Health Policy and Planning, 33, 2018, 123–136

doi: 10.1093/heapol/czx133
Advance Access Publication Date: 2 November 2017
Review

A conceptual framework for investigating the

impacts of international trade and investment
agreements on noncommunicable disease
risk factors

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Ashley Schram1,*, Arne Ruckert6, J Anthony VanDuzer2, Sharon Friel1,
Deborah Gleeson3, Anne-Marie Thow4, David Stuckler5 and
Ronald Labonte6
1
School of Regulation and Global Governance, Australian National University, 8 Fellows Road, Canberra, ACT 2601,
Australia, 2Faculty of Law, University of Ottawa, Ottawa, ON, Canada, 3School of Psychology and Public Health, La
Trobe University, Melbourne, Australia, 4Menzies Centre for Health Policy, School of Public Health, University of
Sydney, Sydney, Australia, 5Carlo F. Dondena Centre for Research on Social Dynamics and Public Policy, Bocconi
University, Milan, Italy and 6School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa,
Ottawa, ON, Canada
*Corresponding author. School of Regulation and Global Governance, Australian National University, 8 Fellows Road,
Canberra, ACT 2601, Australia. E-mail: [Link]@[Link]
Accepted on 4 September 2017

Abstract
We developed a conceptual framework exploring pathways between trade and investment and
noncommunicable disease (NCD) outcomes. Despite increased knowledge of the relevance of so-
cial and structural determinants of health, the discourse on NCD prevention has been dominated
by individualizing paradigms targeted at lifestyle interventions. We situate individual risk factors,
alongside key social determinants of health, as being conditioned and constrained by trade and in-
vestment policy, with the aim of creating a more comprehensive approach to investigations of the
health impacts of trade and investment agreements, and to encourage upstream approaches to
combating rising rates of NCDs. To develop the framework we employed causal chain analysis, a
technique which sequences the immediate causes, underlying causes, and root causes of an
outcome; and realist review, a type of literature review focussed on explaining the underlying
mechanisms connecting two events. The results explore how facilitating trade in goods can in-
crease flows of affordable unhealthy imports; while potentially altering revenues for public service
provision and reshaping domestic economies and labour markets—both of which distribute and re-
distribute resources for healthy lifestyles. The facilitation of cross-border trade in services and
investment can drive foreign investment in unhealthy commodities, which in turn, influences con-
sumption of these products; while altering accessibility to pharmaceuticals that may mediate NCDs
outcomes that result from increased consumption. Furthermore, trade and investment provisions
that influence the policy-making process, set international standards, and restrict policy-space,
may alter a state’s propensity for regulating unhealthy commodities and the efficacy of those regu-
lations. It is the hope that the development of this conceptual framework will encourage capacity
and inclination among a greater number of researchers to investigate a more comprehensive range
of potential health impacts of trade and investment agreements to generate an extensive and
robust evidence-base to guide future policy actions in this area.

C The Author 2017. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.
V
All rights reserved. For permissions, please e-mail: [Link]@[Link] 123
124 Health Policy and Planning, 2018, Vol. 33, No. 1

Keywords: International trade and investment agreements, social determinants of health, lifestyle risk factors, noncommunicable
diseases

Key Messages

• This article develops a conceptual framework, supported by a realist review, of the relationships between trade and in-
vestment policy and NCDs to encourage capacity and inclination among a greater number of researchers to investigate
a more comprehensive range of potential health impacts of trade and investment agreements.
• The review and proposed conceptual framework explicates how provisions within trade and investment agreements
condition and constrain key behavioural risk factors and social determinants of health driving NCD rates.
• Robust empirical evidence on the causal pathways between trade and investment agreements and health outcomes is

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greatly needed to more effectively assess the impacts of international trade and investment rules on NCD rates.

Introduction This article aims to bring together the growing body of literature
connecting trade and investment policy to key lifestyle risk factors in
Noncommunicable disease (NCD) morbidity and mortality together
the WHO’s 444 NCD framework, specifically tobacco, alcohol
present one of the largest threats to social and economic develop-
and unhealthy dietary products [collectively referred to as health
ment in the 21st century (World Health Organization 2013).
harmful commodities (HHCs) throughout this article] to develop
Presently, NCDs are responsible for 38 million deaths annually,
the links between these health behaviours and structural-level poli-
42% of which occur prematurely (before age 70) (World Health
cies. In an attempt to begin constructing more detailed and compre-
Organization 2015). The World Health Organization (WHO) de-
hensive frameworks, we introduce exploratory pathways from trade
veloped what has become a near ubiquitous framing of NCDs in a
and investment to NCDs through access to medicines and select so-
444 framework: four key NCD outcomes (cardiovascular dis-
cial determinants of health (SDH). This study can assist academics,
eases, cancers, chronic respiratory diseases and diabetes); that are
civil society and policy-makers in thinking about an increasingly
caused by four key metabolic risk factors (hypertension, hypergly-
comprehensive range of pathways through which international trade
caemia, hyperlipidemia and overweight/obesity); which are in turn
and investment rules may be producing negative externalities for
driven by four key lifestyle risk factors (tobacco use, alcohol use, un-
health, and encourage future research to enhance the functionality
healthy diet and physical inactivity) (World Health Organization
of the framework introduced here. Moreover, it can help expand the
2015). Although the WHO has advocated more complex and com-
discourse on causal drivers of NCDs beyond individualizing para-
prehensive approaches to NCD outcomes and pathways in various
digms to a focus on upstream policies and health equity.
fora, this highly pervasive and individualizing framework, which
places the onus on individuals and their lifestyle choices (Roberto
et al. 2015), has played an important role in directing NCD policy Methodology
responses at behavioural determinants.
Increased knowledge of social and structural determinants of The conceptual framework was developed with the use of two meth-
health (Commission on Social Determinants of Health 2008) has ex- ods: (1) causal chain analysis, a technique which sequences immedi-
panded the breadth of policy areas that are investigated as drivers of ate causes, underlying causes, and root causes of an outcome
health outcomes, including macroeconomic policy areas such as (Global Environment Facility 2014); and (2) realist review, a litera-
trade and investment agreements. Upstream policy approaches such ture review focussed on explaining the underlying mechanisms con-
as these acknowledge that health behaviours, often framed as indi- necting two events and the context within which that connection
vidual choices, are in fact conditioned and constrained by the poli- occurs, used to assist in developing and validating the pathways of
cies that shape varying aspects of our lives such as our living the framework, and to identify gaps in the literature that connect
environments, educational opportunities, employment conditions, trade and NCD outcomes (Pawson et al. 2005).
distribution of resources and social norms. Although the public
health community has been actively engaging with trade and invest- Framework development—causal chain analysis
ment policy for more than a decade examining multiple pathways The initial draft of the conceptual framework was developed as a
between trade and public health (World Health Organization, composite of existing frameworks which have sequenced the rela-
World Trade Organization 2002), the literature still lacks a compre- tionships between trade (root cause) and health outcomes through a
hensive review of, and conceptual framework synthesizing, the path- set of underlying and immediate causes (Labonte 2004; Thow 2009;
ways between international trade and investment agreements and Friel et al. 2013a, b). As noted above, these frameworks were per-
health outcomes. Existing frameworks have either been very broad, ceived as either too broad or too limited in their subject scope to
such as those examining the larger processes of globalization on guide more comprehensive approaches to evaluating the relation-
health, at the expense of a detailed exploration of trade and invest- ships between trade and investment agreements and NCD outcomes.
ment provisions (Labonte 2004); or very specific, providing a The framework developed here focuses on trade and investment pol-
sophisticated exploration of the health impacts of trade and invest- icy as a driver of the key lifestyle risk factors in the WHO’s 444
ment agreements through one channel, such as food environments, framework on NCDs, specifically tobacco, alcohol and unhealthy
at the expense of a more inclusive suite of intervening factors (Thow diet. Physical inactivity was excluded from the present framework
2009; Legge et al. 2011; Friel et al. 2013b). as it has received relatively little attention in relation to trade and
Health Policy and Planning, 2018, Vol. 33, No. 1 125

