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New horizons are opening for Africa, with a growing number of Chinese andIndian businesses fostering its integration into advanced markets. However,significant imbalances will have to be addressed on both sides of the equation to support long-term growth.

We explore the public policy implications of two new, significant, and inter-related global phenomena. First, the rising share of services, particularly innovation-driven digital and knowledge-based services, in foreign trade and multinational enterprise activity; and second, the increasingly important role of global cities as home and hosts to these activities. Our framework distinguishes between national economic policies to promote trade and FDI, referred to as economic diplomacy, and comparable policies originating in cities, referred to as city diplomacy. National economic diplomacy has traditionally promoted trade and investment in goods, often through trade agreements and promotion agencies, and we explore the limitations of these tools as trade in services becomes more important. However, we also note that trade in services, particularly innovation-driven services, is concentrated in global cities, and traded between them, often within MNEs. We conclude that national policies on trade and investment cannot be divorced from innovation and knowledge strategies, and that these strategies cannot be divorced from cities. We emphasize that national economic diplomacy should be better aligned with city diplomacy. We also discuss how the transition to stronger city diplomacy may have consequences for firms and their strategies for corporate diplomacy.

Background In late 2018 the United States, Canada, and Mexico signed a new trade agreement (most commonly referred to by its US-centric acronym, the United States-Mexico-Canada Agreement, or USMCA) to replace the 1994 North American Free Trade Agreement (NAFTA). The new agreement is the first major trade treaty negotiated under the shadow of the Trump Administration’s unilateral imposition of tariffs to pressure other countries to accept provisions more favourable to protectionist US economic interests. Although not yet ratified, the agreement is widely seen as indicative of how the US will engage in future international trade negotiations. Methods Drawing from methods used in earlier health impact assessments of the Trans-Pacific Partnership agreement, we undertook a detailed analysis of USMCA chapters that have direct or indirect implications for health. We began with an initial reading of the entire agreement, followed by multiple line-by-line readings of key chapters. Secondary sources and inter-rater (comparative) analyses by the four authors were used to ensure rigour in our assessments. Results The USMCA expands intellectual property rights and regulatory constraints that will lead to increased drug costs, particularly in Canada and Mexico. It opens up markets in both Canada and Mexico for US food exports without reducing the subsidies the US provides to its own producers, and introduces a number of new regulatory reforms that weaken public health oversight of food safety. It reduces regulatory policy space through new provisions on ‘technical barriers to trade’ and requirements for greater regulatory coherence and harmonization across the three countries. It puts some limitations on contentious investor-state dispute provisions between the US and Mexico, provisions often used to challenge or chill health and environmental measures, and eliminates them completely in disputes between the US and Canada; but it allows for new ‘legacy claims’ for 3 years after the agreement enters into force. Its labour and environmental chapters contain a few improvements but overall do little to ensure either workers’ rights or environmental protection. Conclusion Rather than enhancing public health protection the USMCA places new, extended, and enforceable obligations on public regulators that increase the power (voice) of corporate (investor) interests during the development of new regulations. It is not a health-enhancing template for future trade agreements that governments should emulate.

The Kyrgyz Republic has made major strides in the past decade in its transition to a market-based economy. Its trade and investment policies are arguably the most liberal among the member countries of the Commonwealth of Independent States. Despite the generally progressive stance on structural policies and a sound record of macroeconomic management in recent years, economic growth has been modest, living standards are low, a large burden of external debt has accumulated, and integration into global production and trade remains limited. The growth agenda must address more carefully the constraints to greater supply-side response to ongoing reforms—an agenda that can facilitate a broad-based growth of economic activity and exports. Risks to sustainability of current growth rates and continued poverty reduction will otherwise remain high as will the economy’s vulnerability to external shocks. This report is aimed at assisting authorities fashioning this agenda by focusing on three key challenges:Identifying strategic options to strengthen prospects for medium- and long-term growth and poverty reduction; Assessing ways of leveraging domestic trade policy reforms and existing regional and multilateral trade agreements for further regional and global integration; and Identifying key areas where greater efforts are necessary to facilitate improvements in enterprise capability and productivity.

