Health Policy
Globalisation and health: the need for a global vision
Lancet 2008; 372: 1670–76
Institute of Population Health,
University of Ottawa, Ontario,
Canada (T Schrecker MA,
R Labonté PhD); and
Department of Epidemiology
and Public Health, University
College London, London, UK
(R De Vogli PhD)
Correspondence to:
Ted Schrecker, Department of
Epidemiology and Community
Medicine, Institute of Population
Health, University of Ottawa,
1 Stewart Street, Ottawa, ON,
K1N 6N5, Canada
tschrecker@gmail.com
1670
Ted Schrecker, Ronald Labonté, Roberto De Vogli
The reduction of health inequities is an ethical imperative, according to the WHO Commission on Social Determinants
of Health (CSDH). Drawing on detailed multidisciplinary evidence assembled by the Globalization Knowledge
Network that supported the CSDH, we define globalisation in mainly economic terms. We consider and reject the
presumption that globalisation will yield health benefits as a result of its contribution to rapid economic growth and
associated reductions in poverty. Expanding on this point, we describe four disequalising dynamics by which
contemporary globalisation causes divergence: the global reorganisation of production and emergence of a global
labour-market; the increasing importance of binding trade agreements and processes to resolve disputes; the rapidly
increasing mobility of financial capital; and the persistence of debt crises in developing countries. Generic policies
designed to reduce health inequities are described with reference to the three Rs of redistribution, regulation, and
rights. We conclude with an examination of the interconnected intellectual and institutional challenges to reduction
of health inequities that are created by contemporary globalisation.
Introduction: is globalisation good for you? Feachem has claimed that “globalisation is good for
The WHO Commission on Social Determinants of your health, mostly”8 because countries that integrate
Health (CSDH) concluded that: “Reducing health more fully into the global economy, especially through
inequities is…an ethical imperative. Social injustice is trade liberalisation, grow faster and are therefore better
killing people on a grand scale.”1 Efforts to correct this able to reduce poverty.9 The argument is compelling, but
injustice should address the context created by it does not fully satisfy the ethical imperative identified
globalisation—the incorporation of national economies by the CSDH, since health inequities exist worldwide
and societies into a world system “through movements even in the absence of poverty, and essentially it is flawed.
of goods and services, capital, technology and (to a lesser Research used to support this argument has shown that
extent) labour”.2 This incorporation results in the countries termed globalisers—in which tariffs fell and
exposure of economies and societies to an expanding the ratio of trade to GDP increased after 1980—grew
range of influences outside their borders. Although it is faster than non-globalisers.9 The findings have been
fundamentally an economic process, contemporary criticised among other reasons for how the globalisers
globalisation is multidimensional, and therefore more were identified, the causal sequence (with the most rapid
complex than an earlier period of globalisation growth in some countries having occurred before major
(1870–1914), in which trade and colonisation were the trade liberalisation), and because many globalisers
main channels of influence. pursued dirigiste economic policies in areas other than
We analyse the health effects of globalisation with trade, whereas some non-globalisers began the period
reference to an established model for explaining health already highly integrated into the global economy.10–12
disparities.3 This model emphasises how social context A more fundamental point is that between 1981 and 2005,
creates differential exposures and vulnerabilities, which while the world’s economic product quadrupled, progress
in turn affect health outcomes. Especially important are toward poverty reduction was limited and uneven. On the
“those central engines in society that generate and basis of World Bank poverty lines updated in 2008, the
distribute power, wealth and risks”.3 Nowadays such estimated number of people living on US$1·25/day or less
engines operate in the environment created by (at 2005 prices, adjusted for purchasing power parity)
globalisation, when they are not actually driven by it. declined by 500 million.13 However, the decline was
Differential exposures and vulnerabilities can be a result accounted for by drastic poverty reductions in China
of material deprivation, which is the case for more than (figure, A), about half of which occurred before its market
800 million chronically undernourished people reforms and export-led growth. Outside of China, extreme
worldwide, 1 billion slum dwellers, and those who lack poverty increased, mainly because the number of
access to basic health services. Relative deprivation or sub-Saharan Africans living in poverty almost doubled.
position within a hierarchy is also important. The Reasons exist for scepticism about whether Chinese
contribution of these two factors to near-ubiquitous poverty reductions will lead to future improvements in
socioeconomic gradients in health is a topic of continuing health, since privatisation of China’s health system has
controversy.4,5 Although their contribution will probably been accompanied by increases in the cost of health care,
depend on the context, stress-related biological thereby reducing affordability and access.1 This problem is
mechanisms of action that explain the health not unique to China.14,15 With a poverty line of US$2·50/
consequences of relative deprivation have been well day, worldwide numbers living in poverty increased from
studied in both animal and human models.6,7 Globalisation about 2·7 billion to 3·1 billion, with reductions in China
can also create new economic opportunities (for some) offset by a substantial increase in India (288 million) and
and limit the options for policies that improve health. sub-Saharan Africa (294 million) (figure, B). In general,
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 Health Policy

growth is an increasingly ineffective means of poverty especially low-income countries, because trade
reduction because the benefits of growth rarely reach the liberalisation has slashed tariff revenues far in advance of
world’s poorest people.16 the development of alternative revenue sources.
