> Disease surveillance and data collection were limited to a handful of acute epidemic infections (eg, cholera, plague, and yellow fever), the spread of which was associated with trade. The measures adopted focused on actions to be taken at the border to protect trading powers from external threats, and did not require states to improve, for example, health deter- minants within their own territories, let alone population health in other countries. > Adverse effects on health associated with industrialisation implicated trade because industrial products were often the goods traded in international commerce. Competition from cheaper imports created pressures to reduce costs, often pursued at the expense of worker health and safety, and environmental degradation. This situation led to the [[International Labour Organization (ILO)]]’s efforts to harmonise labour protections across countries, and attempts to control transboundary pollution through international standards and treaties The origin of [[International Health Regulation (IHR)]] stems from trade and health during Cold War. From GATT to International Sanitary Regulations, and finally as IHR. However, GATT's development did not include substantial efforts to address policy linkages. Attention to the direct and indirect links between trade and health waned during the Cold War. The [[General Agreement on Tariffs and Trade (GATT)]], adopted in 1947, and the International Sanitary Regulations (ISR, which later became the International Health Regulations [IHR]), adopted by WHO in 1951, included provisions for balancing trade and health interests. However, although occasional controversies arose, GATT’s development did not include substantial efforts to address policy linkages. Trade became caught up in the geopolitical struggle between the USA and the Soviet Union. The trade and health relation was marginalised in the process. - [[Interlink between trade and health inspired the establishment and expansion of WTO]] The interface between trade and health has changed since the end of the Cold War, characterised foremost by a greater converge of policy issues. When established in 1947, GATT had 23 contracting parties and was limited to trade in goods. Today, the WTO has 153 members (which account for 97% of world trade) with another 29 countries seeking accession, and includes trade in goods and services and the protection of intellectual property rights. # Trade, health, and governance [[International trade is highly structured while global health governance provides little structure coherence]] Balancing trade and health policies requires cooperation through international institutional mechanisms. Comparing the mechanisms within the two realms reveals why trade has so far dominated governance of this relationship. ==International trade has a highly structured, formalised, and demanding governance system. By contrast, global health governance exhibits little structural coherence, a greater diversity of actors and approaches, and weaker legal obligations on states== ## Cross-cutting WTO features that affect the trade-health relationship ### 1. Centralised and comprehensive governance architecture Trade liberalisation within a multilateral system has produced a core structure with strong legal foundations (eg, GATT) and the incentive and capacity to handle new issues (eg, General Agreement on Trade in Services (GATS), TRIPS). ==This architecture contrasts with the unstructured plurality of global health governance. The fragmented, diversified, and multiplied global health governance has challenged WHO's position as the central organizing body.== ### 2. WTO's political and substantive scope compared to WHO WTO membership is extensive and expanding, proving its importance to developed and developing countries. WTO has risen to become one of the most important IGOs because of the widely shared perception that economic growth and public welfare depend on participation in a robust system of international trade. WHO, on the other hand, derives its influence from technical expertise used in the promotion of non-binding collective action across its member states (eg, eradication of smallpox and polio). WHO is also expected to address new and emerging global health issues, such as public health innovation and intellectual property rights, and sharing of influenza viruses and related benefits. Only recently have member states used WHO as a forum to negotiate international legal instruments (the Framework Convention on Tobacco Control 25 and the International Health Regulations 2005). [[Agreements to join WTO is breathtaking. Hence, the scope of issues are highly structured and extensive. Compared to WHO, membership does not involve acceptance of multiple, extensive legal obligations, so WHO membership lacks the broad, deep, and binding commitments WTO membership imposes.]] Substantively, the scope of issues covered by WTO agreements is breathtaking. To become a WTO member, a country has to agree to accept no less than 17 main multilateral agreements and 60 agreements, annexes, decisions, and understandings that contain binding obligations on, among other things, tariffs and non-tariff barriers on industrial and agricultural goods; trade in all kinds of services; application of measures to protect human, animal, and plant health (sanitary and phytosanitary measures); implementation of technical barriers to trade; use of trade-related investment measures; imposition of additional tariffs on dumped or subsidised imports; and protection of intellectual property rights. The large number of WTO member states means that most of the international community has committed itself to implementing this vast array of obligations. Although the WHO Constitution contains a broad definition of health, WHO membership does not involve acceptance of multiple, extensive legal obligations. The WHO Constitution does not require member states to accept other international legal