Policy On International Trade

SHA policy

This is a discussion document not agreed policy.

The rationale for international trade is clear. No country can be self-sufficient in everything it requires, whether this is because of the geographical distribution of natural resources, climatic constraints on agriculture, or the benefits that come with concentration of particular types of expertise. However, it is important that this trade takes place in ways that bring benefits for all concerned. Unfortunately, this is not the case with many existing global and regional trade agreements. Too often, they are designed in ways that allow the powerful to exploit the powerless, whether by exploiting weak labour standards, damaging the environment, or preventing poor countries from adopting effective public health measures. In particular, many incorporate systems of investor state dispute settlement processes that enable global corporations to undermine public health, avoiding the protections provided by courts.[1]

There is now very extensive body of research on the health implications of international trade. For example, the removal of tariff and quota barriers can drive increasing consumption of unhealthy products.[2, 3] The following recommendations flow from this literature.

  1. All trade agreements should include an explicit commitment to safeguarding and promoting a high level of human health;
  2. Governments should be free to adopt evidence-based measures to protect health and the environment, which should not be considered to be non-tariff barriers to trade;
  3. International trade agreements should work towards the progressive realisation of equivalent standards of employment, health, and safety in those sectors included in the agreements in all of the countries participating;
  4. Disputes between parties should be addressed in a judicial setting, decided by judges selected by an independent body, meeting in public, with publication of all of the evidence being considered, and with provision for cases to be joined by other interested parties, including trade unions, non-governmental organisations, and professional associations;
  5. Independent monitoring systems should be established to ensure that international trade does not undermine health and the environment, drawing models such as the shadow reports produced by NGOs or the UN system of special rapporteurs.

Finally, there is a need to address the particular circumstances of the NHS. Neither European Union law other international trade agreements require the UK to open up its health services to competition. Health care, along with education, social services, and public services broadcasting among others is considered to be a service of general interest. Internal market rules apply to the services only to the extent that public authorities have opened them up to the market and “insofar as the application of such rules does not obstruct the performance, in law or in fact, of the particular tasks assigned to them” (Art 86(2). Thus, in the United Kingdom, Scotland, Wales, and Northern Ireland have avoided many of the problems that have arisen following the Health and Social Care Act in England.[4] Moreover, in its rulings, the European Court of Justice has consistently given a high priority to the sustainability of national health systems.[5] Thus, the opening up of public health systems to competition law is entirely a decision for national governments.

The recommendations above are already in place within the European Union (e.g. the Social Chapter). Thus, it includes measures to achieve equivalence of labour, health and safety standards in its trade agreements with countries such as Vietnam and Peru, the European Court of Justice has consistently emphasised a high level of human health in its judgements, and, it is notable, that in its negotiating position on the TTIP, the European Union was arguing for a judicial model of dispute resolution. Consequently, there is a real danger that these protections will be lost should the UK actually leave the European Union.[6] Indeed, it is apparent that the main justification for many of those advocating Brexit is to remove these protections.


1. Steele SL, Gilmore AB, McKee M, Stuckler D: The role of public law-based litigation in tobacco companies’ strategies in high-income, FCTC ratifying countries, 2004-14. Journal of public health (Oxford, England) 2016, 38(3):516-521.

2. Mendez Lopez A, Loopstra R, McKee M, Stuckler D: Is trade liberalisation a vector for the spread of sugar-sweetened beverages? A cross-national longitudinal analysis of 44 low- and middle-income countries. Social science & medicine (1982) 2017, 172:21-27.

3. Stuckler D, McKee M, Ebrahim S, Basu S: Manufacturing epidemics: the role of global producers in increased consumption of unhealthy commodities including processed foods, alcohol, and tobacco. PLoS medicine 2012, 9(6):e1001235.

4. Reynolds L, Attaran A, Hervey T, McKee M: Competition-based reform of the National Health Service in England: a one-way street? International journal of health services : planning, administration, evaluation 2012, 42(2):213-217.

5. Greer SL, Hervey TK, Mackenbach JP, McKee M: Health law and policy in the European Union. Lancet (London, England) 2013, 381(9872):1135-1144.

6. McKee M: Brexit: the NHS is far safer inside the European Union. BMJ (Clinical research ed) 2016, 353:i2489.