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Will the next generation of preferential trade and investment agreements undermine implementation of the Global Action Plan...

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Health Policy 119 (2015) 88–96

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Health Policy

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Will the next generation of preferential trade and investment agreements undermine prevention of noncommunicable diseases? A prospective policy analysis of the Trans Pacific Partnership Agreement

Anne Marie Thowa,∗, Wendy Snowdonb, Ronald Labontéc, Deborah Gleesond, David Stucklere, Libby Hattersley f, Ashley Schramc, Adrian Kayf, Sharon Friel f

a University of Sydney, Menzies Centre for Health Policy, Victor Coppleson Building (D02), Sydney 2006, NSW, Australia b Fiji National University, Samabula, Fiji1 c University of Ottawa, Ottawa, ON, Canada d La Trobe University, Melbourne, Australia e University of Oxford, Oxford, United Kingdom f Australian National University, Canberra, Australia

a r t i c l e i n f o

Article history: Received 21 March 2014 Received in revised form 21 July 2014 Accepted 1 August 2014

Keywords: Nutrition Trade Policy analysis Policy space

a b s t r a c t

The Trans Pacific Partnership Agreement (TPPA) is one of a new generation of ‘deep’ pref- erential trade and investment agreements that will extend many of the provisions seen in previous agreements. This paper presents a prospective policy analysis of the likely text of the TPPA, with reference to nutrition policy space. Specifically, we analyse how the TPPA may constrain governments’ policy space to implement the ‘policy options for promoting a healthy diet’ in the World Health Organization’s Global Action Plan for Prevention and Control of Noncommunicable Diseases (NCDs) 2013–2020.

This policy analysis suggests that if certain binding commitments are made under the TPPA, they could constrain the ability of governments to protect nutrition policy from the influence of vested interests, reduce the range of interventions available to actively discour- age consumption of less healthy food (and to promote healthy food) and limit governments’ capacity to implement these interventions, and reduce resources available for nutrition

education initiatives. There is scope to protect policy space by including specific exclusions and/or exceptions during negotiation of trade and investment agreements like the TPPA, and by strengthening global health frameworks for nutrition to enable them to be used as reference during disputes in trade fora.

1. Introduction

Achieving coherence between trade and noncommuni- cable disease (NCD) prevention policy, such that neither

∗ Corresponding author. Tel.: +61 2 9036 7003; fax: +61 2 9351 5204. E-mail address: [email protected] (A.M. Thow).

1 At the time of preparation.

http://dx.doi.org/10.1016/j.healthpol.2014.08.002 0168-8510/© 2014 Elsevier Ireland Ltd. All rights reserved.

© 2014 Elsevier Ireland Ltd. All rights reserved.

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 remov- ing 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

lth Policy 119 (2015) 88–96 89

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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. For- eign 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 part- ners, or between imported and domestically produced goods, once goods have entered the market. Foreign goods or committed services covered by a trade agree- ment 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, stan- dards, 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 bilat- eral, regional or multilateral. The use of the prefix ‘preferential’ highlights that such agreements favour member parties over non-members by extending tar- iff and other non-tariff preferences. The term ‘trade and investment agreement’ can also be used to differ- entiate trade agreements that include an investment chapter with similar text to international investment

A.M. Thow et al. / Hea

ood and Drug Administration proposed a law intended to educe children’s consumption of unhealthy snack foods y requiring that the warning message ‘Children Should ake Less’ be displayed in red text on the packaging of hese products, as well as traffic-light coloured symbols or energy, sugar, fat and sodium content. After some WTO

embers raised concerns over the labelling plan in the ommittee on Technical Barriers to Trade, one of the WTO’s 0 agreements, the regulation was delayed and in 2011 n industry-preferred option – Guideline Daily Amount

thumbnail’ labelling – was mandated instead [4]. These are two examples of how trade agreements can

ffect the ability of governments to implement effec- ive policies to improve diets and prevent NCDs, and rovide an indication of how trade agreements might onstrain countries’ abilities to implement the recom- endations outlined in the World Health Organization’s

WHO’s) Global Action Plan for the Prevention and Control f NCDs, 2013–2020 (NCD Global Action Plan) [5]. While he WTO has increasingly recognised the importance of ealth concerns in trade disputes, particularly in relation o tobacco [6], bilateral and regional trade and investment greements often contain provisions that exceed those of he WTO agreements and have much less transparent dis- ute settlement mechanisms (which limits the opportunity or precedent) [7].

