David Woodward

The GATS and trade in health services: implications for health care in developing countries

The literature on the GATS and trade in health services is limited, largely speculative, and polarised between ‘trade’ and ‘health systems’ perspectives. The distinctive features of the market for health services, particularly in developing countries, means that the ‘benefits of trade’ argument is not applicable: the potential economic benefits of trade in health services are limited, while its potential effects on health systems, particularly through the supply of health professionals to public services, are substantially negative in almost all developing countries. GATS commitments have not encouraged trade, and there is little reason to anticipate this, except possibly in Mode 3; but they seriously constrain health policy. The effectiveness of GATS safeguard provisions is at best doubtful; and the stronger domestic regulation needed in open health service markets is beyond the capacity of most developing countries. Proposed GATS-consistent regulations to offset adverse effects of trade in health services are untested, unrealistic, impracticable, ineffectual, and/or have serious limitations or adverse side-effects. GATS commitments are binding, backed by sanctions, and of indefinite duration; but key provisions are ambiguous, and the future extent, nature and effects of trade in health services very uncertain. Analysis and data are very limited and analytical frameworks undeveloped. There is thus no basis for informed decision-making on GATS commitments; and decision-making processes mean that health considerations play a very limited role. Therefore, the GATS framework is inappropriate as a basis for international rules on trade in health services; and it is undesirable for developing countries to make GATS commitments in the health sector.

A new Director General for WHO--an opportunity for bold and inspirational leadership.

But further discussion is needed before the election of a new Director-General this November. What challenges are faced by WHO and its new head, and how can individuals and institutions strengthen WHO’s capacity to respond eff ectively to the world’s health challenges? These are not idle questions, for all is not well at WHO. For millions of people, the prospect of a basic level of health security remains a distant hope. Furthermore, as the importance of global and supranational determinants of health increases, so does that of global public-health institutions. In this article, the People’s Health Movement, a worldwide network of individuals and civil society organisations committed to the vision and principles of the 1978 Alma Ata Declaration, identifi es three sets of global health challenges and the kind of response it would like from WHO. We also discuss the constraints and barriers faced by WHO itself, and suggest actions that should be taken by WHO and its new Director-General, as well as by governments and civil society. Key global health challenges Poverty and the global political economy Poverty remains the world’s biggest health problem, underlying the HIV/AIDS crisis, the high mortality attributed to tuberculosis and malaria, and the 30 000 deaths of children every day from preventable and treatable causes. It also results in governments being unable to foster socioeconomic development and invest in eff ective health, welfare, and education systems. Frequent references are made to the World Bank calculation that the number and proportion of people living on less than US

Engaging the health community in global economic reform

1 per day has fallen since the late 1980s. However, less is said about this calculation’s systematic underestimation of the extent of impoverishment. 4

Towards health-equitable globalisation: rights, regulation and redistribution. Final Report to the Commission on Social Determinants of Health

www.thelancet.com Vol 373 March 21, 2009 987 is trained in the social determinants of health, and raise public awareness of these determinants. This Lancet Series shows that there is ample ability, if not capacity, within Palestinian society to address the third challenge. Addressing the fi rst challenge requires an end to the current conditions of occupation and siege. Addressing the second challenge requires an end both to factional government and the culture of donor dependency. For too long, the health and welfare of Palestinians within the occupied territory have been secondary to powerful outside interests. As Virchow might have put it, the solution lies in justice, sovereignty, and self-determination for the people of the West Bank and Gaza Strip.