Experience suggests that economic growth can benefit Baunsgaard and colleagues37 showed that low-income
poor populations, but this requires “strong commitments countries “have recovered, at best, no more than about
on the part of policymakers”,17 who could have other 30 cents of each lost dollar” of tariff revenue, and Glenday38
priorities, such as obtaining military hardware or simple reported that only six of 28 low-income countries that lost
self-enrichment. In some cases, the expressed aim of tariff revenues were able to replace them from other
reducing health disparities might not be supported by
actual resources18 or opportunities to achieve major
A
reductions in disparities at low cost might be missed.19,20 3500 Worldwide
Such policy choices must be considered in relation to the Worldwide excluding China
East Asia and Pacific†
context created by globalisation (panel). South Asia*
3000 Sub-Saharan Africa
Globalisation is disequalising Latin America and Caribbean
Middle East and north Africa
A key element of the context created by globalisation is Eastern Europe and central Asia
2500
its “inherently disequalising”22 character, which means
that it tends to reinforce divergence of incomes, wealth,
Number of people (millions)

and opportunity.23,24 This tendency is strengthened by

2000
substantial disparities in the ability to change the rules
and institutions of the global marketplace. We consider
four disequalising dynamics of globalisation, although 1500
the list is not exhaustive.
First, production has been reorganised into global
commodity or value chains, which divide production 1000
across many national borders to maximise returns.25–27
The “new international division of labour”,28 which was
500
identified more than 30 years ago, has led to an emerging
global labour-market,29,30 and the world’s labour force has
roughly doubled in size with the integration of India, 0
China, and transition countries into the world economy.31
To simplify, the result is intensified competition between B
low-income workers, because potential employees are 3500

abundant, and governments competing for foreign

investment and contract production have a strong
3000
incentive to maintain flexibility in wages and labour
standards. Conversely, employers compete for
highly-valued skills at the top of the income scale, where 2500
employees are increasingly mobile. The World Bank
Number of people (millions)

predicts that labour-market outcomes will increase

economic inequality in much of the developing world 2000
because the “unskilled poor”30 population will be left
further behind. This pattern is established in several
Latin American countries32 and it is emerging in much of 1500

Asia;33 this so-called unskilled population have already

been left behind in the industrialised world.34,35
1000
Second, binding trade agreements and processes to
resolve disputes, exemplified by the World Trade
Organization (WTO), provide essential infrastructure for 500
the global marketplace. Substantial differences in
countries’ market size and government resources affect
both their initial bargaining leverage in trade negotiations, 0
1981 1984 1987 1990 1993 1996 1999 2002 2005
and their ability to make effective use of dispute resolution
Calendar year
mechanisms.36 As countries open up to imports,
livelihoods are lost in formerly protected industries. Social Figure: Global poverty below the US$1·25/day (A) and US$2·50/day (B) poverty lines according to the World
protection measures can partly compensate, but financing Bank13
them could be difficult for many middle-income and *Includes India. †Includes China.

www.thelancet.com Vol 372 November 8, 2008 1671

 Health Policy
Panel: Globalisation and health: pathways of transmission
and evidence of effects
An innovative econometric analysis undertaken for the
Globalization Knowledge Network21 classified a range of
variables affecting mortality as: related to policy choices made
in the context of globalisation (such as income inequality or
immunisation rates); independent of globalisation for
purposes of the analysis (medical progress); or “shocks” (such
as wars, natural disasters, or infection with HIV/AIDS). The
analysis compared trends in life expectancy at birth (LEB),
between 1980 and 2000, with those that would be predicted
on the basis of a counterfactual set of assumptions, in which
the relevant variables remained at the 1980 value or
continued the same trend as the period before 1980.
The results showed that worldwide, between 1980 and 2000,
globalisation cancelled out most of the progress towards better
health (measured by LEB) attributable to diffusion of medical
advances. The effects of shocks combined with globalisation
resulted in a slight worldwide decline in LEB (0·13 years),
contrary to the counterfactual. On a regional basis, the largest
effects occurred in the transition economies (decline of
3·57 years, almost entirely caused by globalisation) and sub-
Saharan Africa (decline of 8·95 years, almost equally caused by
globalisation and the AIDS epidemic, despite some offsetting
benefits from the diffusion of medical advances). The authors
concede the importance of the data limitations and difficulties
with inferring causation, but nevertheless emphasise that “the
negative association found between liberalisation-
globalisation policies, poor economic performance and
unsatisfactory health trends…seems to be quite robust.”
sources. This erosion of revenue-raising ability almost
certainly compromises public investment in education
and health care. The urgency of securing market access
for exports can lead countries with limited bargaining
power to accept provisions on intellectual property rights
that undermine equitable access to health care,39 and
vitiate benefits that globalisation of access to medical
technology might otherwise have conferred.21
Third, there has been a rapid increase in the mobility
of investment capital as a result of the interaction between
technological advances and the deregulation of national
financial markets. Financial market integration has not
led to the growth payoffs predicted by conventional
economics40–42 and the frequency of financial crises has
increased since the late 1970s.43 In extreme cases, volatile
flows of short-term investment in shares and government
bonds have destabilised entire economies, which
occurred in Mexico (1994–95), south Asia (1997–98), and
Argentina (2001–02). In each case, the national currency
depreciated by more than 50% and millions of people
were precipitated into poverty and economic insecurity.