Trade and investment agreements can play an impor- ant role in providing fair treatment and a predictable olicy environment for companies, and may also, in ome circumstances, provide opportunities for govern- ents to resist domestic lobbying by local industry.

ut they also constrain the domestic policy space avail- ble to national governments (the ‘freedom, scope, and echanisms that governments have to choose, design,

nd implement public policies to fulfil their aims’ [8]), nd can thus affect the autonomy of national govern- ents in policy-making across all sectors of government

7,9].

Policy analysis can help to identify possible areas of ncoherence between binding trade policies and other egitimate aims of government [11–14]. Indeed, efforts to mprove nutrition and prevent NCDs have a recognised otential for conflict with trade policies. During the past 0 years there has been significant growth in global trade nd investment in highly processed foods (often high in alt, saturated fat and sugar, and associated with diet- elated NCDs) [15,16], as well as cross-border investment n food retail, advertising and promotion [17,18]. This rade and investment has contributed to increased avail- bility, accessibility and affordability of less-healthy foods elative to healthy foods, and has been associated with hifts to poorer nutritional quality diets [19–22]. The ‘pol- cy options for promoting a healthy diet’ recommended n the NCD Global Action Plan will apply to the prod- cts of trade and investment, which are also governed by

nternational trade agreements. With binding international

greements to liberalise food-related trade and investment n one hand, and non-binding international commitments o NCD prevention on the other, there is potential for trade nd investment agreements to trump health policy and

agreements. Source: Adapted from Thow [10]

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 [8,23–27], but to date there has been no sys- tematic 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 Partner- ship Agreement (TPPA) and other preferential trade and investment agreements may constrain governments’ pol- icy space to operationalise the NCD Global Action Plan ‘policy options for promoting a healthy diet’, and (2) oppor- tunities to improve policy coherence between trade and public health in this context.

Countries currently involved in the TPPA negotia- tions, 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

90 A.M. Thow et al. / Health Policy 119 (2015) 88–96

Table 1 Analytical framework and overview of findings: Trade and investment agreement inclusions with potential implications for nutrition policy space, based on the policy options in the WHO NCD Global Action Plan.

Preferential trade and investment agreement inclusions

WHO NCD Global Action Plan

Protecting policy making from

vested interests

Specific policy options to improve

healthfulness of food supply (reduce less healthy food

options)

Specific policy options to improve

healthfulness of food supply

(increase healthy food options)

Policies to support institutional action

and consumer education

Chapters in KORUS

1. Initial Provisions and Definitions 2. National Treatment and Market Access

for Goods 3. Agriculture 4. Textiles and Apparel 5. Pharmaceuticals and Medical Devices 6. Rules of Origin and Origin Procedures 7. Customs Administration and Trade

Facilitation 8. Sanitary and Phytosanitary Measures 9. Technical Barriers to Trade 10. Trade Remedies 11. Investment 12. Cross-Border Trade in Services 13. Financial Services 14. Telecommunications 15. Electronic Commerce 16. Competition-Related Matters 17. Government Procurement 18. Intellectual Property Rights 19. Labor 20. Environment 21. Transparency 22. Institutional Provisions and Dispute

Settlement 23. Exceptions New additions proposed for TPPA Regulatory Coherence State-Owned Enterprises E-Commerce Competitiveness and Supply Chains

