School of Regulation and Global Governance, Australian National University, 8 Fellows Road, Canberra, ACT 2601, Australia.
School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada.
Health Policy Plan. 2018 Jan 1;33(1):123-136. doi: 10.1093/heapol/czx133.
We developed a conceptual framework exploring pathways between trade and investment and noncommunicable disease (NCD) outcomes. Despite increased knowledge of the relevance of social and structural determinants of health, the discourse on NCD prevention has been dominated by individualizing paradigms targeted at lifestyle interventions. We situate individual risk factors, alongside key social determinants of health, as being conditioned and constrained by trade and investment policy, with the aim of creating a more comprehensive approach to investigations of the health impacts of trade and investment agreements, and to encourage upstream approaches to combating rising rates of NCDs. To develop the framework we employed causal chain analysis, a technique which sequences the immediate causes, underlying causes, and root causes of an outcome; and realist review, a type of literature review focussed on explaining the underlying mechanisms connecting two events. The results explore how facilitating trade in goods can increase flows of affordable unhealthy imports; while potentially altering revenues for public service provision and reshaping domestic economies and labour markets-both of which distribute and redistribute resources for healthy lifestyles. The facilitation of cross-border trade in services and investment can drive foreign investment in unhealthy commodities, which in turn, influences consumption of these products; while altering accessibility to pharmaceuticals that may mediate NCDs outcomes that result from increased consumption. Furthermore, trade and investment provisions that influence the policy-making process, set international standards, and restrict policy-space, may alter a state's propensity for regulating unhealthy commodities and the efficacy of those regulations. It is the hope that the development of this conceptual framework will encourage capacity and inclination among a greater number of researchers to investigate a more comprehensive range of potential health impacts of trade and investment agreements to generate an extensive and robust evidence-base to guide future policy actions in this area.
我们制定了一个概念框架，探索贸易和投资与非传染性疾病（NCD）结果之间的途径。尽管人们越来越了解健康的社会和结构性决定因素的相关性，但 NCD 预防的讨论一直以来都以针对生活方式干预的个体化范式为主导。我们将个体风险因素与关键健康社会决定因素一起，置于贸易和投资政策的条件和限制之下，旨在为贸易和投资协定对健康影响的调查创建一个更全面的方法，并鼓励采取上游方法来应对 NCD 发病率的上升。为了制定该框架，我们采用了因果链分析，这是一种按顺序排列结果的直接原因、根本原因和潜在原因的技术；并进行了现实主义综述，这是一种专注于解释两个事件之间潜在机制的文献综述类型。研究结果探讨了促进货物贸易如何增加负担得起的不健康进口的流动；同时可能改变公共服务提供的收入，并重塑国内经济和劳动力市场，这两者都为健康生活方式分配和再分配资源。跨境服务贸易和投资的便利化可以推动对不健康商品的外国投资，进而影响这些产品的消费；同时改变可能调节因消费增加而导致的 NCD 结果的药物的可及性。此外，影响决策过程、制定国际标准和限制政策空间的贸易和投资条款，可能会改变一个国家对监管不健康商品的倾向和这些规定的效力。我们希望，这一概念框架的制定将鼓励更多研究人员增强能力并倾向于调查贸易和投资协定更广泛的潜在健康影响，以生成广泛而有力的证据基础，为该领域的未来政策行动提供指导。
