SAPs on health in developing countriesdeveloping countries
Health dimensions of economic reform (WHO, 1992)
Breman and Shelton (2001) Structural adjustment and health: a literature review of the debate, its role-players and presented empirical evidence
http://www.cmhealth.org/docs/wg6_paper6.pdf
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Poverty Reduction Strategy PapersPoverty Reduction Strategy Papers
SAPs reinventedSAPs reinvented Country governments required to devise their Country governments required to devise their
own SAPsown SAPs IMF funding is still contingent on neo-liberal IMF funding is still contingent on neo-liberal
‘reforms’‘reforms’
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World BankWorld Bank
1944+: to fund large scale development projects (in 1944+: to fund large scale development projects (in developed world)developed world)
1950s - 1980s: private sector funding takes over long 1950s - 1980s: private sector funding takes over long term capital funding (for developed world); WB term capital funding (for developed world); WB attention shifts to developing countriesattention shifts to developing countries
1980s+: WB joins IMF in managing Third World 1980s+: WB joins IMF in managing Third World debtdebt
1990s+: WB becomes major development assistance 1990s+: WB becomes major development assistance funder (far surpasses WHO as a donor to health funder (far surpasses WHO as a donor to health projects)projects)
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‘‘Investing in Health’ (WB, 1993)Investing in Health’ (WB, 1993) Response to criticism of impact of SAPs on Response to criticism of impact of SAPs on
healthhealth Reconciling structural adjustment with health Reconciling structural adjustment with health
improvement?improvement? health improvement despite povertyhealth improvement despite poverty proceeding with SAPs regardlessproceeding with SAPs regardless
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Trade regulationTrade regulation
1944 - 1995 GATT 1944 - 1995 GATT progressive re-negotiation of international agreements on progressive re-negotiation of international agreements on
tariffstariffs slow progress towards trade liberalisation (especially slow progress towards trade liberalisation (especially
manufactured goods)manufactured goods) 1995:1995:
finalisation of the Uruguay Round of GATT negotiationsfinalisation of the Uruguay Round of GATT negotiations establishment of World Trade Organisationestablishment of World Trade Organisation
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World Trade OrganisationWorld Trade Organisation
Established 1995, based in GenevaEstablished 1995, based in Geneva 141 member countries141 member countries StructuresStructures
Director-GeneralDirector-General Secretariat Secretariat Ministerial ConferenceMinisterial Conference General Council General Council specific councilsspecific councils Disputes Settlements Body (DSB)Disputes Settlements Body (DSB)
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AgreementsAgreements
Multilateral Agreements on Trade in Goods (13)Multilateral Agreements on Trade in Goods (13) General Agreement on Trade in Services (GATS)General Agreement on Trade in Services (GATS) Agreement on Trade-related Intellectual Property Agreement on Trade-related Intellectual Property
Rights (TRIPs)Rights (TRIPs) Understanding on Rules and Procedures Understanding on Rules and Procedures
Governing the Settlement of Disputes (DSU)Governing the Settlement of Disputes (DSU) Trade Policy Review Mechanism (TPRM)Trade Policy Review Mechanism (TPRM) (non mandatory) agreements (5)(non mandatory) agreements (5)
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Agreements on Trade in GoodsAgreements on Trade in Goods
General Agreement on Tariffs and Trade (GATT) General Agreement on Tariffs and Trade (GATT) Agriculture (AoA)Agriculture (AoA) Sanitary and phyto-sanitary measures (SPS)Sanitary and phyto-sanitary measures (SPS) Textiles and clothingTextiles and clothing Technical barriers to trade (TBT)Technical barriers to trade (TBT) Trade Related Investment Measures (TRIMs)Trade Related Investment Measures (TRIMs) Anti dumping agreementAnti dumping agreement Rules of originRules of origin Import licensingImport licensing Subsidies and countervailing measuresSubsidies and countervailing measures
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Non-mandatory AgreementsNon-mandatory Agreements
Trade in civil aircraftTrade in civil aircraft Government procurementGovernment procurement Dairy agreementDairy agreement Bovine meatBovine meat
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Disputes between trading partnersDisputes between trading partners
““Disputes” the heart of the WTO systemDisputes” the heart of the WTO system Member states can bring complaints before the Member states can bring complaints before the
DSB that one or more of its trading partners is DSB that one or more of its trading partners is violating some (of the 24,000 pages of) WTO violating some (of the 24,000 pages of) WTO agreementsagreements