Such crises undermine the health of the vulnerable both
directly and indirectly.44 These effects are worsened by
the fact that after such crises, employment recovers more
1672
slowly than growth.45 Conversely, the ease of capital flight
in the global financial marketplace enables wealthy
people to seek higher returns and lower risks by investing
assets abroad, which further increases inequality as the
costs of maintaining services for poorer people are
socialised, in the form of government debt.46,47
Fourth, external debt has long been recognised to be a
limiting factor on the ability of many developing
economies to meet the basic needs of their populations.48,49
In some cases, odious debts50,51 enriched corrupt leaders
or financed the repression of political dissent. A recent
study by Mandel52 reports that about US$726 billion of the
debt owed at present by 13 developing countries is odious,
under international law it should be cancelled, and ten of
the countries should receive refunds of US$383 billion in
past payments on such debts.52 From the 1970s onwards, a
much larger number of developing economies were
caught in a trap of rising interest rates and oil prices,
declining prices for their commodity exports, and debt
obligations that increased in value as a result of currency
devaluation under pressure from investors and
multilateral lenders. Over the past decade, partial debt
cancellation initiatives, such as the recent Multilateral
Debt Relief Initiative (MDRI), have increased the ability
of some low-income countries to invest in health and
education. However, this effect has not been universal.
The criteria for debt sustainability—the amount of debt a
national government is expected to service on the basis of
its own revenues before it becomes eligible for debt
cancellation—continue to prioritise creditor interests and
limit the number of eligible countries. In most developing
countries, development assistance receipts are still
dwarfed by outflows of debt service payments.53
The influence of globalisation can be offset or
compounded by domestic policy choices. Between 1997
and 1998, the financial crises in several south Asian
countries mobilised domestic political support for
expanded social protection programmes.54 By contrast,
most African countries have not reached the 2001 Abuja
declaration commitment to spend 15% of general
government revenue on health,55 and oil-rich Nigeria has
been one of the poorest performers. Development
economist Paul Collier estimates “that something around
40% of Africa’s military spending is inadvertently financed
by aid”,56 which is undoubtedly of interest to arms exporters
based in donor countries. Drawing worldwide attention to
such examples could be one of the most immediately
positive effects of the CSDH report. A key social scientific
question is how globalisation’s disequalising influence
will affect the formation of the necessary political coalitions
to support the reduction of health inequities.
Three Rs for health equity
The CSDH correctly identified reduction of health
disparities as an ethical imperative. From this perspective,
the issue is not globalisation itself but rather, as
philosopher Thomas Pogge has pointed out, whether
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plausible alternative sets of social arrangements or
institutions, which would be less inimical to meeting the
ethical objective in question (in this case health equity),
can be imagined.57–59 The evidence is more than sufficient
to meet this test, suggesting the need to consider how
institutions might be changed. Globalisation did not just
happen.60 Technological change has operated partly
outside of the control of policy makers but key elements
of globalisation—trade liberalisation, privatisation of
state-owned assets, financial deregulation, and
labour-market flexibility—have been actively promoted
by G7 governments, transnational corporations, and
multilateral institutions, for example, through the
structural adjustment conditionalities of the International
Monetary Fund (IMF) and the World Bank.61,62
Citing the need for collective policy choices and
initiatives to counterbalance the dominance of
market-driven globalisation, the Globalization Knowledge
Network53 that supported the CSDH identified the generic
importance of “redistribution, regulation, and rights”—a
rubric borrowed from the Finnish social policy research
unit STAKES.63 For example, the ability of national and
subnational governments to intervene in support of health
equity can be protected by use of the international human
rights law framework,64 identified in a CSDH background
paper as “the appropriate conceptual structure within
which to advance towards health equity through action on
social determinants of health”.65 Potential policy initiatives
include development of mechanisms to assess
health-equity effects of trade policy, which was urged by
the UN Special Rapporteur on the right to health in 2004,66
and creation of a formal linkage between the results of
such negotiations and the outcomes of trade negotiations
and proceedings to resolve disputes.
Despite the need for caution about unanticipated effects
that would actually increase inequity,67 recent analysis
suggests that linking market access under trade agreements
with respect for labour standards is viable.68 Choices made
by the representatives of high-income countries on the
governing bodies of such institutions as the World Bank
and the IMF should also take human rights into account.69
For example, IMF-recommended wage-bill ceilings,
justified on the basis of macroeconomic soundness, have
prevented countries in sub-Saharan Africa from hiring
essential teachers and nurses, even when short-term funds
were available from promised development assistance.55,70
This consequence of the IMF recommendations is arguably
a contravention of the human rights obligations of
countries that dominate IMF decision-making.
The paralysis of WTO negotiations in 2006 and again
in 2008, with regard to agricultural market access and
development policy flexibility, underscored the difficulty of
integrating trade and development policy objectives, which
is essential for long-term growth and poverty reduction.36,71,72
Even if the industrialised world abandoned its resistance to
integrating development objectives into trade policy, for
example by incorporating up-front redistribution into
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Health Policy
future trade negotiations as proposed by Collier,73 there
would be little immediate effect. Many low-income
countries would remain decades away from being able to
finance the cost of basic health care for the entire
population, about US$40 per person each year,74 much less
the costs of meeting other health-related basic needs such
as education, water, and sanitation.
