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...