The Transatlantic Trade and Investment Partnership (TTIP) currently being negotiated between the European Union (EU) and the United States has been sold by politicians on both sides as a strategic opportunity to shape globalization to the benefit of both parties. But a new research paper from Chatham House finds that the risks of such an ambitious project are significant – whether or not the current deadlock in negotiations can be overcome – and the UK vote for Brexit increases those risks.

The primary strategic benefit of TTIP would be to enable the United States and the EU to set the ‘rules of the road’ for international trade in the 21st century. TTIP’s backers hope that if the EU and the United States can agree on a new set of standards, the power of their combined markets will lead other countries to adopt the same rules. According to Realizing TTIP’s Strategic Potential one of the risks of agreeing such far-reaching rules is that they set the bar too high for other countries to accept. By imposing restrictive rules unilaterally on, for example, state-owned enterprises, TTIP could provoke retaliation and encourage other countries to establish alternative rules.

TTIP also has the potential to attract other countries to align themselves economically and politically with the EU and the United States due to their ‘soft-power’. But this benefit will only materialise if strategically important countries, such as Turkey, are able to join. The research finds that the demands placed on Turkey may be too high for this to be a realistic prospect in the near future. Ukraine is another strategic country that could be targeted for expansion of TTIP, but extending membership to Ukraine would be regarded by Russia as a 'serious escalation' by the West in their confrontation.

The paper argues there would be benefits to the UK, the EU and the United States if the UK were to join TTIP after the UK leaves the EU. For the UK it could provide the only real prospect of being able to influence international standards and a relatively quick means to conclude a comprehensive trade deal with the United States. For the EU and the United States, it would ensure the scale and attractiveness of TTIP is not reduced by the loss of one of the major European economies. It would also provide an immediate opportunity to establish TTIP as a plurilateral deal that is open to new members. The process would be made easier if the UK were to maintain an active role in the development of the EU position on TTIP, while the UK is still a member of the EU. This would mean that the UK would be in a position to accept the terms required to join TTIP relatively quickly upon exiting the EU. There will inevitably be sensitivities in the UK, other EU member states and the EU institutions about this, but it is in the strategic interests of all parties.

The most immediate risk for TTIP, however, is of failure. Despite 14 rounds of negotiations so far there is still disagreement over what should be included in the scope of the negotiations, including issues such as financial services regulation, which the United States is determined to exclude, and how to handle politically sensitive questions such as investor-state dispute settlement, which has become a hot-button issue in the EU. Even if an agreement is reached it must then be ratified by a sceptical US Congress, where there are challenges on both sides of the aisle, and by EU institutions and member states. The hostility to TTIP in many parts of Europe, especially in Germany, is not encouraging.

If the negotiations break down, or a deal is reached that falls short of the ambition set for it, this would send a damaging signal to the rest of the world about the ability of the EU and the United States to work together. It could also hasten the demise of their influence. For the EU, the stakes are greater now that the UK has decided to leave the EU.

The paper notes that the EU-US trade relationship is still the largest bilateral relationship in the world 'for now', but that in most sectors the lead over China is decreasing. If they miss this opportunity, the United States and the EU may not get another chance to set the standards that will govern the global trading order in the 21st century.

Report author, Gregor Irwin, said:

'TTIP negotiations are hanging in the balance. If they succeed TTIP has the potential to shape the next generation of trade rules and ensure a transatlantic vision for the international trading system prevails.  

'For now, both sides are facing off against each other in the negotiations and failing to focus enough on the strategic risks and opportunities from TTIP. If the full strategic potential from TTIP is to be realized they must pay more attention to how other countries are likely to respond.

'The UK’s decision to leave to leave the EU should sharpen the incentives that both sides have to conclude a deal. It is in everyone’s interest to ensure that the UK is able to join TTIP once the UK leaves the EU.

'Further opening up TTIP to include Turkey could create an alternative anchor for its economic and political relationship with the EU, short of EU membership. It could transform Turkey’s relationship with the EU, just as the North American Free Trade Agreement (NAFTA) has transformed Mexico’s relationship with the US.'

England and Australia are considered standard-bearers of universal access to health services, with the former’s National Health Service (NHS) recognized as a global brand and the latter’s Medicare seen as a leader in the Asia-Pacific region. However, through the exclusion of migrant and refugee groups, each is failing to deliver true universality in their health services. These exclusions breach both their own national policies and of international commitments they have made.