Although private investment needs to be mobilised,
there is widely shared recognition that redistribution of
resources across national borders in support of meeting
basic human needs is an obligation.75,76 This means that the
burden of proving how health equity can be achieved in an
acceptable time without major increases in development
assistance now rests with the aid sceptics. There is
abundant evidence that the availability of proven
interventions would increase population health at relatively
low cost.20,77 Effective scaling-up faces many challenges and
will often depend on the availability of external resources.
Increasing aid, however, should not mean doing more of
the same. Aid should be directed towards meeting basic
human needs, such as those identified in the Millennium
Development Goals.20,78 As the CSDH insisted, aid should
also be linked to action plans on social determinants of
health and accountability mechanisms1 that go beyond the
health sector, to make intersectoral action for health
possible. Donor countries must also avoid undermining
the effectiveness of aid with conditionalities such as
wage-bill ceilings, or IMF insistence that countries
liberalise imports more rapidly than agreed to in WTO
commitments to qualify for debt cancellation.79
As another element of international redistribution,
eligibility for debt cancellation should be expanded, and
criteria for debt sustainability should be redefined with
reference to the cost of meeting basic needs, rather than
the ability of a country to earn export revenues.80
Additionally, with respect to development assistance,
accountability mechanisms should ensure that fiscal
flexibility created by debt cancellation is used for purposes
related to social determinants of health—a crucial area
for multilateral agreement and institutional innovation.
Finally, creditor nations should work towards a solution
to the odious debt problem that prevents private-sector
creditors, aid agencies, and multilateral lenders from
trying to collect such debts.52
Intellectual and institutional challenges
When Williamson81 coined the term “Washington
consensus” to describe official wisdom on development
policy in about 1989, he “deliberately excluded from the
list anything which was primarily redistributive, as
opposed to having equitable consequences as a byproduct
of seeking efficiency objectives, because [he] felt the
Washington of the 1980s to be a city that was essentially
contemptuous of equity concerns”. Although that hostility
might have receded, mainstream economists remain
committed to market solutions and efficiency (a concept
that is indifferent to initial distributions of resources) in
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 Health Policy
resource allocations, and they regard correcting for
market failures resulting from such factors as imperfect
information on the part of buyers and sellers to be the
primary rationale for most forms of policy intervention.
Even at the national and subnational levels the resulting
challenges are big, complicated, untidy, and largely outside
of the remit and often the professional competence of
health ministries. Hence, the CSDH’s call for intersectoral
action for health is critically important, but health
ministries could face an uphill battle integrating health
concerns into areas that are generally the domain of
finance and treasury ministries. Further, many
governments committed to redistributive policy operate
within constraints created by globalisation, such as the
threat of capital flight82,83 and the continued need for the
World Bank and IMF to approve national Poverty
Reduction Strategy Papers, which are a precondition for
debt cancellation and other forms of development
assistance.84
Coordinated value-driven action will be needed
internationally to address these constraints, to counter
globalisation’s disequalising dynamics, and to support
national and subnational action to reduce health inequity.
For example, redesign of the World Bank and the IMF to
reduce the over-representation of a few high-income
countries, and increase the transparency of deci-
sion making, has long been advocated by academic and
civil society commentators85,86 and is now advocated by the
Commonwealth Heads of Government.87 Agreement is
also emerging on preventing financial crises, and
therefore their destructive effects on health,44 as a true
public good that is at present inadequately provided.88
New sources of financing for development could be
mobilised by means of a small tax on foreign currency
transactions, which have a present value of more than
US$3·2 trillion/day, and measures to restrict tax avoidance
through offshore financial centres. A tax on the annual
income from wealth estimated to be held in such centres
could yield an annual revenue stream equivalent to the
estimated cost of meeting the Millennium Development
Goals.1
Mobilisation of support for health equity at the
international level implies a shift from self-interest to
altruism by the world’s largest and most powerful
countries. Also needed will be the ability to overcome
resistance from rich and powerful actors, such as
managers of transnational corporations and a global
economic-elite that is increasingly detached from national
allegiances. Who shall lead? As anticipated by the CSDH,
WHO might be well placed to rediscover an advocacy
voice that it has lost in recent decades. However, WHO
now functions in a complex environment featuring
multiple actors. No one governance structure for global
health exists that is even roughly comparable to the WTO
in trade policy,89 and WHO’s core budget is now less than
the annual expenditures of a single private foundation,
which is arguably “a scandal of global health governance”90
1674
in need of immediate action by high-income countries to
reduce WHO’s reliance on idiosyncratic, off-budget
financing. The comparison also instantiates the broad
shift from public to private power, derived from property
rights, that is associated with globalisation.
WHO leadership will thus depend on effective
organisational reinvention, both internally and externally.
Internally, WHO needs a more transdisciplinary, rather
than biomedical, orientation and it needs to engage
credibly and proactively in a range of debates about the
direction of the world economic and geopolitical order.
