Does trade liberalization reduce child mortality in low- and middle-income countries? A synthetic control analysis of 36 policy experiments, 1963-2005

Is Economic Growth Good for Population Health? A Critical Review

A large multidisciplinary literature discusses the relationship between economic growth and population health. The idea that economic growth is good for societies has inspired extensive academic debate, but conclusions have been mixed. To help shed light on the subject, this paper focuses on opportunities for consensus in this large literature. Much scholarship finds that the health-growth relationship varies according to (1) which aspect of "health" is under consideration, (2) shape (e.g., positive linear or logarithmic), (3) issues of timing (e.g., growth over the short or long term), (4) a focus on health inequalities as opposed to population averages, and (5) multivariable relationships with additional factors. After reflecting upon these findings, I propose that economic growth promotes health in some respects, for some countries, and in conjunction with other life-supporting priorities, but does not by itself improve population health generally speaking. I then argue there is already wide, interdisciplinary consensus to support this stance. Moreover, policies focusing exclusively on economic growth threaten harm to both population health and growth, which is to say that political dynamics are also implicated. Yet multivariable approaches can help clarify the bigger picture of how growth relates to health. For moving this literature forward, the best opportunities may involve the simultaneous analysis of multiple factors. The recognition of consensus around these issues would be welcome, and timely.

Supplementary Information

The online version contains supplementary material available at 10.1007/s42650-023-00072-y.

Regional Effects of Maternal Mortality Determinants in Africa and the Middle East: How About Political Risks of Conflicts?

Background

As per the United Nations Women data, the maternal mortality rate in war-affected countries is critical and more than 800 million people live in war-affected countries (ICRC). External and internal conflicts such as foreign pressure, war and cross-border, civil disorder, terrorism, and civil war, are characteristics of Middle Eastern and African countries. Therefore considering the rapid increment of political risks and internal and external conflicts in Africa and the Middle East during the last decade, and considering warfare as a key contributor to maternal mortality; This paper seeks to evaluate the factors that have caused significant rates of maternal mortality in Middle Eastern and African countries by emphasizing the contributions of a number of political risk aspects as Civil Disorder Index, Terrorism Index, Civil War Index, Foreign Pressures Index, Cross-Border Conflict Index, War Index along with other socio-economic factors.

Method

Data were collected from forty-six countries during 2011–2016 to explore the regional contributions of political risk aspects to the maternal mortality rate through spatial approaches.

Results

It was found that GDP per capita, energy intensity, and urbanization strongly impacted maternal mortality. Also, it was observed that natural resource rents and economic growth significantly influenced the reduction of mortality by expanding healthcare services. The urban expansion was found to have elevated maternal mortality. A majority of external and internal conflicts reduced the orientation of production toward healthcare services and thus raised maternal mortality. On the other hand, war and cross-border were found to pose opposite impacts.

Conclusion

The findings revealed that political risks arising from terrorism, foreign pressure, and war in the adjacent countries would elevate the rate of mortality in the original country. This implies the spillover impacts of regional conflicts on maternal mortality elevation at the regional scale.

JEL Classification Codes: C23; I10; I18; N37:

Reassessing the health impacts of trade and investment agreements: a systematic review of quantitative studies, 2016-20

To ensure a high level of health protection, governments must ensure that health and trade policy objectives are aligned. We conducted a systematic review of the health impacts of trade policies, including trade and investment agreements (TIAs), to provide a timely overview of this field. We systematically reviewed studies evaluating the health impacts of trade policies published between Jan 19, 2016, and July 10, 2020. Included studies were quantitative studies evaluating the impact of TIAs and trade policies on health determinants or outcomes. We evaluated methodological quality and performed a narrative synthesis. 21 of 28 067 articles identified via searches met our criteria. Methodologically strong studies found reduced child mortality, deteriorating worker health, rising supplies of sugar, ultra-processed food, tobacco, and alcohol supplies, and increased drug overdoses following trade reforms, compared with the time periods before trade reform. However, associations varied substantially across contexts and socioeconomic characteristics. Our findings show that trade policies, including TIAs, have diverse effects on health and health determinants. These effects vary substantially across contexts and socioeconomic groups. Governments seeking to adopt healthy trade policies should consider these updated findings to ensure that opportunities for health improvement are leveraged and widely shared, while harms are avoided, especially among vulnerable groups.

