International trade and investment liberalization, corporate power and noncommunicable disease prevention policy: A case study of nutrition and alcohol policy non-decisions in South Africa

Abstract

Introduction: Understanding how corporations can use trade and investment agreements to constrain public health policy action has been of growing concern over the past decade. However, few empirical studies have adopted a political economy approach to understand how trade, health and corporate actors’ strategic responses to trade and investment liberalization may affect health policy decisions, particularly in low- or middle-income country settings. Further, although power analysis is increasingly recognised as essential to understanding public health policy processes, trade and health research has largely not engaged with theories of power. This PhD therefore aims to apply an integrated political economy and power analysis approach to understand how corporate power – visible, hidden and invisible – linked to the international trade and investment systems influence non-communicable disease (NCD) prevention policy (non-)decisionsin South Africa, with a specific focus on nutrition and alcohol policy. Methods: A conceptual framework for analysing power in public health policymaking was constructed and two realist reviews of existing literature were conducted to map current evidence of how the international trade and investment systems facilitate corporate power in health policymaking. In-depth semi-structured interviews were then conducted with 39 stakeholders. Thematic analysis and qualitative system dynamic modelling (SDM) methods including purposive text analysis, model-building and validation were then applied to this interview data. Findings: Trade liberalization has stimulated government’s focus on export-driven value-added economic growth, facilitating food and alcohol corporations’ instrumental and structural power in NCD prevention policymaking. While corporations attempt to capture discursive power, it also emerges through deterministic mechanisms where internalization of the neoliberal paradigm generates policymaking norms that often prioritize economic/trade interests over health. No evidence was identified of corporations using South Africa’s bilateral investment treaty obligations to generate a chilling effect on nutrition and alcohol lregulation. However, food and alcohol corporations’ power to promote NCD prevention policy non-decisions has been enhanced by international trade agreements. System modelling illustrates significant inter-connectedness between the various mechanisms of power linked to trade and investment liberalization in diet-related NCD prevention policymaking. Feedback structures entrench existing power relations over time, preventing transformative policy action. Key leverage points to promote more progressive and cohesive NCD prevention policy action include capacity-building and increased co-ordination across government departments; shifting evidential requirements from health actors to corporations; requiring corporate actors to internalize the health costs they generate; reducing the social acceptability of corporations/products; and promoting an alternative to the neoliberal paradigm. Conclusions: By integrating political economy and power theory, this research contributes a new approach for analysing power in health policymaking. The empirical findings of this research suggest trade and health academics and advocates should move beyond a narrow focus on trade and investment rules/agreements and increase their attention to the system of power in health policymaking that is generated by neoliberal policy, including trade and investment liberalization, enabling corporations to prevent progressive action on NCDs. Methodologically, this work provides useful insights into the benefits and challenges of using qualitative system dynamics modelling to enhance understanding of public health policymaking.