Externally, WHO needs to function more effectively in
the new environment for governance of global health, for
example by pursuing closer relationships with the UN
Economic and Social Council, other UN system agencies
(such as the Office of the High Commissioner for Human
Rights and the International Labour Organization), and
civil society organisations and professional bodies.
WHO’s member states will ultimately be judged on their
willingness to create the conditions and supply resources
for the necessary reinvention. Past initiatives to direct
globalisation in positive directions, such as the
Framework Convention on Tobacco Control and
subordinating intellectual property rights to health
protection imperatives to ensure access to essential
medicines, have shown the importance of civil society
campaigns informed by both evidence and ethics.
Conflict of interest statement
We declare that we have no conflict of interest.
Acknowledgments
The thoughtful comments of three external reviewers substantially
improved this article. The operations of the Globalization Knowledge
Network were supported by a grant from the International Affairs
Directorate of Health Canada. This paper is informed by the work of the
Globalization Knowledge Network, but all views are those of the article
authors, or cited authors, and are not those of Health Canada, other
members of the Globalization Knowledge Network, the CSDH, or WHO.
The funding agency played no role in the design or execution of the
research.
References
1 Commission on Social Determinants of Health. Closing the gap in a
generation: health equity through action on the social determinants
of health (final report). Geneva: World Health Organization, 2008.
http://whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf
(accessed Oct 9, 2008).
2 Jenkins R. Globalization, production, employment and poverty:
debates and evidence. J Int Dev 2004; 16: 1–12.
3 Diderichsen F, Evans T, Whitehead M. The social basis of
disparities in health. In: Whitehead M, Evans T, Diderichsen F,
Bhuiya A, Wirth M, eds. Challenging inequities in health: from
ethics to action. New York: Oxford University Press, 2001: 13–23.
4 Lynch JW, Smith GD, Kaplan GA, House JS. Income inequality
and mortality: importance to health of individual income,
psychosocial environment, or material conditions. BMJ 2000;
320: 1220–24.
5 Marmot M, Wilkinson RG. Psychosocial and material pathways in
the relation between income and health: a response to Lynch et al.
BMJ 2001; 322: 1233–36.
6 Brunner E, Marmot M. Social organization, stress, and health.
In: Marmot M, Wilkinson RG, eds. Social determinants of health,
2nd edn. New York: Oxford University Press, 2005: 6–30.
7 Geronimus AT, Hicken M, Keene D, Bound J. “Weathering” and age
patterns of allostatic load scores among blacks and whites in the
United States. Am J Public Health 2006; 96: 826–33.
www.thelancet.com Vol 372 November 8, 2008

8 Feachem RGA. Globalisation is good for your health, mostly. BMJ
2001; 323: 504–06.
9 Dollar D, Kraay A. Trade, growth, and poverty. Economic J 2004;
114: F22–49.
10 Kawachi I, Wamala S. Poverty and inequality in a globalizing world.
In: Kawachi I, Wamala S, eds. Globalisation and health.
Oxford: Oxford University Press, 2007: 122–37.
11 Rodrik, D. How to save globalization from its cheerleaders.
Cambridge, MA: John F Kennedy School of Government, Harvard
University; 2007. http://ksghome.harvard.edu/~drodrik/
Saving%20globalization.pdf (accessed Oct 1, 2008).
12 Cornia GA. Globalization and health: results and options.
Bull World Health Organ 2001; 79: 834–41.
13 Chen S, Ravallion M. The developing world is poorer than we
thought, but no less successful in the fight against poverty. Policy
research working paper 4703. Washington, DC: World Bank, 2008.
http://www-wds.worldbank.org/external/default/
WDSContentServer/IW3P/IB/2008/08/26/000158349_
20080826113239/Rendered/PDF/WPS4703.pdf (accessed
Oct 1, 2008).
14 Sepehri A, Chernomas R, Akram-Lodhi H. Penalizing patients and
rewarding providers: user charges and health care utilization in
Vietnam. Health Policy Plan 2005; 20: 90–99.
15 United Nations Country Team Viet Nam. Health care financing for
Viet Nam, discussion paper no.2. Ha Noi: United Nations
Viet Nam, 2003.
16 Woodward D, Simms A. Growth isn’t working: the unbalanced
distribution of benefits and costs from economic growth.
London: New Economics Foundation, 2006. http://www.
neweconomics.org/NEF070625/NEF_Registration070625add.
aspx?returnurl=/gen/uploads/hrfu5w555mzd3f55m2vqwty5020220
06112929.pdf (accessed Oct 1, 2008).
17 Nissanke M, Thorbecke E. Channels and policy debate in the
globalization-inequality-poverty nexus. World Dev 2006; 34: 1338–60.
18 Shaw M, Davey Smith G, Dorling D. Health inequalities and New
Labour: how the promises compare with real progress. BMJ 2005;
330: 1016–21.
19 Murray CJ, Laakso T, Shibuya K, Hill K, Lopez AD. Can we achieve
Millennium Development Goal 4? New analysis of country trends
and forecasts of under-5 mortality to 2015. Lancet 2007;
370: 1040–54.
20 Countdown Working Group. Tracking progress in maternal,
newborn and child survival: the 2008 report. New York: UNICEF,
2008. http://www.countdown2015mnch.org/index.
php?option=com_content&view=article&id=68&Itemid=61
(accessed Oct 1, 2008).