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Figure 1. Medline (PubMed) trend for papers indexed with trade and various health topics

investment provisions (see Figure 1), and would generally be im- The initial framework was generated by a core development
pacted in different ways than HHCs, which can be considered in ag- team of three experts in trade and health and was modelled on an
gregate. For example, while provisions regarding technical barriers existing framework mapping the pathways between trade libera-
to trade or regulatory coherence would be important for regulatory lization and nutrition transition (Thow 2009). This was then aug-
responses, such as labelling or advertizing restrictions, to increasing mented with novel constructs present in the remaining existing
volumes of HHCs, facilitated by lower tariff rates; physical inactiv- frameworks (Labonte 2004; Friel et al. 2013a, b), and expanded to
ity lacks a direct relationship with tariff rates or compensatory regu- capture tobacco and alcohol, access to medicines and the selected
latory responses. The complex indirect relationships between trade SDH. The first draft of the framework was then distributed for feed-
and investment agreements and barriers or opportunities for back to the remaining four members of a larger research project
increased physical inactivity should be explored in future studies team and subsequently revised. The revised framework was next cir-
and incorporated into future revisions of this framework. culated to a five member expert advisory panel. Members of the pro-
To enhance the comprehensiveness of this framework, access to ject team and the advisory panel were selected based on expertise in
medicines was included on the rationale that pharmaceuticals play health policy, trade policy, law and political science from academia
an important role in attenuating NCD outcomes by preventing the and civil society; as well as involvement in the development of the
development of metabolic risk factors or limiting their ensuing previous frameworks. Two iterations of this process were completed
health effects after increased exposure to HHCs; and that access to before the framework was finalized.
medicines has been a key area of study in the literature on trade and
health. In addition, we integrated potential impacts of trade and in-
vestment agreements on select SDH—income, employment and Framework development—realist review
health and social services. We theorized that trade and investment The search strategy for the realist review included multiple combin-
provisions would present several avenues to affect change in these ations of search term sets (see Table 1) using three multidisciplinary
identified domains, which could each have direct and indirect im- databases: Web of Knowledge, Proquest and Scopus. Articles were
pacts on HHC consumption and NCD outcomes. For example, the restricted to the timeframe between January 2000 and June 2014 to
level of disposable household income—theoretically impacted by cover the vast majority of the period of expansion of contemporary
trade and investment liberalization, including through altered em- trade and investment agreements (World Trade Organization), while
ployment opportunities—may determine monetary resources avail- maintaining feasibility of the review. Search terms within the eco-
able for the purchase of HHCs; while new employment conditions nomic issues subset were intended to capture the selected SDH;
may trigger changes in levels of stress and subsequent consumption however, to restrict the vast coverage of trade and economic issues
of HHCs as a coping mechanism. Negative health outcomes of ele- in the literature, we paired economic terms with health and risk fac-
vated HHC consumption can be mediated by access to health ser- tor search terms to keep the results within scope and relevant to our
vices—either through government provided services, employer review. Thus, the terms from trade and economic issues in Table 1
provided health insurance or disposable income for out-of-pocket were always paired with either food supply, tobacco, alcohol, access
payments—all of which are possibly influenced by trade and invest- to medicines or health. Searches combining terms from trade, trade
ment provisions. This example demonstrates that SDH have the cap- and health policy issues and policy were included to cover topics ap-
acity to influence health behaviours, and mediate health outcomes, plicable to all HHCs. The initial search results returned 24 343 art-
through a number of complex interactions. The current framework icles. Inclusion criteria required articles to be within the timeframe,
attempts to integrate some of this complexity but will benefit from published in English, and to connect trade and investment to any
ongoing development in this area. one or more of the following areas: diet, tobacco, alcohol, access to
126 Health Policy and Planning, 2018, Vol. 33, No. 1

Table 1. Realist review search terms

Concept Terms

Trade trade, investment, liberali*, globali*

Trade and health marketing, label*, tax*, ban*, packag*, warn*, additive*, flav*,
policy issues advertis*, licens*, dispute*
Economic issues FDI, welfare, economic growth, employment, unemployment, labo*,
poverty, neolib*, income, wage*
Food supply fast food, processed food, prepared food, snack food, obesogenic food, soda, soft drink,
packaged food, convenience food, sugar sweetened beverage, grocery, food retail,
food market*, food advertis*
Tobacco tobacco, smoking, nicotine
Alcohol alcohol, liquor, wine, spirits, beer
Access to medicine medicine, patent, data exclusivity

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Policy regulat*, policy space, policy capacity, FCTC, codex alimentarius, domestic
Health nutrition*, diet*, overweight, obes*, malnutrition, non-communicable disease