(includes harmonisation) Small- and Medium-Sized Enterprises

the trend towards ‘economic integration’ agreements, with significant efforts to harmonise ‘behind the border’ regula- tion [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 analy- sis of this leaked text by academics and non-government organisations, and other publicly available information on the TPPA negotiations, for example, from the USA Congres- sional Research Service, which publishes regular updates (e.g. [29]). Preferential trade agreements involving the USA

tend to use a template approach, building on each suc- cessive agreement to continually extend the provisions contained in the agreements of the WTO. Basing our anal- ysis 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 pol- icy 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 sub- ject 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 invest- ment agreements for policy space in public health more broadly [8,23–28].

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).

A.M. Thow et al. / Health Policy 119 (2015) 88–96 91

Box 2: Global Action Plan for the Prevention and Control of NCDs 2013-2020: policy options for member states to promote healthy diets Broad recommendation for nutrition policy, including protection from vested interests: 38. Member States should consider developing or strengthening national food and nutrition policies . . .while protecting dietary guidance and food policy from undue influence of commercial and other vested interests Policy options to improve healthfulness of food sup- ply: 39.(c) Develop guidelines, recommendations or pol- icy measures that engage different relevant sectors, such as food producers and processors, and other rel- evant commercial operators, as well as consumers, to: Reduce the level of salt/sodium added to food (pre- pared or processed); Increase availability, affordability and consumption of fruit and vegetables; Reduce sat- urated fatty acids in food and replace them with unsaturated fatty acids; Replace trans-fats with unsat- urated fats; Reduce the content of free and added sugars in food and non-alcoholic beverages; Limit excess calorie intake, reduce portion size and energy density of foods 39.(d) Develop policy measures that engage food retailers and caterers to improve the availability, affordability and acceptability of healthier food prod- ucts (plant foods, including fruit and vegetables, an products with reduced content of salt/sodium, saturated fatty acids, trans-fatty acids and free sugars). 39.(e) Promote the provision and availability of healthy food in all public institutions including schools, other educational institutions and the workplace. 39.(f) As appropriate to national context, con- sider economic tools that are justified by evidence and may include taxes and subsidies, that create incentives for behaviours associated with improved health outcomes, improve the affordability and encourage consumption of healthier food products and discourage the consumption of less healthy options. 39.(g) Develop policy measures in cooperation with the agricultural sector to reinforce the measures directed at food processors, retailers, caterers and public institutions, and provide greater opportunities for utilization of healthy agricultural products and foods. Policy options to support consumer education and institutional action: 39.(b) Implement WHO’s set of recommendations on the marketing of foods and non-alcoholic beverages to children, including mechanisms for monitoring. 39.(h) Conduct evidence-informed public health cam- paigns and social marketing initiatives to inform and encourage consumers about healthy dietary practices. Campaigns should be linked to supporting actions across the community and within specific settings for maximum benefit and impact. 39.(i) Create health- and nutrition-promoting envi- ronments, including through nutrition education, in schools, child care centres and other educational insti- tutions, workplaces, clinics and hospitals, and other public and private institutions.

39.(j) Promote nutrition labelling, according but not limited to, international standards, in particular the Codex Alimentarius, for all pre-packaged foods includ- ing those for which nutrition or health claims are made. Source: World Health Organization [5] Note: Subhead- ings are authors’ own.