21 Cornia GA, Rosignoli S, Tiberti L. Globalisation and health:
pathways of transmission and evidence of impact. Globalization
Knowledge Network research papers. Ottawa: Institute of Population
Health, University of Ottawa, 2008. http://www.globalhealthequity.
ca/electronic%20library/Globalisation%20and%20Health%20Pathw
ays%20of %20Transmission%20and%20Evidence%20of %20Impact
%20Final.pdf (accessed Oct 9, 2008).
22 Birdsall N. The world is not flat: inequality and injustice in our
global economy, WIDER annual lecture 2005. Helsinki: World
Institute for Development Economics Research, 2006. http://www.
wider.unu.edu/publications/annual-lectures/en_GB/AL9/_
files/78121127186268214/default/annual-lecture-2005.pdf (accessed
Oct 9, 2008).
23 Birdsall N. Globalization at work: life is unfair: inequality in the
world. Foreign Policy 1998; 111: 76–93.
24 Sutcliffe B. A converging or diverging world? DESA working paper
no. 2, ST/ESA/2005/DWP/2. New York: United Nations
Department of Economic and Social Affairs, 2005. http://www.
un.org/esa/desa/papers/2005/wp2_2005.pdf (accessed Oct 1, 2008).
25 Commodity chains and global capitalism. Gereffi G,
Korzeniewicz M, eds. New York: Praeger, 1994.
26 Bair J. Global capitalism and commodity chains: looking back,
going forward. Competition Change 2005; 9: 153–80.
27 Dicken P. Global shift: reshaping the global economic map in the
21st century, 5th edn. New York: Guilford Press, 2007.
28 Fröbel F, Heinrichs J, Kreye O. The new international division of
labour. Cambridge: Cambridge University Press, 1980 [original
German publication 1977].
www.thelancet.com Vol 372 November 8, 2008
Health Policy
29 World Bank. World development report 1995: workers in an
integrating world. New York: Oxford University Press, 1995.
30 World Bank. Global economic prospects 2007: managing the next
wave of globalization. Washington, DC: World Bank, 2007.
31 Freeman RB. The challenge of the growing globalization of labor
markets to economic and social policy. In: Paus E, ed. Global
capitalism unbound: winners and losers from offshore outsourcing.
Houndmills: Palgrave Macmillan, 2007: 23–40.
32 United Nations Economic Commission for Latin America and the
Caribbean. Social panorama of Latin America 1999–2000.
Santiago: ECLAC, 2000. http://www.cepal.cl/cgi-bin/getProd.
asp?xml=/publicaciones/xml/2/6002/P6002.xml&xsl=/dds/tpl-i/
p9f.xsl&base=/tpl-i/top-bottom.xsl (accessed Oct 1, 2008).
33 Development Indicators and Policy Research Division, Asian
Development Bank. Key indicators 2007: inequality in Asia.
Manila: Asian Development Bank, 2007. http://www.adb.org/
Documents/Books/Key_Indicators/2007/default.asp (accessed
Oct 1, 2008).
34 Nickell S, Bell B. The collapse in demand for the unskilled and
unemployment across the OECD. Oxford Rev Econ Policy 1995;
11: 40–62.
35 Wood A. Globalisation and the rise in labour market inequalities.
Econ J 1998; 108: 1463–82.
36 Stiglitz J, Charlton A. Common values for the development round.
World Trade Rev 2004; 3: 495–506.
37 Baunsgaard T, Keen M. Tax revenue and (or?) trade liberalization,
IMF working paper, WP/05/112. Washington, DC: International
Monetary Fund, 2005. http://www.imf.org/external/pubs/ft/
wp/2005/wp05112.pdf (accessed Oct 1, 2008).
38 Glenday G. Toward fiscally feasible and efficient trade liberalization.
Durham, NC: Duke Center for Internal Development, Duke
University, 2006. http://www.fiscalreform.net/library/pdfs/
Glenday_paper_May_18,_2006_SA_%20rev.pdf (accessed
Oct 1, 2008).
39 Correa CM. Public health and the implementation of the TRIPS
agreement in Latin America. In: Blouin C, Drager N, Heymann J,
eds. Trade and health: seeking common ground. Montreal:
McGill-Queen’s University Press, 2008: 11–40.
40 Gourinchas P-O, Jeanne O. The elusive gains from international
financial integration. Rev Econ Stud 2006; 73: 715–41.
41 Prasad E, Rajan RG. A pragmatic approach to capital account
liberalization, IZA discussion paper no. 3475. Bonn: Institute for
the Study of Labor, 2008. http://ideas.repec.org/p/iza/izadps/
dp3475.html (accessed Oct 1, 2008).
42 Edison HJ, Levine R, Ricci L, Sløk T. International financial
integration and economic growth. J Int Money Finance 2002;
21: 749–76.
43 Claessens S, Klingebiel D, Laeven L. Resolving systemic financial
crises: policies and institutions. World Bank Policy Research
Working Paper 3377. Washington, DC: World Bank, 2004. http://
www-wds.worldbank.org/servlet/WDSContentServer/WDSP/
IB/2004/09/07/000160016_20040907154538/Rendered/PDF/
wps3377.pdf (accessed October 9, 2008).