PenaltiesPenalties payment of compensation to the foreign payment of compensation to the foreign
government or corporationgovernment or corporation retaliatory trade restrictions on exports from the retaliatory trade restrictions on exports from the
offending nationoffending nation
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Dispute resolution principlesDispute resolution principles
Least trade restrictive regulationLeast trade restrictive regulation Voluntary rather than compulsoryVoluntary rather than compulsory Consumer information rather than bansConsumer information rather than bans Individual rather than public Individual rather than public
responsibilityresponsibility
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Asbestos case (September 2000)Asbestos case (September 2000)
January 1997. Ban on the manufacturing, processing January 1997. Ban on the manufacturing, processing and sale of asbestos within France and sale of asbestos within France
Canada complains to WTO: ban is illegal because it Canada complains to WTO: ban is illegal because it damaged Canadian economic interests and was a damaged Canadian economic interests and was a barrier to free tradebarrier to free trade
September 2000. WTO rules that the ban is a barrier September 2000. WTO rules that the ban is a barrier to free trade but that it is legal on health grounds to free trade but that it is legal on health grounds
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EC Sugar case (2005)EC Sugar case (2005)
Australia Brazil and Thailand complained that Australia Brazil and Thailand complained that EC subsidising the production of sugar for EC subsidising the production of sugar for exportexport
Panel appointed by DSB under DSU Panel appointed by DSB under DSU EC appealed Panel decisionEC appealed Panel decision AB supported Panel findings under AoA but AB supported Panel findings under AoA but
criticised it for not determining challenge criticised it for not determining challenge under SCM Agtunder SCM Agt
AB finding supported by DSBAB finding supported by DSB
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AgreementsAgreements particularly relevant to healthparticularly relevant to health
AgricultureAgriculture GATSGATS TRIPsTRIPs SPSSPS TBTTBT
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Agreement on AgricultureAgreement on Agriculture
Not focused on healthNot focused on health But damaging to people’s health in agricultural But damaging to people’s health in agricultural
exporting countries (including very poor countries) exporting countries (including very poor countries) are:are: agricultural barriers to rich country markets (Eu, Japan and agricultural barriers to rich country markets (Eu, Japan and
US), US), subsidies in those markets to support local producers (and subsidies in those markets to support local producers (and
exporters) and exporters) and dumping by rich countries in poor country markets dumping by rich countries in poor country markets
including in producer countriesincluding in producer countries
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rich world protection, domestic support and
export siubsidy
loss of agricultural income
over supply (push to export ag)
low prices for dev country farmers
weak demandlow volumes
rural poverty
health effects of poverty (rural and urban) and displacement
widening income inequalities
weakening of social solidarity: public expenditure and
public policy
rural urban migration
urban poverty (reserved army of
unemployed)
low wages
cheapfood in cities
growth in unskilled labour intensive
export processing
rise of urban middle class business, skilled
staffImpact of Rich World Dumping and Protection
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Protección del mundo rico, apoyo doméstico
y subsidio a exportaciones
Pèrdida de ingreso por agriculturaSobre-abastecimiento
(impulsa export. ag)
Precios bajos para los agricultures PD
Baja demandaPoco volumen
Pobreza rural
Efectos en salud por la pobreza
(rural y urban) y desplazamiento
Incremento de las inequidades en
ingresos
Debilitamiento en solidaridad: gasto público y política
públicas
Migración rural-urb.
Pobreza urbana (ejército de
desempleados)
Salario bajo
Alimentos baratos en ciudades
Crecimiento en mano de obra no
cualificada/intensiva y exportaciones
Incremento en personal calificado de clase
media
Impacto del Dumping y protecionismo del Mundo Rico
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GATSGATS
All servicesAll services Most-favoured-nation (MFN) principle (allow one Most-favoured-nation (MFN) principle (allow one
country in; allow all members in)country in; allow all members in) transparency (accessible data bases of laws and transparency (accessible data bases of laws and
regulations)regulations) Specified servicesSpecified services
market accessmarket access national treatment (eg subsidies)national treatment (eg subsidies)
Ratchet function and schedule for extensionRatchet function and schedule for extension
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What are services?? What are services??