2. Implications for protecting public health nutrition policy from influence of vested interests

The Director General of the WHO stated at the 8th Global Conference on Health Promotion in June 2013: ‘Efforts to prevent noncommunicable diseases go against the business interests of powerful economic operators’ [35]. In the context of this analysis, the food indus- try represents a vested interest [36–38]. The protection of national nutrition policy-making from vested inter- ests is likely to become more difficult under trade and investment agreements like the TPPA, because rules about transparency and requirements for regulatory coherence and ‘good regulatory practice’ enshrine the right of, and provide new avenues for, the food industry to provide input into policy development. For example, Article 9.6 in KORUS (on transparency regarding Technical Barriers to Trade) states that ‘Each Party shall allow persons [a national or an enterprise] of the other Party to participate in the development of standards, technical regulations, and conformity assessment procedures’ (also see Article X.3.7 in the leaked draft proposal for the regulatory coher- ence chapter of the TPPA [39]). These provisions mean that food industry representatives from other countries (in addition to the home country) would have the oppor- tunity to participate in policy development, and that the scope to limit their input into policy-making would be restricted. There may also be benefits to public health nutrition policy from increased transparency and con- sultation on policy change, since this can present an opportunity for public health input. However, it should be noted that the lack of transparency of the TPPA negotiations mean that there is limited capacity for public health nutrition input during the negotiation pro- cesses.

The proposed rules on Regulatory Coherence in the TPPA may also influence national nutrition policy-making. These would require the establishment of a central body, similar to the US Office of Information and Regulatory Affairs, to vet proposed regulation and its compliance with trade agreements [29,40,41]. Since public health nutrition policy applies to the products of international trade and investment (outlined below), which are cov- ered by binding trade and investment agreements, this move to ‘coherence’ may result in government reluc- tance to implement strong national nutrition policies that might be perceived as barriers to trade and/or invest- ment, creating what is known as “policy or regulatory

chill” [42].

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3. Implications for policy options to improve healthfulness of food supply by reducing the availability of less healthy food options

The policies identified in the NCD Global Action Plan to improve the healthfulness of the food supply by reducing availability of less healthy food focus on food produc- ers and processors, food retailers and caterers, as well as including broader measures such as fiscal policy. As these policies will apply to the products of investment, commitments made in trade and investment agreements regarding investor protection may constrain policy space for implementing these options. Under many bilateral and preferential agreements, investors are protected from expropriation of their investment (government action that reduces the value of their investment) and unfair treat- ment. In most recent agreements, investors have the option to recourse for expropriation and unfair treatment under Investor State Dispute Settlement (ISDS) mechanisms, which the TPPA is likely to include [43]. These mechanisms allow corporations (investors) to directly sue governments for compensation—in contrast to the dispute settlement mechanisms in the agreements of the WTO, that allow only other governments to contest government policies. The investor-state arbitration process has been criticized for being non-transparent (in contrast to the WTO, where arbitration processes and outcomes are made public), for lacking many of the safeguards of domestic legal processes, and for failing to consider broader issues related to public policy [23]. Civil society has also raised significant concerns that the composition of dispute settlement tribunals (three private sector lawyers) is biased towards the interests of industry and does not support good judicial practice [44].

Policy interventions which successfully discourage con- sumption of less healthy food options could be contested as a form of expropriation by transnational companies who make these products who do not adapt or offer health- ier products. For example, a transnational manufacturer of unhealthy products who had established a factory through direct investment – and whose sales decreased as the result of government intervention for nutrition purposes – might consider that they have a case to contest the regulation under an ISDS mechanism [45]. This would be the case even when the policies are non-discriminatory (in that they would apply equally to domestic and foreign-owned aspects of the food supply). A recent relevant public health example is Phillip Morris Asia’s use of the ISDS mechanism in a Bilateral Investment Treaty to seek compensation for the Australian Government’s plain packaging of tobacco laws [46]. Even if unsuccessful, such action can result in ‘regulatory chill’, in which other governments are unwill- ing or unable to risk expensive litigation regarding their policy decisions [26,47,48]. This can effectively delay action by other governments and has the potential to stifle inno- vation in public health policy-making.

