Global trade, public health, and health services: stakeholders' constructions of the key issues

Focusing mainly on the United States and Latin America, we aimed to identify the constructions of social reality held by the major stakeholders participating in policy debates about global trade, public health, and health services. In a multi-method, qualitative design, we used three sources of data: research and archival literature, 1980-2004; interviews with key informants who represented major organizations participating in these debates, 2002-2004; and organizational reports, 1980-2004. We targeted several types of organizations: government agencies, international financial institutions (IFIs) and trade organizations, international health organizations, multinational corporations, and advocacy groups. Many governments in Latin America define health as a right and health services as a public good. Thus, the government bears responsibility for that right. In contrast, the US government's philosophy of free trade and promoting a market economy assumes that by expanding the private sector, improved economic conditions will improve overall health with a minimum government provision of health care. US government agencies also view promotion of global health as a means to serve US interests. IFIs have emphasized reforms that include reduction and privatization of public sector services. International health organizations have tended to adopt the policy perspectives of IFIs and trade organizations. Advocacy groups have emphasized the deleterious effects of international trade agreements on public health and health services. Organizational stakeholders hold widely divergent constructions of reality regarding trade, public health, and health services. Social constructions concerning trade and health reflect broad ideologies concerning the impacts of market processes. Such constructions manifest features of "creed," regarding the role of the market in advancing human purposes and meeting human needs. Differences in constructions of trade and health constrain policies to address the profound changes generated by global trade.