Addressing trade policy as a macro-structural determinant of health: The role of institutions and ideas

A strong theme from the public health community regarding how to address health problems is the need to engage with the ‘upstream’ or structural determinants that shape individual behaviours and risk – the so-called ‘causes of the causes’ of health outcomes. Interventions addressing disease risk at the individual level remain important, but many of the key determinants of health and wellbeing are considered to be best addressed at a population level (McKee et al., 2014; Marmot and Allen, 2014). This concept is perhaps most clearly illustrated in the work of the World Health Organization’s (WHO) Commission on the Social Determinants of Health (2008) and is described by various frameworks, several of which have been recently summarised in a report of the Canadian Council on Social Determinants of Health (2015). One of the most commonly seen of these is the Dahlgren and Whitehead (1991) rainbow model of the wider determinants of health (Dahlgren and Whitehead, 1992) (Figure 1). The determinants on the outer layer of the model are those often described as the ‘macro-structural’ determinants of health. They include macroeconomic policy and social policy and have significant influence over our living and working conditions and our lifestyle choices and behaviours. Trade policy is one example of such a macro-structural determinant (Blouin et al., 2009; Labonté and Schrecker, 2007; Woodward et al., 2001), with increasingly well-recognised health outcomes (cf. Baker et al., 2014; Blouin et al., 2009; Hawkes, 2006; Labonte et al., 2011).

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Figure 1.

A conceptual model of the wider determinants of health.

The health effects of macro-structural determinants such as trade policy are mediated through the policy and governance mechanisms of economic, social and political institutions (Commission on Social Determinants of Health, 2008). Thus, responding to these determinants will typically require actions that generate institutional and policy change. Yet the public and global health communities have often struggled to apply approaches outside traditional biomedical or public health perspectives that might target these higher level determining structures. In regard to trade and health research, several authors have already critiqued the limitations of the health sector in such ways (cf. Hanefeld et al., 2017; McNamara, 2017; Walls et al., 2016b). McNamara (2017), for instance, arguing that there has been ‘little methodological reflection on what theories, research designs or methods best inform analysis of trade and health’. Here, we discuss how a perspective informed by political science might inform new ways of investigating and addressing trade policy to improve health outcomes.

While there are an abundance of theories developed to explain features of policy-making or processes of policy change (Hill, 2005; John, 1998; Parsons, 1995), a common approach often taken is to consider the relevance of the so-called ‘3Is’ of interests, institutions and ideas to explain policy outcomes (Hall, 1997). While many descriptions of policy-making might focus on the means by which stakeholders pursue their various interests, considering institutions and ideas has been shown to shed light on many critical features influencing the policy process beyond this initial starting point (cf. Beland, 2009, 2016; Lowndes and Roberts, 2013; Smith, 2013a). Institutions include political, economic and cultural structures – both formal structures (e.g. regulations, laws and ‘brick and mortar’ organisations) and less formal rules and patterns of behaviour. Ideational approaches consider aspects such as the way issues are framed or the roles that ideas play as motivating forces for change. Institutions and ideas are in many ways intertwined. Ideas help to conceptualise what is important within the remit of different institutional bodies, while institutions have their own ‘logics of appropriateness’ that reinforce certain ideas about what is appropriate action to take (Lowndes and Roberts, 2013; March and Olsen, 1984, 2011; Peters, 2008). Thus, as Berman (2001) has noted, ideas persist over time through the process of institutionalisation (Berman, 2001).

A growing number of scholars in the global health community have been considering how the interaction of institutions and ideas works to dictate which health issues are addressed (and which are not), by whom and how (cf. Shearer et al., 2016; Shiffman et al., 2002; Shiffman and Smith, 2007; Smith et al., 2014; Walls et al., 2017). But the challenges in addressing the macro-structural determinants of health remain. An example of these challenges, and the value of a more conceptually informed policy analysis approach in helping to find a way forward, can be seen in the social determinants of health as described by the report of the WHO Commission on Social Determinants of Health (2008).

The WHO Commission on the Social Determinants of Health was established in 2005 to synthesise the evidence on how to address health inequities globally (Commission on Social Determinants of Health, 2008). The Commission’s overarching recommendations were to (1) improve the daily living conditions; (2) tackle the inequitable distribution of power, money and resources; and (3) measure and understand the problems and assess the impact of action. Despite the high profile of this work, the overall lack of progress in addressing these recommendations has disappointed many in the global health community.