While the marginalization of mobile populations is not a new phenomenon, in recent years there has been a global increase in anti-migrant rhetoric, and such health care exclusions reflect a global trend in which undocumented migrants, refugees and asylum seekers are denied rights.

They are also increasingly excluded in the interpretation of phrases such as ‘leave no one behind’ and ‘universal health coverage’, commonly used by UN bodies and member states, despite explicit language in UN declarations that commits countries to include mobile groups.

Giving all people – including undocumented migrants and asylum seekers – access to health care is essential not just for the health of the migrant groups but also the public health of the populations that host them. In a world with almost one billion people on the move, failing to take account of such mobility leaves services ill-equipped and will result in missed early and preventative treatment, an increased burden on services and a susceptibility to the spread of infectious disease.

England

While in the three other nations of the UK, the health services are accountable to the devolved government, the central UK government is responsible for the NHS in England, where there are considerably greater restrictions in access.

Undocumented migrants and refused asylum seekers are entitled to access all health care services if doctors deem it clinically urgent or immediately necessary to provide it. However, the Home Office’s ‘hostile environment’ policies towards undocumented migrants, implemented aggressively and without training for clinical staff, are leading to the inappropriate denial of urgent and clearly necessary care.

One example is the case of Elfreda Spencer, whose treatment for myeloma was delayed for one year, allowing the disease to progress, resulting in her death.

In England, these policies, which closely link health care and immigration enforcement, are also deterring people from seeking health care they are entitled to. For example, medical bills received by migrants contain threats to inform immigration enforcement of their details if balances are not cleared in a certain timeframe. Of particular concern, the NGO Maternity Action has demonstrated that such a link to immigration officials results in the deterrence of pregnant women from seeking care during their pregnancy.

Almost all leading medical organizations in the United Kingdom have raised concerns about these policies, highlighting the negative impact on public health and the lack of financial justification for their implementation. Many have highlighted that undocument migrants use just and estimated 0.3% of the NHS budget and have pointed to international evidence that suggests that restrictive health care policies may cost the system more.

Australia

In Australia, all people who seek refuge by boat are held, and have their cases processed offshore in Papua New Guinea (PNG) and Nauru, at a cost of almost A$5 billion between 2013 and 2017. Through this international agreement, in place since 2013, Australia has committed to arrange and pay for the care for the refugees, including health services ‘to a standard of care broadly comparable to that available to the general Australian community under the public health system’.

However, the standard of care made available to the refugees is far from comparable to that available to the general population in Australia. Findings against the current care provision contractor on PNG, Pacific International Hospital, which took over in the last year, are particularly damning.

For instance, an Australian coroner investigating the 2014 death from a treatable leg infection of an asylum seeker held in PNG concluded that the contractor lacked ‘necessary clinical skills’, and provided ‘inadequate’ care. The coroner’s report, issued in 2018, found the company had also, in other cases, denied care, withheld pain relief, distributed expired medication and had generally poor standards of care, with broken or missing equipment and medication, and services often closed when they were supposed to be open.

This has also been reiterated by the Royal Australasian College of Physicians, which has appealed to the Australian government to end its policies of offshore processing immediately, due to health implications for asylum seekers. This echoes concerns of the medical community around the government’s ongoing attempts to repeal the ‘Medivac’ legislation, which enables emergency medical evacuation from PNG and Nauru.

Bad policy

Both governments have signed up to UN Sustainable Development Goals commitment to ‘safe and orderly migration’, an essential component of which is access to health care. The vision for this was laid out in a global action plan on promoting the health of refugees and migrants, agreed by member states at the 2019 World Health Assembly.

However, rather than allow national policies to be informed by such international plans and the evidence put forward by leading health professionals and medical organizations, the unsubstantiated framing of migrants as a security risk and economic burden has curtailed migrant and refugee access to health care.

The inclusion of migrants and refugees within universal access to health services is not merely a matter of human rights. Despite being framed as a financial burden, ensuring access for all people may reduce costs on health services through prevention of costly later-stage medical complications, increased transmission of infections and inefficient administrative costs of determining eligibility.

Thailand provides an example of a middle-income country that recognized this, successfully including all migrants and refugees in its health reforms in 2002. Alongside entitling all residents to join the universal coverage scheme, the country also ensured that services were ‘migrant friendly’, including through the provision of translators. A key justification for the approach was the economic benefit of ensuring a healthy migrant population, including the undocumented population.