Trade and tourismTrade and tourism Business, professional and technical Business, professional and technical TelecommunicationsTelecommunications Asset management Asset management EducationEducation Medical servicesMedical services EnergyEnergy ConstructionConstruction
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‘‘Modes of supply’ Modes of supply’ (for specified commitments)(for specified commitments)
Cross border supply (telemedicine)Cross border supply (telemedicine) Consumption abroad (patients travel Consumption abroad (patients travel
abroad)abroad) Commercial presence (foreign owned Commercial presence (foreign owned
health insurance, foreign owned health health insurance, foreign owned health care corporations)care corporations)
The presence of natural persons (flying The presence of natural persons (flying doctors)doctors)
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(1) cross border supply, (2) consumption abroad, (3) commercial presence, (4) presence of natural persons
Market access National Treatment Comments
8. HEALTH RELATED AND SOCIAL SERVICES B. Other human health services Covers podiatry and chiropody services. Includes podiatry services carried out in health clinics, residential health facilities other than hospitals as well as in own consulting rooms, patients’ homes or elsewhere
(1) Unbound (2) None (3) None (4) Unbound except as indicated in the horizontal section
1) Unbound (2) None (3) None (4) Unbound except as indicated in the horizontal section. Permanent residency requirement for chiropodists (South Australia). Permanent residency requirement for podiatrists (Western Australia).
Australia’s health-related GATS commitmentsAustralia’s health-related GATS commitments
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The GATS renewalThe GATS renewal
Criticisms of GATS 1994 by financial services Criticisms of GATS 1994 by financial services industryindustry
Article XIX. Commitment to renegotiation from Article XIX. Commitment to renegotiation from 20002000
Current renegotiations Current renegotiations preparatory “issue identification” phase (from January preparatory “issue identification” phase (from January
2000)2000) request / offer phase (30 June 2002 / 31 March 2003)request / offer phase (30 June 2002 / 31 March 2003) formalisation (1 January 2005)formalisation (1 January 2005)
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Apprehensions about the renewal of GATSApprehensions about the renewal of GATS
Non-democratic processes of the WTONon-democratic processes of the WTO what is happening behind closed doors?what is happening behind closed doors?
Privatisation of health care?Privatisation of health care? stratified health insurance arrangementsstratified health insurance arrangements stratified health care provisionstratified health care provision foreign owned corporate control of health careforeign owned corporate control of health care deregulation of environmental and food controlsderegulation of environmental and food controls
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TRIPsTRIPs
Agreement on trade related intellectual Agreement on trade related intellectual property rightsproperty rights Principles of national treatment and MFN Principles of national treatment and MFN
treatmenttreatment Uniform protection of IPRsUniform protection of IPRs Patents (20 years +), trademarks, designs, Patents (20 years +), trademarks, designs,
trade secretstrade secrets
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Access to pharmaceuticalsAccess to pharmaceuticals
BrazilBrazil South AfricaSouth Africa IndiaIndia ThailandThailand
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BrazilBrazil
Compulsory licences issued for generic equivalents of Compulsory licences issued for generic equivalents of antiretroviralsantiretrovirals
Free care for all HIV+ people, AIDS-related deaths halved in Free care for all HIV+ people, AIDS-related deaths halved in four years, spread of the HIV reduced four years, spread of the HIV reduced
Savings of half a billion dollars by producing the generic Savings of half a billion dollars by producing the generic equivalent of the patented drugs, saved $422 million in equivalent of the patented drugs, saved $422 million in hospitalisation costs. hospitalisation costs.
