Trading Women's Health and Rights: Trade Liberalization and Reproductive Health in Developing Economies

by Marceline White, Alaka M. Basu, Debra Lipson, Sajeda Amin, Doctor Lin Tan

Overview

Around the world, policymakers and civil society are debating how economic and trade policies shape public health. This edited collection adds a new dimension to this debate. It synthesizes research from a variety of disciplines to analyse how the liberalization of international trade affects reproductive health and rights. Case studies from Mexico, Sri Lanka, China, Vietnam, Bangladesh, and Egypt illuminate how trade-related changes in women's employment influence their reproductive needs and capacities. The book demonstrates how global and national trade policies affect the quality, quantity, and cost of reproductive health services. Contributors also explore the implications of the World Trade Organization and the various trade agreements under its purview for reproductive health services and rights. Ultimately, this collection addresses the key policy issues for advocates of both reproductive health and rights and economic justice, and shows how trade agreements weighted against the poor in the South have very specific gendered consequences.

This book is aimed at an inter-disciplinary audience of economists, public health professionals, demographers, sociologists, anthropologists, and women's studies specialists. It will also be of interest to policymakers and representatives of civil society organizations working on health, economic justice, and employment issues.

Product Details

ISBN-13:	9781842777756
Publisher:	Bloomsbury Academic
Publication date:	07/01/2006
Edition description:	New Edition
Pages:	320
Product dimensions:	5.50(w) x 8.50(h) x 0.68(d)

About the Author

Caren Grown is co-director of the Gender Equality and the Economy program at the Levy Economics Institute of Bard College and formerly Director of the Poverty Reduction and Economic Governance Team at ICRW.

Anju Malhotra is group director of social and economic development at the International Center for Research on Women (ICRW).

Elissa Braunstein is an assistant professor of Economics at Colorado State University in Fort Collins.
Caren Grown is co-director of the Gender Equality and the Economy program at the Levy Economics Institute of Bard College and formerly Director of the Poverty Reduction and Economic Governance Team at ICRW.

Anju Malhotra is group director of social and economic development at the International Center for Research on Women (ICRW).

Elissa Braunstein is an assistant professor of Economics at Colorado State University in Fort Collins.

Read an Excerpt

Trading Women's Health and Rights?

Trade Liberalization and Reproductive Health in Developing Economies

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By Caren Grown, Elissa Braunstein, Anju Malhotra

Zed Books Ltd

Copyright © 2006 Caren Grown
All rights reserved.
ISBN: 978-1-84277-775-6

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CHAPTER 1

Trade Liberalization and Reproductive Health: A Framework for Understanding the Linkages

Caren Grown

Introduction

A growing literature discusses the impact of the liberalization of international trade – the progressive reduction of barriers to imports and exports – on health worldwide. Few contributors to this literature, however, have examined the specific impacts of trade liberalization on reproductive health – 'the state of complete physical, mental and social well being in all matters relating to the reproductive system and to its functions and processes' (UN 1995, paragraph 7.2). Yet, such liberalization is likely to affect provision of and access to quality reproductive health services and commodities. Trade liberalization can possibly create new opportunities for improving reproductive health. For instance, a more liberalized health trading system can improve a country's competitive capacity, attract foreign investment, create employment for women, increase income levels, improve access to reproductive health technologies and ultimately raise the quality of health care delivery (UNCTAD/WHO 1998). On the other hand, trade liberalization can also make it more difficult to advance reproductive/sexual health and rights objectives in policies, programmes and services. There is concern about higher costs of services and supplies, concentration of services which may restrict the access of lower-income or remote populations, lower quality of services, and shortages of critical medical personnel (e.g. doctors, nurses and midwives) that result from migration both from the public to the private sector and from developing to developed countries, as health professionals opt for higher salaries and better opportunities for professional development.

To date, there is more heat than light about each of these effects, and the net impacts are not yet well documented. This chapter presents a conceptual framework for understanding the linkages between trade liberalization and reproductive health, and discusses the challenges in tracing the linkages at the national or subnational level. It reviews the theoretical and empirical evidence for the linkages and concludes with recommendations for future research and policy to advance women's reproductive health and rights in a more globalized world. The analysis in this chapter focuses largely on developing countries, although occasional reference will be made to industrialized countries.