The reasons for the lack of progress on the social determinants of health on government agendas are complex, but as several authors have described (cf. Lynch, 2017; Scott-Samuel and Smith, 2015; Smith, 2013a; Smith and Joyce, 2012), they can be attributed to institutionalised norms such as neoliberalism and a dominant biomedical approach to health that sits at odds with thinking about addressing broader social determinants of health. Neoliberalism, the prevailing economic paradigm since the 1980s, focuses on individual responsibility for health behaviours and outcomes and fails to recognise the broader structural factors that have been shown to be crucial in explaining health outcomes (Navarro, 2007a, 2007b, 2009; Rushton and Williams, 2012; Scott-Samuel and Smith, 2015; Smith, 2013b). Similarly, the biomedical approach looks for causes of illness proximal to the individual, such as pathogens or individual behaviours, rather than the broader structural factors that shape the spread of pathogen or influence the behaviour of individuals within a population (Bambra and Schrecker, 2015; Baum et al., 2013; Birn et al., 2009; Glasgow and Schrecker, 2016). These institutionalised ideas can either limit the consideration of the social determinants of health in agenda setting and policy development or result in their adaptation such that the policy as described in documents and vision statements is not reflected in actual on-the-ground implementation (Scott-Samuel and Smith, 2015; Smith, 2013b).

As a result of the institutionalisation of ideas such as neoliberalism and a biomedical approach to health, often supported by powerful private actors who seek to further those particular interests (Moodie et al., 2013; Panjwani and Caraher, 2014; Scott et al., 2017), those seeking to promote the social determinants of health in government policy face substantial barriers to achieving change. For an example, the Public Health Responsibility Deal of England launched in March 2011, a partnership approach to addressing specific behaviours such as alcohol and food consumption. Involving collaborations between public, private and third-sector actors, this approach relies on voluntary private sector actions to help meet public heath goals, has been critiqued as a neoliberal policy that advances private sector values and interests - rather than an approach likely to be effective in addressing important public health concerns (Panjwani and Caraher, 2014).

The institutional constraints to a more structural approach were recently described by Hunsmann (2012) in relation to HIV/AIDS planning. The author explored the political obstacles to integration of a broad set of approaches to addressing the social/structural drivers of HIV within donor agencies working in African settings, through an exploration of Tanzania in particular. He found that donor incentive structures worked against taking a broader structural approach, despite thinking in the field that this approach was increasingly necessary to affect the drivers of HIV risk and transmission (Hunsmann, 2012).

Alternatively, despite the Canadian government’s strong support for a social determinants approach to addressing health and inequities, several authors have described the challenges in Canadian public health practice, which often focuses on inducing individual behavioural change, rather than strategies addressing the social determinants of health that shape such behaviours (Brassolotti et al., 2014; McIntyre et al., 2013; Raphael, 2003).

An analysis of nutritional concerns in the European Union’s Common Agricultural Policy described obstacles in the Commission’s legal mandate that impede addressing nutrition through agricultural policy – institutionalising an approach instead focused on consumer education strategies to improve nutrition. This analysis also uncovered sectoral differences in opinion regarding the appropriateness of addressing nutrition within agricultural policy – an example of ideational differences between different governing institutions that can impede policy development (Walls et al., 2016a).

In various ways, then, research from a number of areas of health helps to point to the institutional and ideational obstacles that may also serve as barriers to achieving more healthy international trade policy. One key factor is the strong industry influence over the process, dominating the ideas around what appropriate goals are to pursue in international trade (principally growth and revenue oriented), as well as reflecting a dominant idea of free market access and minimal regulation (in favour of health and social goals, at least) as supporting such growth (cf. Hawkins and Holden, 2016; McNeill et al., 2017; Walls et al., 2015). Some recent empirical work taking this more politically informed approach to trade and health has also been conducted (cf. Friel et al., 2016; McNamara and Labonté, 2017; Thow et al., 2014, 2015), including the work by Schram and colleagues in this Special Issue (Schram, 2018); however, there is scope for considerable conceptual and methodological development.

Research to improve understanding of the health impact of trade policy is critically important, and this is fortunately an area of growing research interest. However, despite increasing recognition of the importance of macro-structural factors, including trade policy, to health outcomes, systems of policy-making and governance are often structurally aligned in ways that hinder action on these issues. To go beyond descriptions of problematic outcomes to inform positive change will likely require a more explicit political economy approach that challenges the systemic arrangements perpetuating the health outcomes of concern. A range of theories and methods from policy studies will be relevant to explore the mechanisms that hinder change. One way of starting can be to apply institutional and ideational lenses of policy analysis. Research addressing interests will be important, complemented by analyses of power in regard to how it is attained, distributed and exercised, and how organised interests function and propagate favourable arrangements (Lukes, 1993, 2005). But also important will be explicit institutional and ideational approaches to understanding policy processes and informing avenues for macro-structural change.