Corporate power and the international trade regime preventing progressive policy action on non-communicable diseases: a realist review

Abstract

Transnational tobacco, alcohol and ultra-processed food corporations use the international trade regime to prevent policy action on non-communicable diseases (NCDs); i.e. to promote policy ‘non-decisions’. Understanding policy non-decisions can be assisted by identifying power operating in relevant decision-making spaces, but trade and health research rarely explicitly engages with theories of power. This realist review aimed to synthesize evidence of different forms and mechanisms of power active in trade and health decision-making spaces to understand better why NCD policy non-decisions persist and the implications for future transformative action. We iteratively developed power-based theories explaining how transnational health-harmful commodity corporations (THCCs) utilize the international trade regime to encourage NCD policy non-decisions. To support theory development, we also developed a conceptual framework for analysing power in public health policymaking. We searched six databases and relevant grey literature and extracted, synthesized and mapped the evidence against the proposed theories. One hundred and four studies were included. Findings were presented for three key forms of power. Evidence indicates THCCs attempt to exercise instrumental power by extensive lobbying often via privileged access to trade and health decision-making spaces. When their legitimacy declines, THCCs have attempted to shift decision-making to more favourable international trade legal venues. THCCs benefit from structural power through the institutionalization of their involvement in health and trade agenda-setting processes. In terms of discursive power, THCCs effectively frame trade and health issues in ways that echo and amplify dominant neoliberal ideas. These processes may further entrench the individualization of NCDs, restrict conceivable policy solutions and perpetuate policymaking norms that privilege economic/trade interests over health. This review identifies different forms and mechanisms of power active in trade and health policy spaces that enable THCCs to prevent progressive action on NCDs. It also points to potential strategies for challenging these power dynamics and relations.

Defending access to medicines in regional trade agreements: lessons from the Regional Comprehensive Economic Partnership – a qualitative study of policy actors’ views

“…Finally, the findings reaffirm the need for structural reforms in trade policymaking processes both at the national level and in how regional trade agreement negotiations are conducted [ 20 , 24 , 29 , 34 ]. As highlighted above, informants identified power asymmetries between trade and health officials within governments, as well as a lack of transparency and formal processes for engagement with public health experts and NGOs and wider civil society.…”

“…All informants were highly critical of forms of engagement introduced at the national level in RCEP countries, mostly perceived to be superficial and one-sided. Informant’s views of the power of industry actors in the negotiations, and their significant access to negotiators, reaffirms other analyses of the power that industry and transnational corporate actors wield in trade policy [ 3 , 22 , 26 , 29 , 65 , 66 ].…”

“…In the field of international relations, scholars have pointed to constraining and enabling conditions such as asymmetries in economic power between negotiating countries [ 26 ], the particular configuration of negotiation blocs and their negotiating strategies [ 27 ], and domestic interests and constituents, including the role of civil society and their framing strategies [ 28 ]. In the field of public health, key governance challenges identified include issues of transparency, accountability, participation, integrity and capacity [ 20 ], with public health actors operating within a dominant neoliberal paradigm that privileges corporate interests [ 29 , 30 ]. A small set of empirical studies in public health focused on what has worked points to conditions such as requirements for consultation with health experts and public health actors; transparency around trade negotiations; and mandated use of health impact assessments [ 29 – 34 ].…”

“…In the field of public health, key governance challenges identified include issues of transparency, accountability, participation, integrity and capacity [ 20 ], with public health actors operating within a dominant neoliberal paradigm that privileges corporate interests [ 29 , 30 ]. A small set of empirical studies in public health focused on what has worked points to conditions such as requirements for consultation with health experts and public health actors; transparency around trade negotiations; and mandated use of health impact assessments [ 29 – 34 ]. A recent analysis of Australia’s participation in the CP-TPP agreement, for example, found that domestic concerns for access to medicines and protecting regulatory space for tobacco control emerged onto the government’s agenda through a combination of conditions involving actor networking, framing, supportive policy processes, favourable evidence and public support [ 34 ].…”

Why Community Health Systems Have Not Flourished in High Income Countries: What the Australian Experience Tells Us

“…This framework was selected because it can identify ideas, agency and power as well as structures, and has been widely used in the health field. [25][26][27] 'Interests' refers to actors' (organisations or individuals) interests which may shape policy and practice, such as professional interests to safeguard their profession's role. 20,23,26 'Institutions' refers to the written or unwritten rules and structures that govern how the health system is comprised and behaves, which is useful for identifying institutional drivers in the regulatory environment such as funding mechanisms and the mandates or goals of organisations.…”