Achieving coherence between trade and noncommunicable disease (NCD) prevention policy, such that neither undermines the other's goals [1], remains challenging. In 2011, Samoa acceded to the World Trade Organization (WTO) on the condition that the nation remove its ban on turkey tail imports [2]. Although the government of Samoa, a nation with one of the highest obesity rates in the world, introduced the ban to improve health by removing a low quality fatty meat from its food supply, the WTO rules limit use of policies that act as barriers to trade [3]. A similar nutrition policy constraint occurred when the Thai Food and Drug Administration proposed a law intended to reduce children's consumption of unhealthy snack foods by requiring that the warning message ‘Children Should Take Less’ be displayed in red text on the packaging of these products, as well as traffic-light coloured symbols for energy, sugar, fat and sodium content. After some WTO members raised concerns over the labelling plan in the committee on Technical Barriers to Trade, one of the WTO's 30 agreements, the regulation was delayed and in 2011 an industry-preferred option – Guideline Daily Amount ‘thumbnail’ labelling – was mandated instead [4].
These are two examples of how trade agreements can affect the ability of governments to implement effective policies to improve diets and prevent NCDs, and provide an indication of how trade agreements might constrain countries’ abilities to implement the recommendations outlined in the World Health Organization's (WHO's) Global Action Plan for the Prevention and Control of NCDs, 2013–2020 (NCD Global Action Plan) [5]. While the WTO has increasingly recognised the importance of health concerns in trade disputes, particularly in relation to tobacco [6], bilateral and regional trade and investment agreements often contain provisions that exceed those of the WTO agreements and have much less transparent dispute settlement mechanisms (which limits the opportunity for precedent) [7].
Trade and investment agreements can play an important role in providing fair treatment and a predictable policy environment for companies, and may also, in some circumstances, provide opportunities for governments to resist domestic lobbying by local industry. But they also constrain the domestic policy space available to national governments (the ‘freedom, scope, and mechanisms that governments have to choose, design, and implement public policies to fulfil their aims’ [8]), and can thus affect the autonomy of national governments in policy-making across all sectors of government [7], [9].Box 1 Definition of trade terms
Foreign direct investment: An investment in a country other than that of the investor, involving a long-term relationship and substantial, but not necessarily majority, interest in an enterprise by the investor. Foreign direct investment can take place through direct entry or investment in existing firms. International Investment Agreements are designed to facilitate foreign direct investment (e.g. Bilateral Investment Treaties).
Non-discrimination: The practice of not making a distinction in favour of or against certain trading partners, or between imported and domestically produced goods, once goods have entered the market. Foreign goods or committed services covered by a trade agreement must be treated the same as the identical or ‘like’ domestic good or service.
Sanitary and phytosanitary (SPS) measures: Technical barriers designed for the protection of human health or the control of animal and plant pests and diseases.
Subsidy: A direct or indirect benefit/incentive granted by a government for the production or distribution (including export) of a good.
Technical Barriers to Trade (TBT): Regulations, standards, testing and certification procedures, which can create obstacles to trade.
Trade agreement: A negotiated agreement between two or more countries to limit or alter their policies with respect to trade. Trade agreements can be bilateral, regional or multilateral. The use of the prefix ‘preferential’ highlights that such agreements favour member parties over non-members by extending tariff and other non-tariff preferences. The term ‘trade and investment agreement’ can also be used to differentiate trade agreements that include an investment chapter with similar text to international investment agreements.
Source: Adapted from Thow [10]
Policy analysis can help to identify possible areas of incoherence between binding trade policies and other legitimate aims of government [11], [12], [13], [14]. Indeed, efforts to improve nutrition and prevent NCDs have a recognised potential for conflict with trade policies. During the past 30 years there has been significant growth in global trade and investment in highly processed foods (often high in salt, saturated fat and sugar, and associated with diet-related NCDs) [15], [16], as well as cross-border investment in food retail, advertising and promotion [17], [18]. This trade and investment has contributed to increased availability, accessibility and affordability of less-healthy foods relative to healthy foods, and has been associated with shifts to poorer nutritional quality diets [19], [20], [21], [22]. The ‘policy options for promoting a healthy diet’ recommended in the NCD Global Action Plan will apply to the products of trade and investment, which are also governed by international trade agreements. With binding international agreements to liberalise food-related trade and investment on one hand, and non-binding international commitments to NCD prevention on the other, there is potential for trade and investment agreements to trump health policy and constrain or limit national efforts to improve diets and prevent disease. This effect has been documented in other areas of public health such as tobacco control and access to medicines [8], [23], [24], [25], [26], [27], but to date there has been no systematic analysis of the effects of new preferential trade and investment agreements on policy space for promoting healthy diets [28].
This paper aims to help address that evidence gap. Our policy analysis considers (1) how the Trans-Pacific Partnership Agreement (TPPA) and other preferential trade and investment agreements may constrain governments’ policy space to operationalise the NCD Global Action Plan ‘policy options for promoting a healthy diet’, and (2) opportunities to improve policy coherence between trade and public health in this context.
Countries currently involved in the TPPA negotiations, which are reportedly due to conclude in 2014, include Australia, Brunei Darussalam, Canada, Chile, Japan, Malaysia, Mexico, New Zealand, Peru, Singapore, the United States of America (USA) and Vietnam. The TPPA is seen by countries involved as the model for ‘21st century trade agreements’ and will likely set a precedent for further expansion of trade and investment provisions into national policy space [29]. To some extent, the TPPA also represents the trend towards ‘economic integration’ agreements, with significant efforts to harmonise ‘behind the border’ regulation [30].
Publicly available information on the TPPA negotiations is limited by the secrecy of the negotiations, although the USA reports that the draft negotiating text draws heavily on the bilateral agreement between the USA and the Republic of South Korea (‘KORUS’) which entered into force in 2012 [29]. Therefore, we have used the final text of KORUS [31] as the basis for the policy analysis framework, supplemented by leaked draft text of the TPPA, commentary and analysis of this leaked text by academics and non-government organisations, and other publicly available information on the TPPA negotiations, for example, from the USA Congressional Research Service, which publishes regular updates (e.g. [29]). Preferential trade agreements involving the USA tend to use a template approach, building on each successive agreement to continually extend the provisions contained in the agreements of the WTO. Basing our analysis on the most recent preferential trade treaty (KORUS) provides a reasonable indication of the likely inclusions in the TPPA.
We approached this research from a prospective policy analysis perspective [32], and have drawn on ex-ante policy appraisal techniques [33], [34] to analyse the trade and investment provisions as they apply to public health nutrition policy space. The WHO Global Action Plan for the Prevention and Control of NCDs 2013–2020 has been subject to extensive international review and was approved at the 2013 World Health Assembly [5]. It contains current best-practice policy options for ‘promoting a healthy diet’ for the prevention of NCDs. Our analysis was also informed by literature regarding implications of trade and investment agreements for policy space in public health more broadly [8], [23], [24], [25], [26], [27], [28].
Table 1 presents a summary of the analytic framework and key findings. For the purpose of analysis (and to reduce repetition in the Findings section) we grouped the policy options outlined in the Global Action Plan according to their focus (see subheadings in Box 1).