Export Expansion May Increase Adult Illness and Injury: A Quasi-Natural Experiment on China's Accession to the World Trade Organization

Purpose

Exports can boost the economy, but may also cause harm to health through, for example, increased pollution and working hours. Although academic research extensively covers the impact of trade on health, few studies examine the mechanisms through which export expansion affects adult illness or injury within the past 4 weeks (illness/injury).

Method

We utilized China's entry into the World Trade Organization (WTO) as a quasi-natural experiment to investigate the relationship between export expansion and adult illness/injury. We explored the possible mechanisms and the heterogeneity of these associations. Our methodology was based on the analysis of China's Health and Nutrition Survey data, Chinese Customs databases, and China's Statistical Yearbook.

Results

Export expansion, induced by China's accession to the WTO, has a significantly positive effect on adult illness/injury [average effect (AE): 1.83%; 95% CI: 0.38–3.28%]. Our results remain robust following a series of robustness tests. Moreover, the effects of export expansion on adult illness/injury are more pronounced among urban residents (AE: 5.32%; 95% CI: 2.46–8.18%), women (AE: 2.68%; 95% CI: 0.57–4.80%), and higher-income groups (AE: 5.90%; 95% CI: 2.53–9.27%).

Conclusions

We find a statistically significant and positive effect of export expansion on adult illness/injury.

COVID-19, Trade, and Health: This Changes Everything? Comment on "What Generates Attention to Health in Trade Policy-Making? Lessons From Success in Tobacco Control and Access to Medicines: A Qualitative Study of Australia and the (Comprehensive and Progressive) Trans-Pacific Partnership"

Townsend and colleagues highlighted the myriad political forces which fostered attention to health issues during negotiations to establish a new trans-pacific trade deal in Australia (the CP-TPP [Comprehensive and Progressive Agreement for Trans-Pacific Partnership], formerly known as TPP). Among the factors they identify, exporter interests and exogenous events helped to generate attention to trade-related concerns about tobacco and access medicines, and limited attention to nutrition and alcohol. These are important considerations as the United Kingdom negotiates a trade deal with the United States in haste, whilst at the same time attempting to manage the ongoing coronavirus disease 2019 (COVID-19) pandemic. In this commentary, I reflect on changing attention to trade and nutrition during the COVID-19 pandemic in light of Townsend and colleagues' analysis. I explore scope for greater attention to nutrition in US-UK trade negotiations, and the challenges created by the vested interests of major UK and US processed food exporters. I further discuss the utility of the theoretical tools employed by Townsend and colleagues for wider debates in the political economy of health.

Does contracting-out of primary health care services to non-state providers reduce child mortality in South Sudan? A synthetic control analysis

Contracting-out is increasingly utilized as a health system strengthening strategy in lower- and middle-income countries (LMICs), to expand access to health interventions known to reduce child mortality. Existing scholarship suggests its effect has been mixed, limiting a definitive conclusion on its magnitude and direction. There are few studies assessing the impact on under-five mortality rate (U5MR) and fewer evaluations to-date have focused on Sub-Saharan Africa. We test the hypothesis that the contracting-out approach implemented in South Sudan in 2012 led to an observable reduction in U5MR. We use a novel approach, the synthetic control method to construct a synthetic South Sudan from a panel of LMICs using data from the World Bank Developmental Indicators (WDI) database. The analysis shows on average, contracting-out had a limited effect on the rate of decline of U5MR; U5MR declined by 5.2% annually between 2000 and 2011, and by 2.58% between 2012 and 2014. Relative to its synthetic control, U5MR is 2% and 5% higher in 2012 and 2013, continuing to diverge during the observation period. These findings suggest limitations in the contracting approach, and we discuss the possible policy implications of these findings.