In KORUS, expropriation of a covered investment is permitted ‘for a public purpose’ including ‘measures to pro-

tect health’, and this Agreement also has exceptions for existing ‘non-conforming measures’ (i.e. policy measures that do not comply with the agreement) [31]. Exceptions like these may be important in preserving public health

y 119 (2015) 88–96

nutrition policy space and public health policy makers need to be aware of them. Experience with exceptions in the WTO agreements indicates that it is possible to use them to protect public health [25], although policy space may still be constrained by requirements that measures be the ‘least trade-restrictive’ that are technically and economi- cally feasible. However, whether the KORUS safeguards are sufficiently protective has not been tested yet, and South Korea is reportedly seeking the renegotiation of the ISDS clause in KORUS [49]. Evidence from previous agreements with similar exceptions have not prevented claims over environmental pollution [50]. A critical concern regarding the TPPA is that leaked draft text of the rules on investment suggest it is unlikely to allow any general exceptions to safeguard health and consumer protection policies [43,51].

In addition, where fiscal policies such as taxes on less healthy foods or beverages to promote a healthy diet [5] are applied to certain imported foods or beverages deemed to be ‘less healthy’, they may be open to contest under agreements like the TPPA. Trade agreement rules on national treatment are intended to eliminate discrim- ination between ‘like’ products, and definitions of ‘healthy’ and ‘less healthy’ foods made on the basis of public health nutrition criteria may be contestable, in a large part due to the cultural and geographical diversity of food con- sumption behaviours [6]. Previous experience in the WTO indicates that the definition of ‘like’ products can prove contentious. For example, a WTO dispute settlement panel deemed asbestos insulation ‘like’ the less health-damaging local glass–fibre insulation [52,53]. However, this ruling was overturned by the WTO Appellate Body, which has the mandate to review dispute panel decisions.

Trade and investment agreements are becoming increasingly legalistic in their dispute resolution processes, with fewer political oversights that allow for national pol- icy space [54]. While trade rules in these agreements place the ‘burden of proof’ on complainants, in terms of demonstrating their compliance with principles sup- porting evidence-based and ‘least trade-restricting’ public policy measures, the respondents bear the ‘burden of pre- senting evidence’, in terms of demonstrating both the need for intervention, the evidence for effectiveness and that the intervention is the least trade restricting/distorting (in particular, rules relating to Sanitary and Phytosanitary measures) [6]. This might reduce the scope for govern- ments to implement innovative measures that have only indicative evidence for their effectiveness, due to the reg- ulatory chill effect of the cost of both evidence gathering and defending contested policy.

4. Implications for policy options to improve healthfulness of food supply by increasing the availability of healthy food options

Policies to improve the healthfulness of the food sup- ply by increasing healthy food options interface with trade and investment agreements where they apply to govern-

ment procurement and agriculture, which are covered by trade and investment rules on non-discrimination in mar- ket access. There has been growing interest in providing healthy food in public institutions through government

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rocurement systems [55,56]. These measures sometimes lso advocate sourcing foods locally, in an effort to achieve nvironmental, health, social, and development policy oals [57]. This is at least partly due to the fact that fresh roduce can suffer nutritional degradation during storage 58] and transportation [59], both of which are likely to ncrease for imported foods.

However, promoting the provision and availability of ealthy food in public institutions may be interpreted as a iscriminatory measure: (1) against unhealthy food prod- cts (in particular, imports and the products of investment) ecause they are ‘like’ the healthy ones; and (2) between ervice providers on the basis of location (for example, ourcing fresh produce from local farms as opposed to mported produce). Two exceptions in KORUS provide xamples of how public health nutrition policy space ould be specifically protected in relation to government rocurement. Exemptions are provided for government rocurement specifically regarding domestic content equirements (so, government procurement can preferen- ially use domestic produce) and also for ‘human feeding rograms’, which may include school food programs. Gov- rnment procurement is also specifically excluded from ules regarding competition and investment. Another pos- ible protection is that rules for government procurement ften apply only to large-scale contracts (i.e., primarily riented to major capital projects) and generally exclude ontracts related to recurrent expenditures or less costly rograms. This could reduce their likelihood of being used o challenge healthy food programs funded by govern-

ents. However, it is likely that the TPPA negotiators will eek further liberalization regarding procurement [29].