Table 2. Types of international and domestic trade and investment liberalization

Type of Agreement Description Example

Multilateral International trade and/or investment agreement between Trade-Related Aspects of Intellectual
all members of an organization (generally referring to the Property Rights (TRIPS)
agreements of the World Trade Organization)
Plurilateral International trade and/or investment agreement between a Agreement on Government Procurement
subset of members of an organization (generally referring (AGP)
to the agreements of the World Trade Organization)
Regional International trade and/or investment agreement between Trans–Pacific Partnership (TPP)
two or more countries connected by a geographical
region
Bilateral International trade and/or investment agreement between U.S.–Korea Free Trade Agreement
any two countries (KORUS)
Unilateral Domestic trade and investment policy of a single country The Philippines’ Foreign Investments Act
of 1991

medicines or NCDs directly. In order to capitalize on available evi- choose, design, and implement public policies to fulfil their aims”
dence, the realist review included all forms of trade and investment (Koivusalo et al. 2009). Within the discussion of each of the three
liberalization (see Table 2). main pathways (i.e. goods, services and investment and policy
A round of eliminations by title and then by abstract based on space), the text opens with a general introduction to the relevant
the inclusion criteria reduced the results to 6493 articles and 191 trade and investment provisions before turning to a more in depth
articles, respectively. The 191 articles were then reviewed and coded exploration of the pathways between trade and NCDs through
by two team members using NVivo 10 software for validation or re- HHCs and the social determinants of heath, based on the reviewed
finement of the framework pathways. Coding began deductively evidence.
using a line-by-line technique based on the hypothesized pathways
from the initial framework. Inductive coding was also incorporated
when new relationships within the framework became evident from Framework structure
the reviewed articles. After this first phase of coding was completed, It is important to acknowledge at the outset that the influence of
targeted searches within the Google Scholar database, without time- trade and investment liberalization on health can be mediated by a
frames, were performed to explore evidence for pathways that had country’s health system’s capacity to respond to these challenges,
emerged during the iterative development of the framework, and for existing levels of systemic inequities within and between countries,
pathways where little or no evidence had turned up from the initial and economic and social policies enacted at national and interna-
search strategy, which resulted in 46 additional articles in the realist tional levels (e.g. tax systems, social welfare policy, structural ad-
review. justment programmes). The framework has been designed with
neutral language to permit either positive or negative health out-
comes depending on the domestic context within which the causal
Results chain occurs, although at present the content focuses disproportion-
This section begins by outlining the structure and key principles of ately on health risks rather than health opportunities given the focus
the framework. It then provides an overview of the changes to the on the WHO 444 framework exploring risk factors. In addition,
underlying and immediate causes of NCDs as a consequence of the in contrast to systems thinking which focuses on a dynamic and
facilitation of: (1) trade in goods; (2) services and investment; and complex interacting system, causal chain analysis examines cause
(3) changes to domestic policy space. Policy space is defined here as, and effect using a linear approach (Global Environment Facility
“. . . the freedom, scope, and mechanisms that governments have to 2014). Nevertheless, it is recognized that the proposed causal chains
Health Policy and Planning, 2018, Vol. 33, No. 1 127

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Figure 2. Conceptual framework of international trade and investment agreements and NCD

Figure 3. Facilitation of trade in goods pathway

are a part of a larger policy system and that the processes and out- Partnership (TPP) agreement, and existing frameworks within the
comes of each stage have the potential to feedback into earlier proc- literature, as noted earlier.
esses creating loops and interactions throughout the framework.

Underlying and immediate causes

Trade and investment policy provisions The second and third columns from the left identify the theorized
The first column on the left of the framework (see Figure 2) identi- underlying and immediate causes, respectively, of the identified pro-
fies key provisions with relevance for NCD outcomes within a trade visions. In general, the underlying causes are those that pertain to
and investment agreement (the root cause). It is divided into three the business and regulatory environment, that is, changes relevant to
sections: (1) facilitation of trade in goods; (2) facilitation of services industry and investors regarding how they operate and to govern-
and investment; and (3) domestic policy space and governance. The ments and policy-makers regarding how they regulate. Immediate
structure of this section was informed by the North American Free causes are those that pertain generally to the individual and their im-
Trade Agreement (NAFTA), proposed chapters in the Trans–Pacific mediate environment, as a consumer, as a worker and as a resident
128 Health Policy and Planning, 2018, Vol. 33, No. 1

of a particular community or country. The pathways between trade volume and diversity of products; and the quality of traded goods.
and investment provisions and NCD morbidity and mortality are Tariff reductions often mean a reduction in the cost of imported
divided into impacts through HHCs and access to medicines, and goods (Thow and Hawkes 2009; Zeigler 2009; Pouliot and Larue
impacts through the selected SDH. 2012). The health implications of this will vary based on whether
the increased volumes reflect health-harmful or health-promoting
products. Lower priced goods can be beneficial for consumers, spe-
Noncommunicable disease outcomes
cifically, lower priced, healthful food imports (Auslin 2012); how-
The fourth column from the left identifies the beginning of the
ever, imports can also have negative effects when the price of HHCs
WHO 444 framework on NCDs, starting with the key lifestyle
is driven down as in the case of tobacco or alcohol (Hill 2004; Lee
risk factors which are concerned principally with individual health
et al. 2009, 2012b). Market competition may also create a situation
behaviours including consumption of tobacco, alcohol and un-
where cheaper but less healthy imported products replace traditional
healthy dietary products. This model has been altered here with the
domestic goods, as seen in the case of Samoa where processed and
exclusion of physical inactivity and the addition of access and adher-
hydrogenated oils replaced locally produced coconut oils after an
ence to medical treatment. The final column on the right identifies