duties,27 so WHO membership lacks the broad, deep, and binding commitments WTO membership imposes. This observation does not mean that WHO member states refrain from entering into other international agreements. These other arrangements, such as human rights instruments that include the right to health and environmental treaties that seek to protect human health, have arisen outside WHO’s auspices, creating a patchwork effect rather than a centralised, integrated set of legal obligations on health - ### 3. WTO agreements place extensive demands on individual countries (legally binding) while WHO membership is not legally binding on states ### 4. WTO reinforces the scope and demanding nature of its rules through its dispute settlement mechanism WTO's dispute settlement provisions are comprehensive, allowing members countries to use trade sanctions to enforce rulings against member states that fail to comply with decisions. By contrast, health-specific legal agreements, such as FCTC or the revised IHR (2005), do not contain compulsory dispute settlement and enforcement provisions, and thus lack the compliance bite that WTO rules have. [[This difference could affect how seriously countries take obligations connected to the WTO and WHO]] since WTO dispute settlement mechanism heightens the political and economic significance, including those rules that could affect health policy. > A key question then, becomes whether this governance environment permits countries to pursue trade and heath interests in ways that do not privilege one are to the detriment of the other. # Towards policy coherence Policy coherence requires common ground with respect to substantive policy objectives, which is often not easy to find/construct because of divergent public and private interests. The search for policy coherence is also complicated by the need for broad agenda because trade and health have direct and indirect links. In addition, coherence has to be achieved within and across individual countries. Direct linkage: when trade in goods contaminated with harmful pathogens or containing dangerous substances, such as [[General Agreement on Tariffs and Trade (GATT)]] or [[International Health Regulation (IHR)]] agreements: for example, was the measure applied in a non-discriminatory manner, based on scientific evidence, or the least trade-restrictive measure reasonably available to achieve the level of health protection sought? Some trade rules have no impact on health, such as non-discriminatory trade measures. Health officials do not need to discriminate based on the origin of the product in order to protect health. Other rules, such as requirement for trade-restricting health measures to be the least trade-restrictive measures reasonably available. Whether one measure is more or less trade restrictive than another, and over whether the least trade-restrictive measure is actually feasible for the country in question to implement. Basically, indikator-indikator trade-restrictive measures ini, diantara beberapa opsi yang lain, ada weigh yang berbeda. Apakah boleh memilih yang least restrictive? Bagaimana dampaknya ke health measure supaya memudahkan negara terkait untuk melakukan trade? [[Policy coherence from the application of the trade rules does not ensure policy coherence in practice]] Such failures may resulted from lack of political will, competence, or capability rather than the presence of skewed rules. For example, direct link context - ==liberalising trade in health-related services require sophisticated analysis== in order for policy makers to achieve their political and economic objectives (eg, wealth creation, economic, and health equities) for their population. In Indonesia, for example, the govt wants independence through local manufacturing in hope that it will create wealth and economic boost in national level while opening up access to medicines. Indirect link context - trade could affect macroeconomic conditions that influence employment levels and income inequities, which affect access to health services. Or, trade is only part of the problem (access to essential medicines, the growth in obesity-related diseases, health harms from environmental degradation). Achieving policy coherence and how it relates to concepts of fairness and equity constitute more difficult questions because of the substantial number and nature of the variables to be analysed and regulated. Simplistic responses, such as ignoring the link or blanket opposition to trade liberalisation, do not provide foundations for policy coherence. [[Achieving policy coherence unfolds through separate responses in distinct policy spheres using multiple instruments at different times]] (eg, liberalise trade internationally through trade law, redistribute wealth domestically through national fiscal measures, and reform access to health services through health policy) [[Insights]]Indonesia is poised to achieve this through the recently passed Health Law but the next thing is how Indonesia will balance the easier access to healthcare with ensuring quality of care? While trade is easier and flows of medicine will start coming, Indonesia must consider the market shape of its healthcare services, safeguard people's health without compromising the quality. [[Insights]] It's apparent that this paper which was written in 2009 proven to be spot on on how COVID-19 pandemic medical countermeasures thingy unfolded. WTO did not grant TRIPS waiver and countries complied to that despite WHO and member countries pushed for it. The political and economic stakes were higher in WTO than in other international fora, including G20. It also proven to relate to how economics of global health policy notion stated in the [[GHM101 Session 01 The Economics of Global Health Policy]]: when do self-interest decision is also public interest? The interlinkage of trade and health, as far as this paper has elaborated, certainly did not match self-interest and global interest.