The denial of quality health services to refugees and undocumented migrants is a poor policy choice. Governments may find it tempting to gain political capital through excluding these groups, but providing adequate access to health services is part of both governments’ commitments made at the national and international levels. Not only are inclusive health services feasible to implement and good for the health of migrants and refugees, in the long term, they are safer for public health and may save money.

The international community’s response to the Syria crisis has been unsatisfactory on many fronts, and humanitarian aid and development is no exception. While there has been renewed emphasis by development organizations on the importance of engaging local actors − notably highlighted in the new Sustainable Development Goals − the reality is this has been woefully lacking in practice. And Syria is simply one example of many where the failure of UN agencies and other humanitarian actors to partner with local actors has hampered the response to humanitarian crises.

Double standards

The problem is that international agencies usually have high and unfair expectations from Syrian individuals and organizations, requiring them to speak the ‘language’ of development, meet international standards, and demonstrate a wide range of expertise. However, these demands are not reciprocated by international organizations and experts being expected to have the same depth of knowledge of the local context in which they are operating. In addition, while Syrian actors are expected to be neutral, impartial and politically unaffiliated, foreign aid appears to be driven − explicitly and unashamedly − by the political objectives of the donor countries.

There is a double standard at work. In many cases, international ‘experts’ on Syria have little local knowledge, but there are no channels to measure or question their level of expertise. At the same time, including local Syrians in decision-making is seen as a threat to predetermined objectives, rather than as an asset.

Syrians could add an indispensable source of knowledge and context to international agencies, as well as add local credibility. But too often they are brought on board to be part of the humanitarian and development picture or to get their simple feedback for evaluation and needs assessment reports to satisfy donors’ requirements, rather than employed as an integral component of designing and implementing projects. Though some of this is down to a pretext of lack of capacity, it raises the question of whether there is an international political willingness and genuine organizational courage to involve Syrians at programming, decision and policy making-levels.

The importance of local

The Syrian example is not isolated. While there is now a debate to encourage engaging local actors, this does not happen in practice. The Local to Global Protection Initiative study reported that local and national humanitarian actors received only 0.2% of the overall direct global humanitarian response in 2013.

Moreover, the international humanitarian and development systems are designed, together with foreign aid policy, to be self-contained and to exclude local actors. This allows donor governments to use the systems as political tools for leveraging control. It is equally difficult for both outsiders as well as insiders to understand how the system really functions. The UN-led coordination structure is one example of the heavy international architecture that remains unable to reform itself, learn from its previous mistakes, or to engage with local actors.

And that engagement matters. The Independent Research Forum emphasized in its brief in February 2014 how engaging local researchers and implementing bottom-up participatory learning can make countries better prepared to achieve the post-2015 Sustainable Development Goals. Those goals, as well as the upcoming World Humanitarian Summit, highlight the importance of including local actors in the humanitarian and development responses.

Moving forward

Fortunately, such initiatives are creating a momentum within the development community to make radical changes through bottom-up approaches that put sustainability into practice. But if the Sustainable Development Goals want to affect real change, there will have to be a significant drive to move from rhetoric and ‘intentions’ to reality and actions. Currently it seems that the international community prefers to simply maintain the current status quo. It only takes a brief reflection on how many Syrians are included in every project or programme and how many Syrians are in positions to contribute at the policy and decision-making levels to realise the scale of the impetus required to change this system. To make that change might provide an opportunity for Syrians to restore some of the ownership to the outcomes and decisions of their conflict.

To comment on this article, please contact Chatham House Feedback

England and Australia are considered standard-bearers of universal access to health services, with the former’s National Health Service (NHS) recognized as a global brand and the latter’s Medicare seen as a leader in the Asia-Pacific region. However, through the exclusion of migrant and refugee groups, each is failing to deliver true universality in their health services. These exclusions breach both their own national policies and of international commitments they have made.

While the marginalization of mobile populations is not a new phenomenon, in recent years there has been a global increase in anti-migrant rhetoric, and such health care exclusions reflect a global trend in which undocumented migrants, refugees and asylum seekers are denied rights.

They are also increasingly excluded in the interpretation of phrases such as ‘leave no one behind’ and ‘universal health coverage’, commonly used by UN bodies and member states, despite explicit language in UN declarations that commits countries to include mobile groups.

