A health impact assessment of the proposed Trans-Pacific Partnership Agreement recently made headlines and won some political attention for the wide-ranging public health concerns raised. What were the factors that contributed to this splash?

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Fiona Haigh and Katie Hirono write:

The Trans-Pacific Partnership Agreement (TPP) is a large regional trade agreement currently in the final stages of negotiation and involves countries around the Pacific Rim, including Australia.

Traditionally, a free trade agreement (FTA) is an agreement between two or more countries, which aims to remove barriers to trade such as tariffs or import quotas to member countries. Increasingly FTAs have shifted to encompass not just the regulations related to the exchange of goods and services but also to rules regarding intellectual property, investment and many other issues.

As these rules have expanded, so too has their potential to impact on public health. For example, changes to intellectual property rules can lead to increasing costs of medicines and an investor state dispute mechanism can threaten public health measures such as tobacco plain packaging.

The TPP is being negotiated under conditions of confidentiality, and consequently negotiating documents are not made public and limited information is available. This makes it difficult for those interested in public health to engage in the process and provide expert input into decision-making process.

There are growing concerns that the TPP may have serious negative consequences for public health.

At the end of 2013 a small group of public health academics decided to carry out a Health Impact Assessment (HIA) of the TPP. HIA involves predicting how a proposal (such as the TPP) may impact on public health and developing evidence-informed recommendations to inform decision-making and implementation.

HIA has been identified as one of a limited number of methods that are available to address the social and environmental determinants of health prior to implementation of proposed policies, plans or projects to maximise future health benefits and to minimise risks to health.

The process
The HIA team at CHETRE worked with a group of academics and Australian non-governmental organisations to carry out the HIA. We focused on four areas of potential impact:

  • The cost of medicines;
  • Tobacco control policies;
  • Alcohol control policies; and
  • Food labelling.

For the HIA we applied a range of methods including:

  • reviewing literature for evidence about the potential impacts of trade agreements on health;
  • accessing national data;
  • consulting with experts; and
  • carrying out an assessment workshop with 35 participants.

There were some technical challenges with trying to do an HIA on something that is being kept secret. We had to base our assessment on leaked documents and consultation with knowledgeable academics  and policy experts.

We also faced the challenge of trying to predict likely future public health policies that could be affected by the trade agreement (since some parts of the TPP are more likely to affect future policies than policies that are already in place). We approached this by working with policy experts to identify likely future public health policies in our scoped areas of focus that could be impacted by the TPP.

Since the purpose of the HIA was to inform advocacy around the TPP negotiations, we decided that that we needed to engage with these groups throughout the process.  We did this by establishing an Advocacy Advisory Group, which included 11 advocacy groups.

We also set up a technical advisory group made up of leading experts in various fields related to the potential health impacts relating to the TPP.  Both of these groups helped us decide what areas to focus on, directed us to relevant evidence and provided their expert input.  A crucial part of this was the assessment workshop where we all met to discuss and agree on the evidence-informed impact pathways for each scoped area and then use this analysis to identify some initial recommendations.

We found that many of the provisions that have been proposed for the TPP are likely to result in negative impacts to public health. In particular:

Medicine
The TPP risks increasing the cost of the Pharmaceutical Benefits Scheme (PBS), which is likely to flow on to the Australian public in terms of increased co-payments (out-of-pocket expenses) for medicines. This may result in medical non-adherence for prescription use and prioritising health costs over other necessities (food, housing, etc.). Vulnerable groups include those from low socioeconomic backgrounds, people with chronic conditions, younger populations, and Aboriginal and Torres Strait Islander peoples. Potential risks to health outcomes include declining health status in the community, increased hospitalisations and increased mortality.

Tobacco
The TPP provisions pose risks to the ability of Government to regulate and restrict tobacco advertising. This could potentially lead to increased tobacco use and smoking prevalence, resulting in increases in tobacco related health harms across the community but particularly for existing vulnerable groups, such as youth and people with low socioeconomic status.

Alcohol
Some provisions proposed for the TPP have the potential to limit regulation of alcohol availability and alcohol marketing, and restrict alcohol control measures such as pregnancy warning labels. This risks increasing alcohol consumption rates and abuse, especially amongst young members of the community. This may lead to increased alcohol related disorders, worsening mental health and social disruption in the community.

Food
There is the potential for TPP provisions to restrict the ability of Government to implement new food labelling policies, limiting reductions in consumption of unhealthy foods. This is associated with rates of overweight/obesity and related health outcomes.

(TPP HIA report pg iv)

 Recommendations and outcomes
Based on the results of the assessment, we developed 19 recommendations to mitigate the potential harms. The recommendations are made to the Department of Foreign Affairs and Trade (DFAT) and Government regarding TPP provisions; the Australian Government regarding the TPP negotiating process; and Broader policy recommendations to Government in the areas of medicines, tobacco, alcohol, and food.

One of our main recommendations is that when the text does become available, a comprehensive impact assessment should be carried out. (TPP HIA report pg 22)

The report has attracted a lot of attention and in general has been a different experience from the typical HIAs with which we have been involved. We have been reflecting on the process, and would like to share a few thoughts.

This HIA was different from the outset in that we weren’t commissioned to do the HIA – a small group of us thought it would be a worthwhile thing to do and we managed with some support from CHETRE and the Public Health Association of Australia to keep it going.

Being uncommissioned meant that we could be flexible in our approach and adapt the process to fit the context. The support from CHETRE enabled us to bring in a researcher to do a lot of the analysis and writing and we were supported by a group of experts and advocacy groups who contributed their expertise and advice.

We also ‘walked the talk’ of taking a participatory approach, which meant sharing power with the technical advisory group and the advocacy groups that we worked with throughout the process. We feel that this has worked really well – it meant that we focused on issues they identified as important and we have produced a report that they have been able to immediately use for their advocacy.

Without them we’re pretty sure this report would not be having the impact it has had so far. The report is being talked about on the front pages of major newspapers, there have been multiple radio interviews, a social media campaign led by one of our advocacy partners CHOICE, and public conversation on Twitter and Facebook.

Perhaps most satisfying of all is that the report appears to be influencing the political sphere. Media reports of the HIA findings have been dismissed by the Minister for Trade and Investment as a ‘beat up’ and the Greens spokesperson for Trade, Senator Peter Whish-Wilson, defended those who raise concerns about the TPP; the Labour shadow minister for health also called for greater transparency in the negotiations; and the report is being talked about in Parliament .

The value thus far of having done this HIA is that we have been able to provide evidence-based research that is useful to our advocacy partners to create a collective voice around the potential impacts of the TPP. One of our colleagues said that in the four years she’s been working to publish on this type of work, she’s never gotten close to the type of response this HIA has generated. We’ve been fortunate to have provided important evidence near the tipping point of a relevant public issue.

Our hope is that the HIA proves its worth and that some of the harms we’ve predicted from the TPP are avoided as a result of our work and the way it has stimulated public discussion about these issues at a critical stage in the TPP negotiations.


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