Advocacy strategies for advancing health in all policies: what works for trade policymaking?

Microphone with blurred background

Dr Belinda Townsend, Australian Research Centre for Health Equity, Australian National University, Ms Brigitte Tenni, School of Psychology and Population Health, La Trobe University & Nossal Institute for Global Health, University of Melbourne, Ms Sharni Goldman, Australian Research Centre for Health Equity, Australian National University & Associate Prof Deborah Gleeson, School of Psychology and Population Health, La Trobe University.

One of the longstanding barriers for health equity in Australia is the lack of intersectoral action for health and health equity to be prioritised in all areas of policymaking.

This is true in trade policymaking, where government economic interests to promote export markets dominate, and health goals remain peripheral.

While much is known about the impacts of economic determinants on health, less is known about how to advance health goals in policymaking in areas outside the health portfolio.

Our recent study, published in Globalization and Health, aimed to help fill this gap by identifying what strategies have been useful in advancing health goals in trade-related policy processes. In doing so, we sought to analyse the mechanisms and strategies that led to change for health. This may be of interest for public health advocates concerned with the commercial determinants of health more broadly.

We conducted a narrative review of scholarly peer-reviewed literature across policy studies, political science, law and economics. Studies were included if they sought to explain why a health issue had received attention on a trade-related policy agenda, and were in English. Out of 18,604 studies identified, 65 studies met the inclusion criteria. We found that the health issues that have received prioritisation in trade policymaking include access to medicines,  nutrition and food security, tobacco control, non-communicable disease risk factors, access to knowledge, and asbestos harm.

From our analysis, we developed a framework of common strategies used to advance health goals in trade-related policymaking (Figure 1).

Figure 1 Framework of common conditions and strategies influencing health in trade-related policymaking

Image from research: Figure 1 Framework of common conditions and strategies influencing health in trade-related policymaking. Image is two circles inside one another. On the outside circle it outlines strategies: "Using and transforming multiple forms of evidence, acting in coalitions, strategic framing, leveraging exogenous factors, legal strategy and shifting forums." The inside circle outlines conditions: "favourable media attention, leadership by trade and health ministers, public support and political party support". Arrows representing "influence" point from the strategies to the conditions.

(Image: Globalization and Health)

We identified four enabling conditions which were identified in many of the studies as important for influencing the elevation of health goals in trade policymaking (see the inner circle of Figure 1). In order of most commonly identified these were:

(1) favourable media attention to the health issue,

(2) leadership in favour of health taken by Trade and Health Ministers,

(3) public support for the issue, and

(4) political party support for the health issue.

Often, these conditions were interrelated, for example, favourable media attention was intimately connected to increased public opinion and political party support for a health issue.

Mapped around these conditions, we identified six strategies successfully used by public health advocates (civil society, academics and government officials) to influence media attention, public opinion, political party support and ministerial leadership (see Figure 1, outer circle). These were:

(1) using multiple forms of evidence,

(2) acting in coalitions with others,

(3) using strategic frames to influence policy actors,

(4) leveraging exogenous events,

(5) using legal strategies, and

(6) shifting forums to venues more open to health goals.

It is perhaps unsurprising for public health advocates that a key strategy was using and translating multiple forms of evidence. By way of example, health impact assessments (HIA) have provided useful technical evidence to promote access to medicines in trade negotiations in Australia [54], Thailand [61, 66], and Peru and Colombia [71].

Translation of evidence refers to translating evidence into an easy to understand format for lay audiences. Health experts’ public debunking of industry claims, for example, was highlighted as a ‘pivotal turning point’ that led to Canada’s trade ban on asbestos. Other forms of evidence that have been influential include personal stories and economic evidence to support health evidence.

A second common strategy was health actors acting in coalitions, and this included coalitions between low and middle-income countries (LMICs), between civil society organisations, and broader coalitions involving government officials, civil society and other supportive organisations and experts.

By acting as a coalition, LMICs can resist the influence of well-resourced high-income countries in trade negotiations. For example, LMICs acting in a negotiating bloc during the recent Regional Comprehensive Economic Partnership agreement negotiations was found to be crucial for defending elevating access to medicines.

Informal coalitions between government health officials, civil society actors and industry groups were also found to be influential in many studies. For example, a transnational coalition of asbestos victims, health NGOs, trade unions, and health experts was identified as crucial for securing Quebec’s trade ban on asbestos on health grounds.

The third strategy – strategic framing, refers to when policy actors use frames to focus attention to a particular issue and persuade others of its importance. Access to medicines was identified as a powerful framing and norm which shifted debates on intellectual property and trade from private goods to public health. Human rights framing has also been successfully used. In South Africa, for example, NGOs’ use of human rights framing was found to have shaped public support and media uptake of pro-health framing in trade debates.

Advocates also leveraged exogenous events, seizing windows of opportunity to draw attention to health in the trade processes. Exogenous factors outside the trade process included the rise of HIV as a health and security crisis, food pricing and harvest levels and economic crises.

The use of legal strategy referred to using legal arguments in national and international contexts to advance health. Several studies, for example, identified the use of the World Health Organization’s Framework Convention on Tobacco Control (a non-trade treaty) to defend tobacco control measures by Australia, Brazil, Canada, and Uruguay.

The final strategy was shifting forums – where advocates for health manoeuvred across different institutional forums to put pressure on trade-related policy domains. For example, the Thai NGO, FTA Watch, shifted the focus of its advocacy from the trade policy domain to the National Human Rights Commission of Thailand, an independent quasi-government institution, to successfully call for a human rights impact assessment of Thailand’s proposed trade agreement with the USA. At the global level, policy actors have used food security framing to bring the United Nations and Food and Agricultural Organization into debates on food trade, and have successfully brought trade debates into the World Health Organization to focus on potential health impacts of trade negotiations.

This framework suggests that a range of political strategies is needed to advance health when working with government portfolios and departments involved in trade policy-making. The framework could be applied to investigate what leads to success in other areas for elevating health in policymaking, particularly in departments outside of the health portfolio.

This piece was originally published in Croakey Health Media.

Header image credit: Ilyass SEDDOUGUnsplash

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