Negotiations surrounding the Trans-Pacific Partnership (TPP) trade and investment agreement have recently concluded. Although trade and investment agreements, part of a broader shift to global economic integration, have been argued to be vital to improved economic growth, health, and general welfare, these agreements have increasingly come under scrutiny for their direct and indirect health impacts. We conducted a prospective health impact analysis to identify and assess a selected array of potential health risks of the TPP. We adapted the standard protocol for Health impact assessments (HIAs) (screening, scoping, and appraisal) to our aim of assessing potential health risks of trade and investment policy, and selected a health impact review methodology. This methodology is used to create a summary estimation of the most significant impacts on health of a broad policy or cluster of policies, such as a comprehensive trade and investment agreement. Our analysis shows that there are a number of potentially serious health risks associated with the TPP, and details a range of policy implications for the health sector. Of particular focus are the potential implications of changes to intellectual property rights (IPRs), sanitary and phytosanitary measures (SPS), technical barriers to trade (TBT), investor-state dispute settlement (ISDS), and regulatory coherence provisions on a range of issues, including access to medicines and health services, tobacco and alcohol control, diet-related health, and domestic health policy-making. We provide a list of policy recommendations to mitigate potential health risks associated with the TPP, and suggest that broad public consultations, including on the health risks of trade and investment agreements, should be part of all trade negotiations.

Background In early October 2015, 12 nations signed the Trans-Pacific Partnership Agreement (TPPA), promoted as a model ‘21 st century’ trade and investment agreement that other countries would eventually join. There are growing concerns amongst the public health community about the potential health implications of such WTO+ trade and investment agreements, but little existing knowledge on their potential health impacts. Methods and results We conducted a health impact review which allows for a summary estimation of the most significant health impacts of a set of policies, in our case the TPPA. Our analysis shows that there are a number of potentially serious health risks, with the following key pathways linking trade to health: access to medicines, reduced regulatory space, investor-state dispute settlement (ISDS), and environmental protection and labor rights. We also note that economic gains that could translate into health benefits will likely be inequitably distributed. Conclusion Our analysis demonstrates the need for the public health community to be knowledgeable about trade issues and more engaged in trade negotiations. In the context of the COP21 climate change Agreement, and the UN Sustainable Development Goals, this may be an opportune time for TPPA countries to reject it as drafted, and rethink what should be the purpose of such agreements in light of (still) escalating global wealth inequalities and fragile environmental resources—the two most foundational elements to global health equity.

This article proposes a shift to a paradigm that is more extensive than the current narrow focus on North-South climate change technology transfers, towards a more inclusive 'global' paradigm. An implication of the paradigm shift is that there should be a concomitant expansion of the policy agendas of the international climate and trade regimes. The traditional North-South paradigm of technology transfer ignores the increasing importance of developing countries as sources of advanced climate-friendly technologies, and therefore ignores South-North and South-South transfers. Further, whereas the North-South paradigm has emphasized developing countries' intellectual property rights policies as barriers to technology transfers, the 'global' paradigm focuses attention on trade and investment policy barriers, including developed countries' policies that inhibit technology transfer from developing countries. The analysis is relevant to international negotiations in the post-2012 climate regime, and is also relevant to the future development of the trade regime-not only at the multilateral level in the WTO, but also at the regional and bilateral levels.

Prospective studies of the potential health consequences of trade and investment treaties, such as the Trans-Pacific Partnership, are critical. These studies can make visible to trade policy-makers the potential negative impacts associated to such treaties and can influence the outcomes of such negotiations. However, few researchers have examined retrospectively the consequences of trade agreements. With more than 400 trade agreements and more than 2000 investment treaties currently in force, researchers have a large corpus of agreements to analyse in order to assess not only their potential impacts on health system and population health, but also their actual impacts. This comment suggests some research questions that would benefit from retrospective inquiry.

In this commentary, we endorse concerns about the health impact of the trans-pacific partnership (TPP), paying particular attention to its mechanisms for investor state dispute settlement. We then describe the different, judge-led approach being advocated by the European Commission team negotiating the Trans-Atlantic Trade and Investment Partnership, arguing that, while not perfect, it offers significant advantages.