Brexit and trade policy: an analysis of the governance of UK trade policy and what it means for health and social justice

BACKGROUND

There is an extensive body of research demonstrating that trade and globalisation can have wide-ranging implications for health. Robust governance is key to ensuring that health, social justice and sustainability are key considerations within trade policy, and that health risks from trade are effectively mitigated and benefits are maximised. The UK's departure from the EU provides a rare opportunity to examine a context where trade governance arrangements are being created anew, and to explore the consequences of governance choices and structures for health and social justice. Despite its importance to public health, there has been no systematic analysis of the implications of UK trade policy governance. We therefore conducted an analysis of the governance of the UK's trade policy from a public health and social justice perspective.

RESULTS

Several arrangements required for good governance appear to have been implemented - information provision, public consultation, accountability to Parliament, and strengthening of civil service capacity. However, our detailed analyses of these pillars of governance identified significant weaknesses in each of these areas.

CONCLUSION

The establishment of a new trade policy agenda calls for robust systems of governance. However, our analysis demonstrates that, despite decades of mounting evidence on the health and equity impacts of trade and the importance of strong systems of governance, the UK government has largely ignored this evidence and failed to galvanise the opportunity to include public health and equity considerations and strengthen democratic involvement in trade policy. This underscores the point that the evidence alone will not guarantee that health and justice are prioritised. Rather, we need strong systems of governance everywhere that can help seize the health benefits of international trade and minimise its detrimental impacts. A failure to strengthen governance risks poor policy design and implementation, with unintended and inequitable distribution of harms, and 'on-paper' commitments to health, social justice, and democracy unfulfilled in practice. Although the detailed findings relate to the situation in the UK, the issues raised are, we believe, of wider relevance for those with an interest of governing for health in the area of international trade.

COVID-19 and the collapse of global trade: building an effective public health response

The scale of the COVID-19 pandemic is a consequence of international trade and globalisation, with the virus spreading along established trade and travel routes. However, the pandemic also affects international trade through reductions in both supply and demand. In this Viewpoint we describe the many implications for health and propose ways to mitigate them. Problems include reduced access to medical supplies (in particular, personal protective equipment and tests), budgetary shortfalls as a result of reduced tariffs and taxes, and a general decline in economic activity-leading, in many cases, to recessions, threats to social safety nets, and to increased precariousness of income, employment, and food security. However, in exceptional cases, the pandemic has also brought some transient benefits, including to the environment. Looking ahead, there will be great pressure to further liberalise rules on trade to encourage economic recovery, but it is essential that trade policy be informed by its many consequences for health to ensure that the benefits are maximised and threats are minimised through active identification and mitigation.

For the children? A mixed methods analysis of World Bank structural adjustment loans, health projects, and infant mortality in Latin America

Background

The World Bank wields immense financial and normative power in health in the developing world. During the 1980s and 1990s, in the face of intense criticism of its structural adjustment policies, the World Bank purportedly turned its attention to “pro-growth and pro-poor” policies and new lending instruments. One focus has been an investment in maternal and infant health. My analysis uses a mixed methods approach to examine the relationship between traditional structural adjustment and health loans and projects and infant mortality in Latin America and the Caribbean from 2000 to 2015.

Results

My answer to whether the World Bank’s projects in Latin America worked “for the children” is: somewhat. The results are heartening in that quantitatively, health projects are associated with lower infant mortality rates, net of controls, whereas traditional structural adjustment loans do not appear to be negatively associated with infant mortality, though examined across a short time horizon. Qualitative data suggest that infants, children, and mothers are considered in World Bank loans and projects in the context of an economic logic: focusing on productivity, economic growth, and human capital, rather than human rights.

Conclusion

Taken together, my results suggest that the World Bank appears to, at least partially, have amended its approach and its recent work in the region is associated with reductions in infant mortality. However, the World Bank’s economistic approach risks compartmentalizing healthcare and reducing people to their economic potential. As such, there remains work to do, in Latin America and beyond, if health interventions are to be effective at sustainably and holistically protecting vulnerable groups.