Policy options that provide subsidies to the agricultural ector to increase production and availability of health- er foods are also potentially discriminatory because of heir selective application, which gives specific crops a roduction advantage. At this point, however, agricultural ubsidies are largely permissible under trade and invest- ent agreements because agricultural subsidy reduction

s addressed only at the multilateral level (WTO) [29]. In ddition, the recent WTO decision on food security at the ali Ministerial Meeting has clearly protected space to upport agricultural investment in traditional staple foods 60], and may serve to raise awareness of the legitimacy f using subsidies to increase availability of healthy raditional staples. For example, root crops, millets, and orghum are all traditional staple crops that are relatively igh in nutrients and fibre.

. Implications for policy options to support onsumer education and institutional action

Governments seeking to introduce restrictions on mar- eting of foods and beverages for health purposes may ace constrained policy space under preferential trade and nvestment agreements because such restrictions can be een to represent barriers to cross-border advertising (a

orm of trade in services), which is particularly an issue con- erning marketing of foods to children [61]. While KORUS ecognises the right of countries to regulate and intro- uce new regulations on supply of services, it also requires

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stringent criteria and evidence for any measure that might restrict trade in services. The associated cost and potential for challenge is likely to make it more difficult for govern- ments to implement innovative measures in this area.

Similarly, health policies to improve nutrition labelling may constitute barriers to trade under rules regarding TBT. A priority of TBT rules is that measures should be evidence based and ‘not more trade-restrictive than necessary to ful- fil a legitimate objective’ [62]. Without a clear international standard or reference, the concept of ‘least trade restric- ting’ is open to interpretation, as illustrated by Thailand’s attempt to introduce a traffic light nutrition labelling sys- tem on unhealthy snack foods (described earlier). The TBT rules being negotiated in the TPPA may require that ‘domestic technical regulations of trading partners are recognized as equivalent to domestic regulations when possible’, as part of facilitating trade [29]. This could mean that foods produced in a country with no requirement for nutrition-related labelling might not be required to meet the nutrition labelling requirements of an importing coun- try (if the importing country had agreed to recognise the exporting country’s labelling regulation as sufficient). Har- monisation of technical standards under the TPPA may also reduce countries’ options in developing new standards for labelling requirements that exceed the agreed standard.

Trade and investment agreements are unlikely to have direct effects on campaigns (e.g. in the mass media) to encourage consumers to choose healthy food options and support institutions to make them available. However, these agreements may reduce the resources available to governments to develop and implement such campaigns, as the result of reduced tariff revenue and binding commit- ments to new trade infrastructure such as fora for policy coherence and trade facilitation. Tariffs are an important source of revenue in most low and middle income countries (LMICs), and liberalization commitments before alterna- tive taxation mechanisms have been adequately developed have been found to reduce public revenue in many of these countries [63,64]. NGOs have raised parallel concerns that increased public expenditure on trade facilitation (i.e. ensuring laws, regulations and other public and private infrastructures are compliant with new trade and invest- ment rules) poses a considerable financial burden on LMICs under binding trade agreements [65].

6. Discussion of policy analysis

This analysis suggests that while there is space for pub- lic health nutrition policy intervention, there are five main avenues through which new preferential trade and invest- ment agreements might constrain public health nutrition policy space and affect countries abilities to implement the WHO Global Action Plan for NCDs. First, binding com- mitments to transparency and coherence in regulatory processes mean ensuring input into policy making by any and all interested stakeholders. This may constrain the abil- ity of governments to protect public health nutrition policy

from the influence of vested interests. Second, investor protection provisions may reduce either the range of inter- ventions available to governments to discourage actively consumption of less healthy food options, or their ability

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to implement them. Third, trade rules regarding non- discrimination may reduce government policy space to implement policies that differentiate between ‘like’ prod- ucts, such as fiscal policies to reduce the affordability of less healthy food options or government procurement poli- cies that preference healthy food options. Fourth, rules to reduce technical barriers to trade may restrict the abil- ity of governments to use technical standards (such as labelling requirements) that can act as barriers to trade. Fifth, resources available for initiatives to educate con- sumers in LMICs may suffer due to decreased tariff revenue and increased public expenditure resulting from binding commitments to trade facilitation and harmonisation.