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episode of trade liberalization (Thow et al. 2011).
changes to metabolic risk factors and our key health outcome of
The reduced cost of imported goods after tariff reduction is asso-
interest, NCDs, specific to the key risk factors and key outcomes
ciated with increased volumes and diversity of imported products.
identified by the WHO framework (World Health Organization
Increased flows of imports often include HHCs like tobacco, alcohol
2015).
and ultra-processed food (Hawkes 2006; Clark et al. 2012). For ex-
ample, reduction of import tariffs in Samoa and Fiji during periods
Facilitation of trade in goods of unilateral liberalization resulted in increased import of processed
Trade and investment policy provisions and packaged goods from around the world, including confection-
This section of the framework conceptualizes the pathways between aries, pastries and cereals (Thow et al. 2011); and imports of US
trade in goods and NCDs (see Figure 3), highlighting the role of re- chocolate, candy, cookies, pastries, popcorn, chips and confection-
duction (or elimination) of both tariff and nontariff barriers in facili- ary grew across Central America after a free trade agreement with
tating trade. Market Access chapters in trade and investment the United States (Thow and Hawkes 2009). The impact of trade
agreements list the maximum tariffs (import or border taxes) and and investment liberalization on availability and affordability of
tariff-rate quotas (a two-tiered tariff that provides a starting tariff consumer products, including HHCs, might not always be uniform:
rate and then an increased tariff rate when import volumes exceed a after the implementation of NAFTA consumer food prices decreased
specified quota). Tariff schedules cover all goods, including tobacco, in Canada, while food prices rose significantly faster than inflation
alcohol and agricultural products (including ultra-processed food in Mexico (Otero 2011).
products and key agricultural inputs such as corn, sugar and soy), as
well as pharmaceuticals, vaccines, medical devices and health tech- Health impacts through the SDH. Market access can influence
nologies to diagnose and treat NCDs. NCDs via three main SDH pathways: how it impacts economic ac-
Trade in goods is also influenced by non-tariff barriers, and so tivity and income; the extent to which tariff reductions may remove
trade and investment agreements include chapters on sanitary and a revenue stream for government-provided social and health ser-
phytosanitary standards and technical barriers to trade. Sanitary vices; and the nature of the changes to a country’s export production
and phytosanitary standards indicate how governments can apply
and new import-competition and associated alterations to the do-
food safety standards and animal and plant health measures. Key
mestic economic structure and labour market. Shifts in what a coun-
provisions include references to international standards (including
try imports and exports as a consequence of tariff reductions have
the Codex Alimentarius) and the rules regarding the role of ‘science’
important implications for its domestic economy and labour mar-
and ‘evidence’ needed to justify standards perceived as more strin-
kets. The health case for trade liberalization usually rests on the as-
gent than those agreed upon internationally. Technical barriers to
sumption of health-enhancing benefits of economic growth induced
trade aim to ensure that domestic technical regulations, standards,
by free trade (Dollar 2001; Dollar and Kraay 2004; Berger et al.
and conformity assessment procedures are non-discriminatory and
2013; Francois et al. 2013). However, there is no general agreement
do not create unnecessary obstacles to trade. Provisions may indi-
in the literature on this, except that the implications of trade and in-
cate the level of protection of domestic policy space, formation of
vestment agreements for domestic economies and labour markets
standards, opportunities for private actor involvement in policy-
are highly nuanced and context-dependent (Lopez-Acevedo and
making, and any hindrances to the policy-making process. These
Robertson 2012; McNamara 2015). For example, evidence shows
types of commitments, while highly relevant to trade in goods, influ-
that NAFTA created very little economic gain for Mexico (Arnold
ence health outcomes primarily through restrictions on domestic
2006), with gross domestic product (GDP) growth in Mexico in the
policy space and governance regarding quality standards and regula-
first 10 years of NAFTA (1995–2005) remaining below historic
tory matters of NCD risk factors, such as HHCs. Thus, further ex-
averages (Moreno-Brid et al. 2005; Pacheco-López 2005), while the
ploration of these chapters is included in the final pathway:
United States experienced a growth boost post-NAFTA. Similarly, a
domestic policy space and governance.
recent econometric analysis of the TPP’s impact expects mild eco-
nomic losses for developed TPP economies (0.04% average annual
Underlying and immediate causes GDP change) but some growth for developing economies (þ0.22%
Health impacts through HHCs. Liberalizing market access can gen- average annual GDP change) as directly resulting from the deal
erate changes to import and export flows which, in turn, impact (Petri et al. 2011).
availability and affordability of HHCs. Reduced tariff rates, along- How trade and investment agreements impact tariff generation
side the harmonization of product standards, may result in changes can also affect access to NCD preventive services or treatment.
to: the price of imports and intensified market competition; the Tariffs can be a valuable source of government revenue for public
Health Policy and Planning, 2018, Vol. 33, No. 1 129

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Figure 4. Facilitation of trade in services and investment pathway

services, including health expenditure; although, an individual coun- be in response to global competition that, in part, is increased through
try’s reliance on tariff revenue and its ability to replace such revenue liberalization.
after liberalization through other means, such as domestic excise
taxes or increased employment taxes, varies (Cagé and Gadenne
2014). Middle-income countries have been able to recover between Facilitation of services and investment pathways
40 and 60% on average, while low-income countries have fared Trade and investment policy provisions
worse, recovering between 0 and 30% on average (Labonté 2012). This section of the framework conceptualizes the pathways between
Thus, the impact of lost revenue is likely to be more perceptible in the facilitation of services and investment and NCDs (see Figure 4).
the world’s poorest countries which rely on tariffs for 25–50% of all Trade in services is facilitated by providing foreign investors new or
public revenue (Labonté 2012). Whatever health and social services greater market access to domestic service sectors, usually specified
are being publicly provided in these countries are likely to suffer within a services chapter. The promotion of foreign direct invest-
when tariffs are reduced. The implications of liberalization may ment (FDI) is more multifaceted and FDI inflows depend on a series
compound when labour market insecurities rise simultaneously with of factors like political and economic stability, infrastructure, wages,
tariff losses, which may diminish a state’s capacity to finance health tax structure and proximity to main markets (Morisset and Pirnia
and social support programs to offset labour insecurity (Labonté 2000; Lim 2001). One mode of service sector liberalization, com-
et al. 2007; McNamara, 2015). mercial presence (discussed below), is specific to the promotion of
Changes in the composition of labour sectors are another im- FDI. Moreover, intellectual property rights were subsumed under
portant consideration as they drive the quality and quantity of em- the trade and investment regime on the premise that a strong na-
ployment, including labour conditions. Current evidence suggests tional intellectual property system would encourage FDI, particu-
that the impacts of trade and investment agreements on labour mar- larly FDI into research and development in the industrial and
kets and employment conditions are highly variable (Salvatore scientific fields (Idris 2003). Expansive investor rights and the inclu-
2007). While a shift in what a country imports and exports has im- sion of investor–state dispute settlement mechanisms in trade and in-
portant implications for its domestic labour market, this impact will vestment agreements may also assist in fostering FDI inflows;
vary among individual sectors creating winners and losers. NAFTA, however, as with sanitary and phytosanitary standards and technical
for example, was beneficial for many fruit, vegetable and coffee pro- barriers to trade, these topics will be reserved for in-depth explor-
ducers in Mexico that had advantages in climate, geography and la- ation in the final pathway (domestic policy space and governance)
bour costs; while Mexican grain producers lost due to disadvantages as they affect health outcomes primarily through their impacts on
in climate, mechanization and US government subsidies to their do- policymaking processes.
mestic producers (Fairbrother 2007).
Increased trade and investment liberalization may also be related Services—market access. Trade in services encompasses an excep-
to the recent rise of precarious and informal employment, which may tionally wide range of domestic economic activity and can include
have impacts on NCD rates through increased HHC consumption all services that are commercially or competitively provided. Under
driven by chronic stress, or more directly through material deprivation the WTO rules, member states must provide most-favoured nation
due to bouts of unemployment, greater exposure to hazardous work treatment to foreign service suppliers. WTO members cannot dis-
environments and lack of access to health benefits (Benach et al. criminate between the service suppliers of its trading partners, that
2007). For example, many agricultural labourers in Mexico lost their is, the most favourable conditions provides to service suppliers from
jobs during the implementation of NAFTA, with informal employ- one trading partner must be provided to all trading partners. As
ment after NAFTA accounting for 46% of all Mexican employment well, listing a service creates two primary obligations on states, the
(Arnold 2006). In addition, labour implications are often stratified, first of which is to provide market access to that service sector for
such that high-wage areas gained while regions with more low-skilled foreign individuals and enterprises. Market access is provided for
labour lost. In the USA, these losses have been mitigated in part by under four modes of service provision: (1) cross-border supply of
trade adjustment assistance (Salvatore 2007), something not all coun- services, (2) consumption abroad, (3) commercial presence to pro-
tries are able to provide. Labour market re-structuring is by no means vide a service; and (4) presence of natural persons to temporarily
caused by trade liberalization alone, but is a parallel process argued to provide a service. The second obligation is to provide non-
130 Health Policy and Planning, 2018, Vol. 33, No. 1