44 Hopkins S. Economic stability and health status: evidence from east
Asia before and after the 1990s economic crisis. Health Policy 2006;
75: 347–57.
45 van der Hoeven R, Lübker M. Financial openness and
employment: a challenge for international and national
institutions. Geneva: International Policy Group, International
Labour Office, 2005. http://81.29.96.153/pdf2/gdn_library/annual_
conferences/seventh_annual_conference/Hoeven_Paper_
Lunch%20Time%20Session_ILO.pdf (accessed Oct 9, 2008).
46 Rodriguez MA. Consequences of capital flight for Latin American
debtor countries. In: Lessard DR, Williamson J, eds. Capital flight
and third world debt. Washington, DC: Institute for International
Economics, 1987: 129–52.
47 Helleiner E. Regulating capital flight. Challenge 2001; 44: 19–34.
48 Ramphal S. Debt has a child’s face. In: UNICEF. The progress of
nations 1999. New York: UNICEF; 1999: 26–29.
49 George S. A fate worse than debt. London: Penguin, 1988.
50 King J, Khalfan A, Thomas B. Advancing the odious debt doctrine,
CISDL working paper. Montreal: Centre for International
Sustainable Development Law, McGill University, 2003. http://www.
cisdl.org/pdf/debtentire.pdf (accessed Oct 1, 2008).
1675
 Health Policy
51 Ndikumana L, Boyce JK. Congo’s odious debt: external borrowing
and capital flight in Zaire. Dev Change 1998; 29: 195–217.
52 Mandel S. Odious lending: debt relief as if morals mattered.
London: New Economics Foundation, 2006. http://www.
jubileeresearch.org/news/Odiouslendingfinal.pdf (accessed
Oct 1, 2008).
53 Labonté R, Blouin C, Chopra M, et al. Towards health-equitable
globalization: rights, regulation and redistribution. Globalization
Knowledge Network final report to the Commission on Social
Determinants of Health. Ottawa: Institute of Population Health,
University of Ottawa, 2007. http://www.who.int/social_determinants/
resources/gkn_final_report_042008.pdf (accessed Oct 1, 2008).
54 Blouin C, Bhushan A, Murphy S, Warren B. Trade
liberalization: synthesis paper. Globalization Knowledge Network
research papers. Ottawa: Institute of Population Health, University
of Ottawa, 2008. http://www.globalhealthequity.ca/
electronic%20library/Trade%20Liberalization%20Synthesis%20Pap
er%20Blouin.pdf (accessed Oct 1, 2008).
55 Working group on IMF programs and health spending. Does the
IMF constrain health spending in poor countries? Evidence and
an agenda for action. Washington, DC: Center for Global
Development, 2007.
56 Collier P. The bottom billion: why the poorest countries are failing
and what can be done about it. Oxford: Oxford University Press, 2007.
57 Pogge T. Human rights and human responsibilities. In: De Greiff P,
Cronin C, eds. Global justice & transnational politics. Cambridge,
MA: MIT Press, 2002: 151–95.
58 Pogge T. Recognized and violated by international law: the human
rights of the global poor. Leiden J Int Law 2005; 18: 717–45.
59 Pogge T. Severe poverty as a human rights violation. In: Pogge T, ed.
Freedom from poverty as a human right: who owes what to the very
poor? Oxford: Oxford University Press, 2007: 11–53.
60 Marchak P. The integrated circus: the new right and the restructuring
of global markets. Montreal: McGill-Queen’s University Press, 1991.
61 Babb S. The social consequences of structural adjustment: recent
evidence and current debates. Annu Rev Sociology 2005; 31: 199–222.
62 Labonté R, Schrecker T. Globalization and social determinants of
health: the role of the global marketplace (part 2 of 3). Global Health
2007; 3: 1–17.
63 Deacon B, Ilva M, Koivusalo M, Ollila E, Stubbs P. Copenhagen
Social Summit ten years on: the need for effective social policies
nationally, regionally and globally. GASPP Policy Brief 6.
Helsinki: Globalism and Social Policy Programme, STAKES, 2005.
http://gaspp.stakes.fi/NR/rdonlyres/4F9C6B91-94FD-4042-B781-
3DB7BB9D7496/0/policybrief6.pdf (accessed Oct 1, 2008).
64 Nygren-Krug H. 25 questions and answers on health and human
rights. Health & human rights publication series issue no. 1.
Geneva: World Health Organization, 2002. http://www.who.int/
entity/hhr/NEW37871OMSOK.pdf (accessed Oct 1, 2008).
65 Solar O, Irwin A. A conceptual framework for action on the social
determinants of health. Geneva: Commission on Social
Determinants of Health, World Health Organization, 2007. http://
www.who.int/entity/social_determinants/resources/csdh_
framework_action_05_07.pdf(accessed Oct 1, 2008).
66 Hunt P. Economic, social and cultural rights: The right of everyone to
the enjoyment of the highest attainable standard of physical and
mental health. Addendum: mission to the World Trade Organization,
E/CN.4/2004/49/Add.1. Geneva: United Nations Economic and Social
Council Commission on Human Rights; 2004. http://www.unhchr.
ch/Huridocda/Huridoca.nsf/e06a5300f90fa0238025668700518ca4/
5860d7d863239d82c1256e660056432a/$FILE/G0411390.pdf (accessed
Oct 1, 2008).