However, it is important to note that the potential constriction of policy space we describe is not inevitable. Contextual factors play a significant role in determining countries’ capacity to exert policy autonomy in relation to public health nutrition [66,67]. For example, the types of food industry present in the country and their contribution to Gross Domestic Product often determines the strength of their voice in decision-making and their capacity to con- test policy decisions. Similarly, the type of government and their ideological leaning, as well as the existing capac- ity of industry to engage in political processes, will affect the extent to which opportunities to speak into decision making fora translates into influence or effect. Civil soci- ety organisations also play an essential role in identifying commercial and geopolitical power plays, and the influence of vested interests. This is a critical factor in supporting strong NCD prevention policies and enabling governments to resist political pressure from industry and trading part- ners.

Nevertheless, regulatory chill and financial capacity are very real concerns when it comes to governments acting innovatively to implement the policy options for promot- ing a healthy diet that are identified in the WHO Global Action Plan. Arbitration costs associated with ISDS can amount to millions of dollars and the awards are often in the hundreds of millions [68]. These concerns regarding regulatory chill are likely to be more pronounced for LMICs, which may be more dependent on investment for contin- ued economic growth and may lack resources to counter actual or threatened contest of policy intervention.

The constraints to policy space that we have described are also likely to reduce innovation in policy interventions to improve diets, with binding commitments in trade and investment agreements restricting the available options for trade, fiscal and agricultural policy intervention for NCD prevention. While the list of policy options provided in the NCD Global Action Plan provides a clear framework for action, there is a spectrum of ‘hard’ to ‘soft’ options avail- able for many of the Action Plan goals. For example, the goal of reducing salt in processed foods can theoretically be achieved through legislation, collaborative partnerships between government and industry, or education directed at food processors. Although legislative approaches are increasingly seen as the most effective option [69], the

‘least trade-restrictive’ requirement under TBT and SPS agreements could incentivize non-legislative measures.

This problem is compounded by the lack of relevant international standards to support policy innovation in

y 119 (2015) 88–96

food-related NCD prevention. This is in contrast with tobacco control, for example, where novel measures such as plain packaging are recommended in the Framework Convention on Tobacco Control. The push for trade-related policies at the national level to align with international standards (e.g. [70]) has the potential to reduce policy innovation in NCD prevention, creating challenges in the implementation of the NCD Global Action Plan.

7. What could protect policy space for the prevention of diet-related NCDs?

7.1. International standards

As noted in our analysis, the lack of international stan- dards and frameworks for public health nutrition that could be used as reference in arbitration reduces the likelihood that nutrition will be considered in disputes arising from trade and investment agreements. A key existing standard for nutrition is the Codex Alimentarius, which is used as a reference in trade fora, traditionally mainly in relation to food safety. There has been encouraging progress in addressing NCDs in Codex, such as the inclusion of Nutrient Reference Values for salt and saturated fat [71]. However, these reference values are narrowly focussed on labelling for health purposes (in relation to only salt and fat) and Codex has limited scope to address broader interventions to improve the food supply because of the nature of its remit on labelling and food content [72].

The WHO also has regulatory and treaty-making powers, enabling it to develop legally binding global con- ventions, in addition to more common, non-binding World Health Assembly (WHA) resolutions (such as endorsement of the NCD Global Action Plan). There is potential to draw on strengths of the Framework Convention on Tobacco Con- trol, a legally binding instrument, to enhance and expand international nutrition-related standards [73]. The WHO’s set of recommendations on the marketing of foods and non- alcoholic beverages to children might be one area where a new (stronger) measure could be implemented at the international level, with a view to developing further bind- ing agreements to support the NCD Global Action Plan and increasing policy space for public health nutrition.