discriminatory treatment within committed service sectors through 2009). FDI has also facilitated rapid growth in fast-food retail out-
the right to national treatment. National treatment prevents discrim- lets, creating a growing demand for energy-dense foods (Hawkes
ination between domestic and foreign producers or providers, such 2005), while tobacco companies have used FDI to circumvent high
that imported goods, services, or investments should be treated no tariff rates by establishing production within countries to drive
less favourably than domestic goods, services or investments. down prices and increase sales (Lo 2010). FDI can further increase
Services agreements may permit each country to create a highly cus- the availability and affordability of ultra-processed food products
tomizable schedule of commitments, placing limitations on market (Hawkes 2005; Lo 2010), but it can also introduce entirely new cat-
access and national treatment, and most-favoured nation exemp- egories of (unhealthy) foods into a region, contributing to the emer-
tions. Recent regional trade and investment agreements, however, gence of obesogenic food environments (Thow et al. 2011).
do not provide the level of customization available in the World While trade in services can influence the availability and afford-
Trade Organization’s General Agreement on Trade in Services, and ability of HHCs, service liberalization introduces two additional
use a negative listing approach (only specified services are ex- pathways: what commodities are accessible (driven by the number
empted), which is likely to lead to a greater number of sector libera- and location of retail outlets), and what commodities are acceptable

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lization commitments (Adlung and Mamdouh 2013; Elms 2013). (driven by marketing and advertising) (Friel et al. 2013b). For ex-
ample, liberalization of marketing and advertising services has been
Intellectual property rights. An agreement on intellectual property highly influential in the growth of tobacco, alcohol and fast food
rights establishes the minimum standards of protection including the markets as it allows transnational companies to overcome one of the
subject-matter to be protected, the rights to be conferred and per- most powerful market entry barriers: generating consumer prefer-
missible exceptions to those rights, and the minimum duration of ence for foreign products (Lee et al. 2013).
protection. Such provisions include patent protection terms, added The global regime of intellectual property rights promoted and
time for delays in approval, or easing of the conditions for patent protected by international trade and investment agreements has im-
approvals such as allowing patents for new uses and methods of portant implications for the availability and accessibility of drugs to
existing products regardless of additional therapeutic benefit treat NCDs. Provisions in bilateral and regional free trade agree-
(Monasterio and Gleeson 2014). Provisions may also introduce or ments generally require stronger and longer monopoly protections,
extend the protection of clinical trial data, including for biologics, or enhanced enforcement measures, in comparison with the Trade-
compounds produced through biological processes that are crucial Related Aspects of Intellectual Property Rights (TRIPS) agreement
for treatment of cancer and immune conditions like rheumatoid of the World Trade Organization. These provisions generate market
arthritis (Lexchin and Gleeson 2016). Assessing the health impacts exclusivity for a longer period of time on an increasingly expanding
of enhanced intellectual property protections must balance the po- range of health technologies including pharmaceuticals, vaccines
tential negative impacts of increased public and private drug ex- and medical devices. These exclusivity provisions delay the entry of
penditures, against the incentives they might provide for research generic competition into the market. The TRIPS Agreement intro-
and development into new and needed therapeutic and diagnostic duced a minimum standard of 20-year patent-based monopolies for
techniques and the extent to which increased profits from extended drug developers to prevent generic manufacturers from “free-riding”
intellectual property protections will be (or are actually) re-invested on the brand-name companies that bear the research and develop-
in research and development. ment costs (Drahos and Braithwaite 2002). Expansive
TRIPSþ protections introduced in more recent trade and investment
agreements have been based on this same rationale.
Underlying and immediate causes TRIPSþ protections in trade and investment agreements have
Health impacts through HHCs and access to medicine. The body of reduced the availability and affordability of these products. As an ex-
evidence measuring the outcomes of services and investment libera- ample, the cost of antiretroviral therapy for human immunodeficiency
lization on HHCs is smaller than that examining the implications of virus (HIV) decreased from US$10 000 per person when on patent, to
trade liberalization on the same commodities. However, just as changes US$100 per person when made available generically (Kapczynski
to tariff and non-tariff barriers affect the import and export flow of 2015). New biologic drugs are particularly costly, with some cancer
HHCs across borders, changes to service sector liberalization and for- drugs estimated to cost over US$100 000 per year per patient (The
eign capital constraints can impact FDI flows into production, process- Cost of Cancer Drugs 2014). Estimates suggest that medicines expend-
ing, retailing and marketing and advertising of HHCs (Reardon et al. iture increased by 17% in Jordan from 1999 to 2004 as a result of intel-
2004). Changing levels of foreign capital in these activities can influ- lectual property protections introduced during its accession to the
ence the availability, accessibility, affordability and acceptability of World Trade Organization and the US–Jordan Free Trade Agreement
HHCs, and subsequently NCD rates. Similarly, the nature of intellec-
(Abbott et al. 2012). In the case of the Comprehensive Economic and
tual property rights protection can affect the availability, accessibility
Trade Agreement between the European Union and Canada, it was re-
and affordability of drugs, vaccines, medical devices and other health
cently estimated that additional annual costs to the Canadian health
technologies to diagnose and treat NCDs, including underlying meta-
system would be around CA$850 million when the agreement is fully
bolic risk factors, caused in part by HHC consumption.
phased in Lexchin and Gagnon (2013). Moreover, one study found
Increased FDI inflows often lead to greater concentration of
that the TRIPSþ provisions of the TPP could reduce HIV treatment
ownership and larger market share for transnational food and bever-
coverage in TPP member country, Vietnam, from 68 to 30% of eligible
age companies (Clark et al. 2012), for example Wal-Mart de
Mexico quickly became the country’s leading retailer after the sign- people living with HIV (Moir et al. 2014). Although two of these stud-
ing of NAFTA (Hawkes 2006). Changes in the food retail landscape ies focused on infectious disease, specifically HIV, similar trends can
linked to growing FDI flows, in turn, can impact HHC consumption reasonably be expected for NCD treatments.
patterns. One study found that much of the increased availability of
unhealthy snack foods in Central America following liberalization Health impacts through the SDH. Liberalization of the health sector
was a result of US FDI rather than US exports (Thow and Hawkes may result in increased privatization of health services and health
Health Policy and Planning, 2018, Vol. 33, No. 1 131

