Globalization and Health: A Framework for Analysis and Action(*)

Article excerpt

Voit page 880 le resume en francais. En la pagina 880 figura un resumen en espanol.


Globalization is one of the key challenges facing health policy-makers and public health practitioners (1-3). Although there is a growing literature on the importance of globalization for health (4, 5), there is no consensus either on the pathways and mechanisms through which globalization affects the health of populations or on the appropriate policy responses. There is, however, an increasing tension between the new rules, actors and markets that characterize the modern phase of globalization and the ability of countries to protect and promote health.

This paper proposes a framework for understanding and analysing the economic aspects of globalization and their impacts on health. While health is a complex outcome and the processes of globalization are far from straightforward, we make the case that an explicit framework for research can advance the formulation of appropriate health policy and enable researchers to place their research in the context of a useful model. Presented also is a set of broad objectives for action at the national and international levels for the protection and promotion of health in the context of globalization, particularly for poor populations.

This paper has three key themes. Firstly, that an agreed analytical framework is essential for a reliable assessment of the health effects of globalization, the development of a research agenda, and appropriate policy responses. Secondly, that the indirect effects of globalization operating through the national and household economies are important for health outcomes, as well as the more obvious and direct effects on health risks and health systems. Thirdly, that the effects of globalization will be optimized only when improvements in health and well-being become central objectives of national economic policy-making and the design and management of the international economic system.

Economic globalization: an overview

Economic globalization has been the fundamental driving force behind the overall process of globalization over the last two decades. It has been characterized both by a dramatic growth in the volume of cross-border flows and by major changes in their nature. International trade has grown at an accelerating pace -- nearly 8.6% per year over the period 1990-99 -- with the proportion accounted for by services increasing steadily, reaching nearly 19% in 1999 (6, 7). Financial flows from developed to developing countries have increased much more dramatically over the last decade, more than recovering from the post-debt crisis slump of the 1980s. At one time mostly consisting of aid and commercial loans to governments, these financial flows now go overwhelmingly to the private sector and are dominated by investments in productive capacity by transnational companies and in shares bought by institutional investors (8). However, this transformation has largely bypassed low-income countries,(a) most of which remain critically dependent on aid flows. These aid flows are only now beginning a slow recovery after years of decline, and in 2000 remained 16% below their 1991 levels despite a temporary boost as a result of the Asian financial crisis. Total net official development finance (including non-concessional loans) fell still further, from a peak of US$ 60.9 billion in 1991 to an estimated US$ 38.6 billion in 2000, an overall decline of 37% (10).

These changes in cross-border flows reflect, and were preceded by, a considerable opening of economies, particularly in developing countries, through the lowering of trade barriers, removal of capital controls, and liberalization of foreign exchange restrictions. This opening occurred largely in response to International Monetary Fund and World Bank programmes, and, in the case of trade, has been consolidated by the Uruguay Round Agreements of the General Agreement on Tariffs and Trade (GATT) which established the World Trade Organization (WTO). …