Another useful policy direction would be a WHA reso- lution specifically stating that the NCD Global Action Plan and its recommendations be given due consideration in all trade or investment treaty disputes that may relate to the components of the NCD Global Action Plan. Increased speci- ficity in global nutrition-related plans regarding policy options would also strengthen their capacity to be refer- enced in global trade fora, as specificity is important for global instruments to be considered as a ‘standard’ [6]. Sim- ilarly, new trade and investment treaties, such as the TPPA, could contain specific language requiring consideration of all WHA approved action plans or recommended public health measures in any dispute with public health implica-

tions. Countries could also use the NCD Global Action Plan to support preferential inclusion of non-industry persons, such as public health nutritionists, in decision-making regarding regulatory coherence.

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.2. Exclusions and exceptions

Public health nutrition policy would also be strength- ned with a clearer definition of health exceptions in trade nd investment agreements, such that they are easier to se. Clarification in the NCD Global Action Plan of the pro- ortionality and appropriateness of the measures that are ecommended could increase policy space for NCD preven- ion by making these policy options clearer candidates for his exception. The exclusion of an ISDS mechanism from he TPPA would be a positive option, given the uncertainties ssociated with exceptions and the chilling effect.

Given the changing nature of both trade and health olicy space, increasing flexibility through a general excep- ions clause with a much stronger public health exception han Article 20 of the GATT, as well as more excep- ions/exclusions built into the chapters highlighted in this nalysis, would also increase policy space for public health utrition. It might also be possible to retain specific exclu- ions, as seen in KORUS for government procurement with espect to ‘human feeding programs’.

Investment in building the evidence base for specific ublic health nutrition interventions will also increase the apacity of public health policy makers to defend public ealth nutrition policy interventions against disputes in rade-related fora.

. Conclusion

This analysis indicates that the TPPA could reduce policy pace to implement the WHO NCD Global Action Plan policy ptions for promoting a healthy diet. In effect, we see new referential trade and investment agreements and NCD revention occupying the same policy ‘space’–increasingly ne in which binding commitments made in international greements regarding domestic policy have the potential to onstrain policy intervention to improve diets and prevent isease. Further research is also needed to assess implica- ions for food security.

There is scope to retain policy space for nutrition and ealth by including specific exclusions and/or exceptions uring negotiation, and by strengthening the wording and tatus of the NCD Global Action Plan and other global health rameworks to enable them to be used as references during rade disputes. Ongoing research is needed to fully examine ll of the chapters of the TPPA and other trade and invest- ent agreements during the negotiation stage for their

ossible effects on nutrition and other dimensions of public ealth, and to evaluate the outcomes of such agreements

or nutrition. The extent to which this is possible depends n the level of engagement, consultation, and transparency ermitted during negotiation. It also depends on public ealth researchers and policy makers engaging with the pecific policies, as well as the commercial and geopoliti- al power structures, involved in global trade liberalisation n order to work towards improved policy coherence.

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  • Will the next generation of preferential trade and investment agreements undermine prevention of noncommunicable diseases?...
    • 1 Introduction
    • 2 Implications for protecting public health nutrition policy from influence of vested interests
    • 3 Implications for policy options to improve healthfulness of food supply by reducing the availability of less healthy foo...
    • 4 Implications for policy options to improve healthfulness of food supply by increasing the availability of healthy food o...
    • 5 Implications for policy options to support consumer education and institutional action
    • 6 Discussion of policy analysis
    • 7 What could protect policy space for the prevention of diet-related NCDs?
      • 7.1 International standards
      • 7.2 Exclusions and exceptions
    • 8 Conclusion
    • References