Trade liberalization

The liberalization of international trade is now one of the most important global economic processes. The flows of goods and services that are exported across national borders have increased substantially in the post-war period. Since 1948, the volume of global trade has grown by an annual average of 6 per cent (WTO 2003). Exports from developing countries have grown faster than the world average since the early 1980s and now account for about one-third of world trade (UNCTAD 2004). Moreover, the share of imports and exports in the gross domestic product (GDP) of developing countries increased by 30 per cent between i990 and 2000. The increase was most significant in Europe, Central and East Asia, and in the Pacific, where the increase was by more than 50 per cent.

Although much of this growth has been in the manufacturing sector, trade in services, including health services, has increased rapidly and is estimated as 20 per cent of all exports in 2003 (WTO 2004). The liberalization of health services often involves removing restrictions on entry by foreign health service providers and their terms of practice, changing ownership through privatization, and relaxing regulations (for instance, concerning accreditation and licensing requirements) and making regulations more 'pro-competitive' (Chanda 2001). Comprehensive and internationally comparable data are not available, but cross-border delivery of health services has increased worldwide through the movement of personnel and consumers and through cross-border trade in data processing and other activities (Chanda 2001). There has also been significant growth in foreign direct investment in the health sector. The continuing removal of some of the regulatory barriers to trade at the regional, multilateral and national levels means that trade in health services is likely to assume greater importance in the future (Chanda 2001).

Reproductive health

Reproductive health is critical for national economic development and individual well-being. Yet, women's reproductive health is poor and their reproductive rights remain unrealized in many countries. Table 1.1 summarizes recent trends in some of the salient components of women's reproductive health status. As shown in columns 2–4 of this table, the fertility rate declined in most parts of the world between 1990 and 2002. Maternal mortality rates remain high in many developing countries: maternal deaths per 100,000 live births are well over 1,000 in almost all sub-Saharan African countries.

The overall proportion of HIV-positive women has increased steadily since 1997 (UNAIDS 2004). The epidemic is most 'feminized' in sub-Saharan Africa, where 57 per cent of infected adults are women and 75 percent of infected 15–24 year olds are women and girls (UNAIDS/WHO 2004). The prevalence of HIV-infected women also increased slightly in South and Southeast Asia, and somewhat more so in North America, Latin America and the Caribbean, Eastern Europe, and Central Asia. These reproductive health problems all require technologies and services that are affected by the liberalization of trade.

Pathways between Trade Liberalization and Reproductive Health

The linkages between health and trade are both direct and indirect, and operate at multiple levels (household, country, international). Trade liberalization and reproductive health are multidimensional, and it is important to define them precisely in order to understand the linkages and impacts. Figure 1.1 summarizes some of the most salient dimensions of trade liberalization that are likely to affect reproductive health and some of the key dimensions of reproductive health that are most likely to be affected by growing trade liberalization. This figure distinguishes between trade agreements, trade policies and trade flows on the left, and reproductive health services and reproductive health needs/problems on the right.

Certain trade policies such as the reduction of barriers to imports of medicines and equipment, the removal of domestic subsidies (e.g. for local pharmaceutical firms and health insurance companies), foreign direct investment in private medical facilities and changes in patent regulations can be expected to have direct effects on the quantity and geographic distribution of reproductive health services of various types (e.g. family planning, STD diagnosis and treatment, prenatal care, and assisted delivery); the availability and cost of drugs and lab procedures, including antibiotics, diagnostic kits, HIV vaccines, contraceptive supplies, vacuum aspiration kits, etc.; the availability and cost of services apart from drugs, that is, of trained health professionals at different levels (midwives, nurses, doctors) and in different regions (rural, urban, etc.); the distribution of services between public and private sectors, hospitals and clinics, doctors' offices and informal health service providers, pharmacies, etc.; the quality of services across different sectors and regions; and the nature, scope, terms and cost of health care coverage, private insurance plans, national health schemes and so forth.

Figure 1.2 illustrates two different pathways through which these different dimensions of trade liberalization can affect these different aspects of reproductive health problems and services. The arrow on the right of the triangle illustrates the direct pathway through which trade policies affect the supply, for example, the quality, quantity and cost of reproductive health services. The arrow on the left of the triangle illustrates the indirect pathway through which trade policies and movements in goods and services affect women's demand for services indirectly through changes in their labour force participation. Female labour force participation is an intermediate variable, and it lies on the path because it is an intermediate influence on women's sexual and reproductive health problems and on their access to services.