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Figure 5. Domestic policy space and governance pathway

insurance, although more empirical evidence is needed to better main pathways we identify in the framework include regulatory co-
understand the links between trade agreements and privatization of herence provisions that establish governance mechanisms for the de-
health services. As of 2004, 54 members of the World Trade velopment of domestic policy; sanitary and phytosanitary standards
Organization had made some liberalization commitments under and technical barriers to trade chapters that establish regulatory
health services, although this number rises to 78 when commitments standards; special annexes on publicly provided pharmaceutical
under private health insurance are included (Spiegel et al. 2004). coverage plans; expansive investor rights and the inclusion of in-
When privatization of health services occurs as a result of libera- vestor–state dispute settlement (ISDS) mechanisms; and government
lization, it also may lead to increased out-of-pocket spending on procurement provisions that regulate government contracts.
health services, and thus could result in medical poverty. The United Relative to the previous two pathways, there was considerably less
States, one of the few developed countries without a universal health empirical evidence for the relationships in this pathway captured in
care system (Fisher 2012), spent 17.1% of total GDP on health ex- our literature review, largely due to the novelty of such provisions in
penditures in 2015. This can be contrasted against countries like trade and investment agreements. Therefore, the relationships in this
Canada, New Zealand and Australia which spent 10.9, 9.7 and pathway are largely supported by theoretically informed deductive
9.4%, respectively, under public systems (World Bank 2016). reasoning at this time.
Cumulative public and private spending on healthcare in the USA is Provisions in a regulatory coherence or cooperation chapter,
higher than almost any developed country; however, it fails to out- first seen in the Canada–European Union agreement and in the
perform on any of the common measures of health (Morris 2012). TPP, have the potential to impact domestic policy space for the
As with trade in goods, the liberalization of trade in services has regulation of HHCs (Kelsey 2012, 2013). Provisions in such a chap-
the capacity to alter the composition of employment sectors within a ter may include new rules governing the process of developing pol-
domestic economy. Competitive advantages within the domestic icy, requirements to provide opportunities for private sector input
economy, including human capital, labour standards and natural re- (including private corporations based in other countries party to the
sources, will help determine which, if any, service areas will be desir- agreements), and new documentation required for all current and
able to foreign investors. Many of the implications for employment proposed regulatory policies. Contemporary agreements may also
and the domestic economy discussed under the facilitation of trade begin including provisions on pharmaceutical pricing and reim-
in goods pathway are equally applicable here, as are their implica- bursement procedures that could impact the availability and acces-
tions for NCDs through the distribution and redistribution of re- sibility of NCD treatment. Draft texts of the TPP had included
sources for a healthy lifestyle. Although evidence is still scarce, the measures on reference-based drug pricing, although these provi-
presence of foreign investment has been associated with higher sions did not make the final text (Lexchin and Gleeson 2016).
wages (Lim 2001; Lipsey and Sjöholm 2004). However, FDI inflows Reference-based pricing has been used by some governments as a
may also be inequality-enhancing, as the positive impact on wages is cost–containment mechanism for drug expenditures (Lee et al.
greater for skilled than for unskilled labour (Waldkirch 2008). 2012a; Bach 2016).
The inclusion of an expansive set of investor rights alongside an
ISDS mechanism in an investment chapter is also critical to under-
Domestic policy space and governance standing the potential health impacts of such agreements, given their
Trade and investment policy provisions capacity to empower private actors to challenge public policy meas-
This section of the framework conceptualizes the pathway between ures, including those regulating HHCs. Government procurement
domestic policy space and governance and NCDs (see Figure 5). The provisions may also be included which specify the instances and
132 Health Policy and Planning, 2018, Vol. 33, No. 1

conditions when foreign companies are permitted access to the do- 2015 alone (United Nations Conference on Trade and Development
mestic procurement contract bidding process; as well as change 2015). It has been suggested that ISDS may affect a government’s
stipulations on performance requirements included within these con- willingness to regulate in the public interest (Van Harten and Scott
tracts, such as limitations on requirements on domestic content, 2015). While evidence for regulatory chill is widespread for fields
local labour or even environmental standards. other than health, for example for environmental regulation (Brown
2013), evidence for this phenomenon is just starting to accumulate
in health research (Neumayer 2001; Tienhaara 2011; Van Harten
Underlying and immediate causes and Scott 2015). A concrete example of regulatory chill was the offi-
Health impacts through HHCs and access to medicines. In contem- cial statement from the government of New Zealand that it would
porary trade and investment agreements, considerable attention is not pursue tobacco plain packaging legislation until a decision was
paid to progressing convergence and equivalence of regulation made in the investor-state litigation against Australia for the same
among varying countries (Bhala 2014). For example, while requiring policy (3 News 2015).
adherence to minimum international standards, the Sanitary and Finally, the inclusion of regulatory provisions that seek to inter-