Brazil taken to a WTO dispute panel by US over its patent Brazil taken to a WTO dispute panel by US over its patent legislation but not the issuing of compulsory licenceslegislation but not the issuing of compulsory licences
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South AfricaSouth Africa
1996 South Africa passes a new law for the 1996 South Africa passes a new law for the procurement of medicines; sourcing brand name procurement of medicines; sourcing brand name drugs internationally through cheapest supplierdrugs internationally through cheapest supplier
1998 39 drug makers sued South Africa arguing that 1998 39 drug makers sued South Africa arguing that the law contravened international trade agreementsthe law contravened international trade agreements
2001 Medicins Sans Frontiers petition against the 2001 Medicins Sans Frontiers petition against the lawsuit collects 250,000 signatureslawsuit collects 250,000 signatures
2001 companies withdraw their lawsuit and agreed to 2001 companies withdraw their lawsuit and agreed to pay the government's legal costspay the government's legal costs
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Cipla (India)Cipla (India)
India - process-only patent lawsIndia - process-only patent laws Cipla offers to sell (to MSF) a three-drug Cipla offers to sell (to MSF) a three-drug
cocktail for AIDS treatment at $US350 per cocktail for AIDS treatment at $US350 per year (compared with $10,000 to $12,000 a year (compared with $10,000 to $12,000 a year in western markets)year in western markets)
Cipla offers same cocktail to governments at Cipla offers same cocktail to governments at $600 per year $600 per year
Cipla offers to pay the patent owners a 5% Cipla offers to pay the patent owners a 5% commissioncommission
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Modifications to the Thai Safety Monitoring Modifications to the Thai Safety Monitoring Program (SMP)Program (SMP)
Seeks advance notice of new drugs in the Seeks advance notice of new drugs in the pipeline pipeline
Allows generic manufacturers to commence Allows generic manufacturers to commence bio-equivalence studies during patent period bio-equivalence studies during patent period
Excludes drugs under review from the Excludes drugs under review from the National List of Essential Drugs National List of Essential Drugs
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US response, 1991US response, 1991
US Threatens to put Thailand on the Priority Watch List under US Threatens to put Thailand on the Priority Watch List under Section 301 of US Trade Act Section 301 of US Trade Act
Section 301 allows trade sanctions to be imposed if the USTR Section 301 allows trade sanctions to be imposed if the USTR determines that an act, policy or practice of Thailand 'violates determines that an act, policy or practice of Thailand 'violates or is inconsistent with any trade agreement, denying the rights or is inconsistent with any trade agreement, denying the rights or benefits derived thereof to the United States, or is, or benefits derived thereof to the United States, or is, unjustifiable and burdens or restricts United States commerce'. unjustifiable and burdens or restricts United States commerce'.
See See http://www.cptech.org/ip/health/c/thailand/thailand.htmlhttp://www.cptech.org/ip/health/c/thailand/thailand.html
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SPS (Sanitary and SPS (Sanitary and Phytosanitary Measures)Phytosanitary Measures)
Regulatory standards governing human, animal and Regulatory standards governing human, animal and plant health shall by default be based on recognised plant health shall by default be based on recognised international bodies such as Codex Alimentariusinternational bodies such as Codex Alimentarius
More restrictive regulation must be based on More restrictive regulation must be based on scientific risk assessmentscientific risk assessment EU ban of hormone-treated beef judged to be not supported EU ban of hormone-treated beef judged to be not supported
by science and not addressing defined risksby science and not addressing defined risks
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TBT (Technical Barriers to TBT (Technical Barriers to Trade)Trade)
Encourages use of internationally agreed standards in Encourages use of internationally agreed standards in product regulationproduct regulation not necessarily intergovernmental bodies, not necessarily intergovernmental bodies, can be industry based bodies such as ISOcan be industry based bodies such as ISO
Regulations must be least trade-restrictive necessaryRegulations must be least trade-restrictive necessary Implications for water supply, food production, Implications for water supply, food production,
labelling of foods and drugslabelling of foods and drugs
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Current trade issues with big implications for healthCurrent trade issues with big implications for health
Reform of AoA (protection from dumping, access to markets)Reform of AoA (protection from dumping, access to markets) Implementation of Doha principles with respect to access to Implementation of Doha principles with respect to access to
pharmaceuticalspharmaceuticals Health service provision - privatisation, foreign ownership, Health service provision - privatisation, foreign ownership,
stratificationstratification Environmental standards and food standards Environmental standards and food standards NAMA and deindustrialisation (line by line tariff reduction or NAMA and deindustrialisation (line by line tariff reduction or
average; uniformly down or leave space for industry policy)average; uniformly down or leave space for industry policy)
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WHO Role in Advising on Trade and HealthWHO Role in Advising on Trade and Health
Secretariat paper on Trade and Health discussed at Secretariat paper on Trade and Health discussed at EB (27 May 2005)EB (27 May 2005)
Draft resolution (Thailand + 13 others) calling for Draft resolution (Thailand + 13 others) calling for ‘policy coherence’ across trade and health and calling ‘policy coherence’ across trade and health and calling on WHO to advise and assiston WHO to advise and assist
Opposition (US) plus watering down (Australia, Opposition (US) plus watering down (Australia, France, Luxemburg) lead to deferral (to Jan 06)France, Luxemburg) lead to deferral (to Jan 06)
PHM calls for networks and organisations to support PHM calls for networks and organisations to support the resolution and resist the USthe resolution and resist the US