These figures are very simplified illustrations of complex forces. The effects of trade flows and trade rules on reproductive health services and needs are likely to be multiple, separated in time and country-specific depending on the policies, market conditions and other factors that prevail at any given time in a country. Furthermore, the framework in Figure 1.2 indicates that assigning causality may be complicated as the arrows go in multiple directions, for example, from trade policies to reproductive health and also from health outcomes and health services to trade flows. Well-designed prospective longitudinal studies that track the direction and order of magnitude of effects within countries and over time will be important for disentangling and understanding the causal linkages.

Direct Pathways: Trade Agreements and Provision of Reproductive Health Services

Two core World Trade Organization (WTO) agreements for reproductive health are the General Agreement on Trade in Services (GATS) and the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS). This section reviews the potential impact of these agreements on the provision of reproductive health services, commodities and technologies.

General Agreement on Trade in Services

GATS, established in 1994, is the first multilateral agreement to provide a framework for countries to determine which service sectors of the economy they wish to open up to foreign suppliers and to competition, and what restrictions countries wish to implement to limit trade. Lipson (see Chapter 2) describes the rules and commitments of GATS and their influence on reproductive health services. She notes that, to date, GATS rules and individual country commitments have had minimal direct or significant impact on national policies concerning reproductive health. However, as more countries schedule GATS commitments, and as for-profit actors gain ground in the delivery and financing of reproductive health services, GATS and the public regulation of providers will become more important. Thus, the potential impacts described below provide a guide to the issues that should be documented in future research.

Health services under GATS can be traded through four modes: (1) cross-border supply, defined as the provision of services from a practitioner in one country to a patient or practitioner in another country, predominantly through the Internet, satellite transmission of medical images, teleconference and international telephone calls; (2) consumption abroad, where patients travel from one country to another to obtain treatment; (3) commercial presence, when a foreign company invests in or opens a subsidiary office in another country to provide health services; (4) the emigration of health professionals (doctors, nurses, specialists, paramedics, midwives, technicians, consultants, trainers, health management personnel and other professionals) between different countries. Each of these modes may affect access to and provision of reproductive health services.

The provision of telemedicine across national borders may have several different effects on the availability and quality of reproductive health care for women in developing countries. Telemedicine can help rural women whose reproductive health needs tend to be underserved, owing to the lack of primary health clinics and medical personnel in more remote areas. The quality of reproductive care can be enhanced through exchange of knowledge between medical professionals across borders about the range of reproductive health issues, service provision and new technologies. Moreover, 'virtual' partnerships between hospitals in developing countries and medical research centres in the developed world can facilitate and speed up the transfer of technology and knowledge that increases the quality of health care delivery. The most obvious disadvantage of cross-border supply of health is that it is largely dependent on telecommunication infrastructure, which developing countries generally lack, particularly in rural areas. As a result, it is plausible that cross-border provision will serve a minority of the female population, predominantly from urban areas. This can further exacerbate the persistent inequalities that exist between rural women, who tend to be poorer and have less access to health centres, and urban women, who tend to be better off economically and have better access to quality health care. Moreover, although telemedicine is still in its infancy and is largely being explored through pilot projects on a non-commercial basis, its growth requires substantial investment, which could potentially divert funds from rural and primary health care for women towards specialized centres catering to the more affluent population in developing countries.

Mode 2 of GATS could have a positive benefit for reproductive health if countries invest in the education and training of medical and nursing personnel, medical technology and equipment at public health centres, and if they raise wages and make other improvements that make them desirable medical care destinations. However, there is concern that consumption abroad can create a dual market system consisting of a high-quality expensive structure catering to wealthy nationals and foreigners, and a lower quality and resource constrained system for the poor (Chanda 2001). Thus, it can potentially compromise women's access to affordable and quality reproductive care at public hospitals and health clinics.