Liberal trade policy and food insecurity across the income distribution: an observational analysis in 132 countries, 2014-17

Background

Eradicating food insecurity is necessary for achieving global health goals. Liberal trade policies might increase food supplies but how these policies influence individual-level food insecurity remains uncertain. We aimed to assess the association between liberal trade policies and food insecurity at the individual level, and whether this association varies across country-income and household-income groups.

Methods

For this observational analysis, we combined individual-level data from the Food and Agricultural Organization of the UN with a country-level trade policy index from the Konjunkturforschungsstelle Swiss Economic Institute. We examined the association between a country's trade policy score and the probability of individuals reporting moderate-severe or severe food insecurity using regression models and algorithmic weighting procedures. We controlled for multiple covariates, including gross domestic product, democratisation level, and population size. Additionally, we examined heterogeneity by country and household income.

Results

Our sample comprised 460 102 individuals in 132 countries for the period of 2014–17. Liberal trade policy was not significantly associated with moderate-severe or severe food insecurity after covariate adjustment. However, among households in high-income countries with incomes higher than US$25 430 per person per year (adjusted for purchasing power parity), a unit increase in the trade policy index (more liberal) corresponded to a 0·07% (95% CI −0·10 to −0·04) reduction in the predicted probability of reporting moderate-severe food insecurity. Among households in the lowest income decile (<$450 per person per year) in low-income countries, a unit increase in the trade policy index was associated with a 0·35% (0·06 to 0·60) increase in the predicted probability of reporting moderate-severe food insecurity.

Interpretation

The relationship between liberal trade policy and food insecurity varied across countries and households. Liberal trade policy was predominantly associated with lower food insecurity in high-income countries but corresponded to increased food insecurity among the world's poorest households in low-income countries.

Funding

Joseph Rowntree Foundation, Economic and Social Research Council.

Global disparities in health-systems financing: A cross-national analysis of the impact of tariff reductions and state capacity on public health expenditure in 65 low- and middle-income countries, 1996-2015

Understanding what contributes to cross-national differences in public health spending among low- and middle-income countries (LMICs) can help identify how policy-makers can reduce global disparities. Yet, research on this topic has so far overlooked the potential influence of one of the most strongly recommended economic reforms during the post-war era: reducing international trade taxes, 'tariffs'. Tariffs are an important source of tax revenue for some LMICs. Tariff declines can impact on government finances, and these changes may constrain public health expenditure where states lack the capacity to tax non-trade activities. We examined the association between tariff changes and public health spending in 65 LMICs, 1996-2015. We identify substantial variation in this association according to one indicator of state capacity, a country's score on the World Governance Indicators government effectiveness (GE) index. For example, tariff declines corresponded to reduced public health expenditures in countries with low GE scores. Our results suggest that tariff changes and domestic taxation capacities have an under-recognised impact on public health expenditure and may contribute to global health spending disparities.

Globalization and health equity: The impact of structural adjustment programs on developing countries

Among the many drivers of health inequities, this article focuses on important, yet insufficiently understood, international-level determinants: economic globalization and the organizations that spread market-oriented policies to the developing world. One such organization is the International Monetary Fund (IMF), which provides financial assistance to countries in economic trouble in exchange for policy reforms. Through its 'structural adjustment programs,' countries around the world have liberalized and deregulated their economies. We examine how policy reforms prescribed in structural adjustment programs explain variation in health equity between nations-approximated by health system access and neonatal mortality. Our empirical analysis uses an original dataset of IMF-mandated policy reforms for a panel of up to 137 developing countries between 1980 and 2014. We employ regression analysis to evaluate the relationship between these reforms and health equity, taking into account the non-random selection and design of IMF programs. We find that structural adjustment reforms lower health system access and increase neonatal mortality. Additional analyses show that labor market reforms drive these deleterious effects. Overall, our evidence suggests that structural adjustment programs endanger the attainment of Sustainable Development Goals in developing countries.