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Phytosanitary Standards and Technical Barriers to Trade vene in therapeutic- or value-based drug pricing have the capacity to
Agreements of the World Trade Organization also require that influence drug plan costs, which may mediate individual’s access to
standards are not more trade restrictive than necessary and that any NCD prevention or treatment. Implementing therapeutic reference-
policies that create stricter requirements than the relevant interna- based drug pricing has been estimated to save the Canadian province
tional standards must justify their necessity with scientific evidence. of British Columbia up to CA$44 million annually (Canadian
Thow et al. (2017), for example, explored trade concerns raised in Health Services Research foundation 2005). Review of reference-
the committee on Technical Barriers to Trade regarding front-of- based pricing in Australia, Denmark, Germany, Netherlands, New
pack interpretive nutrition labelling policy, which has been empiric- Zealand, Norway and Sweden also suggest short term savings
ally linked to healthier food choices (Campos et al. 2011; Hersey (Ioannides-Demos et al. 2002).
et al. 2013; Volkova and Mhurchu 2015). They noted that members
had queried such policies in Thailand, Chile, Peru, Indonesia and Health impacts through the SDH. The first pathway that links do-
Ecuador regarding the justification of the specific labelling measures mestic policy space to health through the SDH focuses on changes to
proposed, the scientific evidence for the effectiveness of such meas- government procurement principles outlined in trade treaties.
ures, and the consistency of the measures with international stand- Government procurement has been an important tool for economic
ards. All countries proceeded with legislation to implement these development by creating demand for locally produced goods and ser-
nutrition labelling policies (with the expectation of Thailand which vices, often under conditions that promote equity, social justice and
modified their measure from interpretive labelling to a warning that environmental sustainability (Kaye Nijaki and Worrel 2012). For ex-
children should consume less), suggesting that converging regulation ample, construction of a new government-funded hospital may be
may introduce greater administrative and scientific requirements in built with the intention of improving access to health services; how-
HHC policy development, but may not necessarily deter those states ever, the actual construction project could also potentially have indir-
committed to such policy change. ect health impacts through the income generated for domestic
While sanitary and phytosanitary standards and technical bar- companies and employment opportunities for local labourers; but that
riers to trade chapters are designed to address non-tariff barriers by is only possible if local inputs and labour are used in the construction.
harmonizing standards, regulatory coherence provisions qualita- The second pathway focuses on how government budgets may
tively raise the bar on the type of demands placed on domestic be redirected to cover the costs associated with ISDS. The rise in
policy-makers (Bhala 2014). As regulatory coherence chapters are ISDS claims creates increased costs through potential financial
new, and are not yet included in any agreement in force at the time awards to investors and the costs associated with litigation. To date,
of writing, the implications of such a chapter remain largely hypo- states, and consequently tax-payers, have been ordered to pay over
thetical; although a recent analysis suggests that they will likely in- US$10 billion in legal fees and financial compensation (Van Harten
crease the difficulty of protecting national policy-making from and Malysheuski 2016). Even when investors fail to win their claim,
vested interests (Thow et al. 2015). While increased transparency states must still contend with the costs of litigation, which has been
and reporting requirements present opportunities for improved gov- estimated at US$8 million per case (Gaukrodger and Gordon 2012),
ernance, increased corporate participation in shaping the rules that producing significant opportunity costs of ISDS litigation in terms of
regulate its industry presents a threat to the development of effective foregone revenue for health spending. The redirection of govern-
policies for HHCs (Chan 2013). ment funds to costs associated with ISDS, or budgetary allowances
However, the greatest transformation to domestic policy space is deferred to the implementation of new standards and administrative
arguably related to the addition of investment chapters, particularly demands of regulatory harmonization, is very likely reallocated
so when they offer an investor–state dispute settlement mechanism. from another budget area. Such a diversion of funds is relevant to as-
The inclusion of an ISDS mechanism in an investment chapter cre- sessments of the health impacts of these agreements if spending is di-
ates an opportunity for private foreign investors to initiate litigation verted from the provision of health and social services or any other
against governments for domestic regulations that are perceived to redistributive or welfare spending that affects the SDH. However,
violate investor rights. The likelihood of pursuing an ISDS claim will further empirical evidence for such opportunity costs associated
be mediated by the level of comprehensiveness and ambiguity in the with ISDS and regulatory harmonization is needed.
investor rights language, in addition to factors external to the text
that influence investor decision-making, including the likely size of
an award, chances of success, costs of the process, and risks to repu-
tation with states or consumers. While the use of ISDS only emerged
Discussion
in 1987, for the first 10 years there were no more than ten cases an- Examining contemporary trade and investment agreements reveals
nually. This began to rise in the early 2000s, with 70 new claims in multiple tensions between the goals and effects of trade and
Health Policy and Planning, 2018, Vol. 33, No. 1 133

investment liberalization and the protection and promotion of popu- commitments and exploring causal relationships with FDI inflows in
lation health (Friel et al. 2015). Our conceptual framework was de- varying areas of production, processing, retailing, marketing and
veloped with the intention to inform researchers and policy-makers advertising.
of key provisions within such agreements, and provide a high-level There was a dearth of research in understanding the influence of
analysis and overview of the various ways in which they may influ- services liberalization from trade and investment agreements on na-
ence NCD outcomes. Future health assessments of trade and invest- tional provision of health services and health insurance and subse-
ment agreements can use this framework to identify a broad range quent effects for out-of-pocket expenditures on these services. The
of possible causal pathways for detailed inquiry in localized con- evidence reviewed appears to indicate that privatization of health
texts. In addition, the realist review used to assist in the development services is associated with rising costs and is not consistently associ-
and validation of the conceptual framework underscores the need ated with increases in quality. More robust evidence is needed re-
for robust evidence, particularly as related to the SDH, and in mat- garding the impacts of guaranteeing and enforcing existing levels of
ters outside FDI flows and tariff rates. Finally, this framework was service liberalization, as well as new liberalization, on access to and
designed in an attempt encourage upstream approaches to NCD pre- affordability of health services specifically, and on the SDH more