The third mode, commercial presence, can generate investment in health infrastructure and modern medical technology as well as strengthen health personnel's skills and knowledge about emerging reproductive health issues. Foreign investment may also increase women's employment opportunities in a variety of occupations in the health sector. Increased income may enable women to afford preventative care that can improve their overall health, influence their quality of life and increase their longevity (see the section on 'Indirect Pathways' below). Commercial presence also has the potential to stimulate competition in service delivery, potentially raising the quality of health care. Additionally, partnerships between local hospitals and medical facilities in industrialized countries can also help improve facilities in developing countries by introducing more modern and preventative technologies such as ovarian cancer screening exams.

On the other hand, corporate hospitals may be established, using public funds and subsidies, diverting resources away from the public health system, which can affect the availability of public services and the quality of care. Furthermore, commercial presence exacerbates the danger of a dual health care system, whereby corporate facilities tend to a minority of the population using the latest technologies and more skilled health professionals. Internal 'brain drain' can also result as better-trained nurses and doctors move from the public to the private sector, owing to better salaries and affiliation with a more modern and sophisticated hospital. The drain of medical personnel from the public health care system would affect women, especially poor women, more significantly than men due to their greater use of public health care (PAHO 2002). As the quality of public health care deteriorates, women's reproductive health may be compromised. They may face higher risks of infection and disease that could be prevented with adequate medical staffing and with properly equipped public health centres.

(Continues...)

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Excerpted from Trading Women's Health and Rights? by Caren Grown, Elissa Braunstein, Anju Malhotra. Copyright © 2006 Caren Grown. Excerpted by permission of Zed Books Ltd.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

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Table of Contents

PREFACE

INTRODUCTION
Reproductive Health, Trade Liberalization, and Development
Elissa Braunstein and Caren Grown

PART 1: CONCEPTUAL OVERVIEWS: DIRECT AND INDIRECT LINKAGES

Chapter I
Trade Liberalization and Reproductive Health: A Framework for Understanding the Linkages
Caren Grown
Introduction
Pathways Between Trade Liberalization and Reproductive Health
Direct Pathways: Trade Agreements and Provision of Reproductive Health Services
Indirect Pathways: Trade Liberalization, Women's Employment, and Reproductive Health
Conclusion

Chapter II
Implication of GATS for Reproductive Health Services
Debra Lipson
Introduction
International Trade and Health: A Framework for Analysis
GATS Rules and Their Application to Health Services
GATS and Reproductive Health Services in Developing Countries
Reproductive Health Issues in the WTO GATS Negotiations
Reproductive Health Advocacy in the Context of GATS Negotiations

Chapter III
Women's Work, Autonomy and Reproductive Health: The Role of Trade and Investment Liberalization
Elissa Braunstein
Introduction
Bargaining and Autonomy in the Household
Investment Liberalization and Women's Autonomy
Conclusion

PART 2: COUNTRY CASE STUDIES ON TRADE LIBERALIZATION, WOMEN'S EMPLOYMENT, AND REPRODUCTIVE HEALTH

Chapter IV
Implications of Trade Liberalization for Working Women's Marriage: Case Studies of Bangladesh, Egypt and Vietnam
Sajeda Amin
Introduction
Country Case Studies of Trade Liberalization
Discussion

Chapter V
Trade Liberalization, Women's Migration and Reproductive Health in China
Lin Tan, Zhenzhen Zheng, and Yueping Song
Introduction
Trade Liberalization and Labor Migration
Women, Rural-Urban Migration, and the Private Sector
The Impact of Women's Migration and Employment on Their Reproductive Health in the Context of Trade Liberalization: Positive Versus Negative
Conclusion

Chapter VI
Women's Reproductive Health in Export Industries at National Borders
Catalina Denman
Introduction
Background
The Study
Conclusion

Chapter VII
Runaway Knowledge: Trade Liberalization and Reproductive Practices among Sri Lanka's Garment Factory Workers
Sandya Hewamanne
Introduction
Trade Liberalization, the FTZ, and the

Editorial Reviews

This excellent collection of papers that address concrete trade and health issues in specific countries within a conceptual framework that pretty much makes sense of it all...Trading Women's Health and Rights? sets out its premises at the outset and follows through with illuminating case studies, careful analysis, and a lot of information about trade agreements and their health consequences that are unlikely to be known to population specialists. To the editors and authors of what must have seemed at the outset a most formidable task, Salud!” —Ruth Dixon-Mueller, Book reviews

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