67 Kabeer N. Globalisation, labour standards and women’s
rights: dilemmas of collective (in)action in an interdependent
world. Feminist Econ 2004; 10: 3–35.
68 Barry C, Reddy SG. International trade and labor standards:
a proposal for linkage. Cornell Int Law J 2006; 39: 545–640.
69 Hammonds R, Ooms G. World Bank policies and the obligation of
its members to respect, protect and fulfill the right to health.
Health Hum Rights 2004; 8: 27–60.
70 Independent Evaluation Office, International Monetary Fund. The
IMF and aid to sub-Saharan Africa. Washington, DC: IMF, 2007.
1676
71 Blouin C, Drager N, Heymann J, eds. Trade and health: seeking
common ground. Montreal: McGill-Queen’s University Press, 2008.
72 Garcia FJ. Beyond special and differential treatment.
Boston Coll Int Comp Law Rev 2004; 27: 291–317.
73 Collier P. Why the WTO is deadlocked: and what can be done about
it. The World Econ 2006; 29: 1423–49.
74 Sachs JD. The basic economics of scaling up health care in
low-income settings. In: Working Party on Biotechnology, ed.
Horizontal project on policy coherence: availability of medicines for
emerging and infected neglected diseases, DSTI/STP/BIO(2007)6.
Paris: OECD, 2007: 7–23.
75 Pogge T, ed. Freedom from poverty as a human right: who owes
what to the very poor? Oxford: Oxford University Press, 2007.
76 Ruger JP. Ethics and governance of global health inequalities.
J Epidemiol Community Health 2006; 60: 998–1003.
77 Jamison DT, Breman JG, Measham AR, et al, eds. Disease control
priorities in developing countries. Washington, DC: Oxford
University Press and World Bank, 2006.
78 UN Millennium Project. Investing in development: a practical plan
to achieve the Millennium Development Goals. London: Earthscan,
2005. http://www.unmillenniumproject.org/documents/
MainReportComplete-lowres.pdf (accessed Oct 1, 2008).
79 Brock K, McGee R. Mapping trade policy: understanding the
challenges of civil society participation. IDS working paper 225.
Brighton: Institute for Development Studies, 2004. http://www.ids.
ac.uk/ids/bookshop/wp/wp225.pdf#search=%22%20%22%20%20
Mapping%20Trade%20Policy%3A%20Understanding%20the%20C
hallenges%22%22 (accessed Oct 1, 2008).
80 Mandel S. Debt relief as if people mattered: a rights-based approach
to debt sustainability. London: New Economics Foundation, 2006.
http://www.neweconomics.org/gen/z_sys_publicationdetail.
aspx?pid=223 (accessed Oct 1, 2008).
81 Williamson J. Democracy and the “Washington consensus”.
World Dev 1993; 21: 1329–36.
82 Mosley L. Constraints, opportunities, and information: financial
market-government relations around the world. In: Bardhan P,
Bowles S, Wallerstein M, eds. Globalization and egalitarian
redistribution. New York and Princeton: Russell Sage Foundation
and Princeton University Press, 2006: 87–119.
83 Teichman J. Redistributive conflict and social policy in Latin
America. World Dev 2008; 36: 446–60.
84 Gore C. MDGs and PRSPs: are poor countries enmeshed in a
global-local double bind? Global Soc Policy 2004; 4: 277–83.
85 Woods N, Lombardi D. Uneven patterns of governance: how
developing countries are represented in the IMF. Rev Int Polit Econ
2006; 13: 480–515.
86 Chowla P, Oatham J, Wren C. Bridging the democratic
deficit: double majority decision making and the IMF. London:
One World Trust and Bretton Woods Project, 2007.
87 Commonwealth heads of government meeting on reform of
international institutions. Marlborough House statement on reform
of international institutions. London: Commonwealth Secretariat,
2008. http://www.thecommonwealth.org/files/180214/FileName/
HGM-RII_08_-MARLBOROUGHHOUSESTATEMENTONREFOR
MOFINTERNATIONALINSTITUTIONS.pdf (accessed Oct 1, 2008).
88 Griffith-Jones S. International financial stability and market
efficiency as a global public good. In: Kaul I, Conceição P,
LeGoulven K, Mendoza RU, eds. Providing global public
goods: managing globalization. New York: Oxford University Press
for the United Nations Development Programme, 2003: 435–54.
89 Lee K, Koivusalo M, Ollila E, et al. Globalization, global governance
and the social determinants of health: a review of the linkages and
agenda for action. Globalization Knowledge Network research
papers. Ottawa: Institute of Population Health, University of
Ottawa, 2008. http://www.globalhealthequity.ca/electronic%20
library/Globalization%20Global%20Governance%20and%20SD%2
0of %20H.pdf (accessed Oct 1, 2008).
90 Kickbusch I, Payne L. Constructing global public health in the 21st
century, prepared for meeting on global health governance and
accountability, 2004; Geneva: Kickbusch Health Consult, 2004.
http://www.ilonakickbusch.com/global-health-governance/
GlobalHealth.pdf (accessed Oct 9, 2008).
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