Giving all people – including undocumented migrants and asylum seekers – access to health care is essential not just for the health of the migrant groups but also the public health of the populations that host them. In a world with almost one billion people on the move, failing to take account of such mobility leaves services ill-equipped and will result in missed early and preventative treatment, an increased burden on services and a susceptibility to the spread of infectious disease.

England

While in the three other nations of the UK, the health services are accountable to the devolved government, the central UK government is responsible for the NHS in England, where there are considerably greater restrictions in access.

Undocumented migrants and refused asylum seekers are entitled to access all health care services if doctors deem it clinically urgent or immediately necessary to provide it. However, the Home Office’s ‘hostile environment’ policies towards undocumented migrants, implemented aggressively and without training for clinical staff, are leading to the inappropriate denial of urgent and clearly necessary care.

One example is the case of Elfreda Spencer, whose treatment for myeloma was delayed for one year, allowing the disease to progress, resulting in her death.

In England, these policies, which closely link health care and immigration enforcement, are also deterring people from seeking health care they are entitled to. For example, medical bills received by migrants contain threats to inform immigration enforcement of their details if balances are not cleared in a certain timeframe. Of particular concern, the NGO Maternity Action has demonstrated that such a link to immigration officials results in the deterrence of pregnant women from seeking care during their pregnancy.

Almost all leading medical organizations in the United Kingdom have raised concerns about these policies, highlighting the negative impact on public health and the lack of financial justification for their implementation. Many have highlighted that undocument migrants use just and estimated 0.3% of the NHS budget and have pointed to international evidence that suggests that restrictive health care policies may cost the system more.

Australia

In Australia, all people who seek refuge by boat are held, and have their cases processed offshore in Papua New Guinea (PNG) and Nauru, at a cost of almost A$5 billion between 2013 and 2017. Through this international agreement, in place since 2013, Australia has committed to arrange and pay for the care for the refugees, including health services ‘to a standard of care broadly comparable to that available to the general Australian community under the public health system’.

However, the standard of care made available to the refugees is far from comparable to that available to the general population in Australia. Findings against the current care provision contractor on PNG, Pacific International Hospital, which took over in the last year, are particularly damning.

For instance, an Australian coroner investigating the 2014 death from a treatable leg infection of an asylum seeker held in PNG concluded that the contractor lacked ‘necessary clinical skills’, and provided ‘inadequate’ care. The coroner’s report, issued in 2018, found the company had also, in other cases, denied care, withheld pain relief, distributed expired medication and had generally poor standards of care, with broken or missing equipment and medication, and services often closed when they were supposed to be open.

This has also been reiterated by the Royal Australasian College of Physicians, which has appealed to the Australian government to end its policies of offshore processing immediately, due to health implications for asylum seekers. This echoes concerns of the medical community around the government’s ongoing attempts to repeal the ‘Medivac’ legislation, which enables emergency medical evacuation from PNG and Nauru.

Bad policy

Both governments have signed up to UN Sustainable Development Goals commitment to ‘safe and orderly migration’, an essential component of which is access to health care. The vision for this was laid out in a global action plan on promoting the health of refugees and migrants, agreed by member states at the 2019 World Health Assembly.

However, rather than allow national policies to be informed by such international plans and the evidence put forward by leading health professionals and medical organizations, the unsubstantiated framing of migrants as a security risk and economic burden has curtailed migrant and refugee access to health care.

The inclusion of migrants and refugees within universal access to health services is not merely a matter of human rights. Despite being framed as a financial burden, ensuring access for all people may reduce costs on health services through prevention of costly later-stage medical complications, increased transmission of infections and inefficient administrative costs of determining eligibility.

Thailand provides an example of a middle-income country that recognized this, successfully including all migrants and refugees in its health reforms in 2002. Alongside entitling all residents to join the universal coverage scheme, the country also ensured that services were ‘migrant friendly’, including through the provision of translators. A key justification for the approach was the economic benefit of ensuring a healthy migrant population, including the undocumented population.

The denial of quality health services to refugees and undocumented migrants is a poor policy choice. Governments may find it tempting to gain political capital through excluding these groups, but providing adequate access to health services is part of both governments’ commitments made at the national and international levels. Not only are inclusive health services feasible to implement and good for the health of migrants and refugees, in the long term, they are safer for public health and may save money.