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vention by demonstrating how individually located behavioural risk generally.
factors actually occur within environments that are conditioned and The health impacts of international trade and investment agree-
constrained by macroeconomic policies, such as trade and invest- ments on HHCs, access to medicines and the SDH through the do-
ment, and that addressing these upstream policies may be a product- mestic policy space and governance pathways have the least
ive way to more equitably address rising NCD rates than lifestyle empirical support, with scholarship in this area only recently emerg-
interventions. ing. Hence, the causal connections proposed are largely theoretically
The evidence reviewed for the facilitation of trade in goods path- derived and deductively generated. They should be tested in future
way supports the proposition that the reduction of tariffs results in a empirical investigations. Trade and investment provisions that influ-
higher volume of cheaper imports flowing across borders, increasing ence the policy-making process, set international standards and re-
their availability and affordability in the consumer environment. strict policy-space, whether just perceived or in actual fact, may
This may present a challenge to health when the effects apply dis- alter a state’s propensity for regulating HHCs and the efficacy of
proportionately to HHCs. The development of more robust evidence those regulations. Although it is reasonable to presume that divert-
in the future should contrast applied tariffs before and after the ing government procurement contracts from local developers to for-
agreement, address whether currently applied tariff rates are less eign developers will influence opportunities for local development,
than the bound rates in the agreement, and associate those modifica- empirical evidence is still required to demonstrate the magnitude of
tions with changes in absolute volumes and retail price of imported these impacts and make direct connections to government procure-
HHCs. In addition, future research could contrast the effects on ment agreements. Evidence for the opportunity costs of fees associ-
healthy and unhealthy food products to draw comparisons of access ated with ISDS is also needed.
to healthy and unhealthy diets facilitated by trade in goods. This article has developed a conceptual framework for the path-
The reduction of trade barriers also has the potential to under- ways through which trade and investment provisions impact the
mine tariff revenues needed for the provision of public services, re- business, regulatory and consumer environments, as described
shape domestic economies and thus impact the quality and quantity above. Changes to these environments were of interest in relation to
of employment, and influence economic growth performance. While their ability to condition and constrain individual health behaviours
the relationship between tariff reductions, lost government revenue relevant to NCDs, specifically consumption of tobacco, alcohol and
and reduced capacity to provide health and social services seems vi- ultra-processed foods and beverages. Whether a specific trade and
able, our review did not return any empirical investigations of these investment provision, within a specific domestic environment, will
relationships making this an important area for future research. The result in increased or decreased consumption must be addressed
complexity of the evidence for trade and economic growth makes it based on a case-by-case basis. Pathways between trade and invest-
crucial to assess the potential economic impacts based on a variety ment provisions and access to medicines, income, employment and
of econometric models and data sources for each participating coun- health and social services were also introduced as additional points
try. Such an economic assessment should include heterodox econo- of consideration in future empirical investigations as potential medi-
metric models and data sources (such as the United Nation’s Global ators of the impact of trade and investment liberalization on either
Policy modelling database) to avoid the pro-free trade bias inherent HHC consumption, or access to resources to mediate the health im-
to mainstream econometric models rooted in the flawed neoclassical pacts of elevated consumption.
assumptions of perfect competition, perfect fungibility of resources,
full employment, and static inequality.
In relation to the facilitation of the services and investment path- Limitations
way, the evidence reviewed supports the proposition in the frame- Assessing the health impacts of international trade and investment
work that trade and investment provisions could influence FDI into agreements is a complex process. Changes along the pathways are
the production, processing, retailing and marketing and advertising interconnected, context-dependent and occur over extended periods
of HHCs, as well as the market for pharmaceuticals, vaccines, med- of time, all of which makes establishing and measuring causality
ical devices, and health technologies. This, in turn, influences the highly problematic. Moreover, as the provisions moved further
availability, accessibility, affordability and acceptability of these away from traditional tariff rules to ‘behind-the-border’ measures
products, including life-saving drugs. However, a better understand- impacting on services, investment, domestic policy space and gov-
ing of the impact of services and investment commitments on invest- ernance, the volume and strength of evidence began to decline.
ment inflows for all HHCs, and connections between FDI and Areas requiring more robust evidence have been indicated above.
specific trade and investment liberalization commitments, is needed. The evidence in our realist review does not reflect the entire
In addition, more robust evidence should be generated by reviewing body of available evidence on the concepts included in the frame-
commitments in the agreement relative to existing domestic work, particularly in relation to the expansive body of literature on
134 Health Policy and Planning, 2018, Vol. 33, No. 1

the impacts of trade on the economy and employment. In addition, international trade and investment commitments), focusing on the
while the intent of the review was to explore the impacts of trade new commitments it introduces. Moreover, future investigations
and investment liberalization, a considerable portion of the reviewed may consider the inclusion of corporate and consumer agency
evidence was from studies of liberalization in general, not demon- within the structural determinants outlined in the framework for a
strably undertaken as a result of specific trade and investment com- more complete understanding of the dynamics between actors and
mitments. As more robust evidence is generated for the relationship institutions that together co-create the health outcomes from trade
between trade and NCDs across a broader range of pathways, con- and investment agreements. Developing a better understanding of
clusions regarding specific effects of trade and investment agree- the complex economic implications of trade and investment agree-
ments will become more viable. ments for the SDH, including employment and working conditions,
The reviewed evidence was also heavily weighted towards the individual income and social status, and access to health and social
negative externalities of trade and investment agreements rather services, should be a priority area for future research.
than the positive externalities, due in considerable part to the focus Additional efforts to continue compiling evidence for the path-
on WHO identified NCD risk factors in this framework. ways and refining the framework itself as new evidence emerges will

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Considerable evidence also originated from studies of NAFTA and support future work in this area. It is the hope that the development
the Central America Free Trade Agreement, and relatedly, much of of this conceptual framework will encourage capacity and inclin-
the evidence of changes to the food environment and dietary out- ation among a greater number of researchers to undertake health as-
comes from trade and investment liberalization was restricted to sessments of trade and investment agreements to generate an
Latin America and the Pacific Island Countries. As this body of lit- extensive and robust evidence-base to guide future policy actions in
erature develops, a more balanced and global approach should be this area.
taken, which should also include rigorous investigations of effects
specific to vulnerable populations and impacts across socio-
economic classes. Acknowledgements
This framework captures many but not all factors. One import- We would like to thank Dr. Jeffrey Drope, Vice President, Economic and
ant area for future research is the role of actors and complex power– Health Policy Research, American Cancer Society; Dr. Marc-Andre Gagnon,
structure relationships among them, such as the ways in which cor- Assistant Professor, School of Public Policy and Administration, Carleton
porate global production chains are developed and sustained or University; and Dr. Benn McGrady, Technical Officer (Legal), Prevention of
inequalities in decision-making power within consumer environ- Noncommunicable Diseases, World Health Organization, for their time and
ments. The content of this framework was also limited by focusing contributions to the development of this framework.
on the WHO 444 framing, emphasizing behavioural risk factors
including tobacco, alcohol and unhealthy dietary product consump-
tion. Moreover, while select SDH were incorporated, fuller treat- Funding
ment of these expansive topics and a wider range of determinants is This work was funded by the Canadian Institutes for Health Research (CIHR)
needed. Important environmental concepts were omitted entirely, through operating grant No. 133483. DS is supported by the Wellcome Trust.
such as the impact of trade on NCDs through air pollution or cli-
Conflict of interest statement. None declared.
mate change. As employment and environment are increasingly
incorporated in new sections of trade and investment agreements, la-
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