How the World Trade Organisation is shaping domestic policies in health care

WHO and its transformation - A journey from 1978 to 2024

The Alma-Ata Declaration of 1978 was a historic hallmark in the history of public health of the 20th century. It stressed on comprehensive primary health care and led to the slogan of "Health for All by 2000 A.D." The Conference documents made it clear that primary health care was essential health care based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country could afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It was proclaimed to form an integral part of a country's health system. In addition, as a consequence, the overall social and economic development of the community depended on its survival. It was regarded as the first level of contact of individuals, the family, and community with the national health system bringing health care as close as possible to where people live and work. Instead of disease-centred vertical programs, it emphasised to adopt the horizontal community-based programs. Though the worldwide stir caused by the historic Alma-Ata Conference (1978), giant MNCs of the world remained hibernated for some time but never gave up to turn "health" into "health care" as commodity. Intriguingly enough, health was "forgotten" when the Covenant of the League of Nations was drafted after the First World War. Only at the last moment, world health was included, leading to the Health Section of the League of Nations. Recently, Intergovernmental Negotiating Body has drafted a new Pandemic Treaty which might become disastrous for general well-being and rightful living for citizens in future. All these observations are very much relevant if family medicine and primary care are given due importance at the present moment.

When actions do not match aspirations - comparison of the European Union policy claims against what has been negotiated for health services, trade and investment

Background

Obligations arising from trade and investment agreements can affect how governments can regulate and organise health systems. The European Union has made explicit statements of safeguarding policy space for health systems. We assessed to what extent health systems were safeguarded in trade negotiations using the European Union (EU) negotiation proposals for the Transatlantic Trade and Investment Partnership (TTIP) and the negotiated agreement for the EU-Canada Comprehensive Economic and Trade Agreement (CETA).

Methods

We assessed if and to what extent the European Union policy assurances were upheld in trade negotiations. Our assessment was made using three process tracing informed tests. The tests examined: i) what was covered in negotiation proposals of services and investment chapters, ii) if treatment of health services differed from treatment of another category of services (audiovisual services) with similar EU Treaty considerations, and iii) if other means of general exceptions, declarations or emphases on right to regulate could have resulted in the same outcome.

Results

Our analysis shows that the European Union had sought to secure policy space for publicly funded health services for services chapter, but not for investment and investment protection chapters. In comparison to audiovisual services, exceptions for health services fall short from those on audiovisual services. There is little evidence that the same outcome could have been achieved using other avenues.

Conclusions

The European Union has not achieved its own assurances of protection of regulatory policy space for health services in trade negotiations. The European Union trade negotiation priorities need to change to ensure that its negotiation practices comply with its own assurances for health services and sustainable financing of health systems.

Commercial Health Care Financing: The Cause of U.S., Dutch, and Swiss Health Systems Inefficiency?

This article evaluates the performance of 3 industrialized nations that have pursued market-based financing models, focusing on equity in access to care, care quality, health status, and efficiency. It then assesses the consistency of the findings with those of different research teams. Using secondary data obtained from a semi-structured review of articles from 2000 to 2017, we discuss the hypothesis that commercial health care insurance is detrimental to accessing professional health care and to population health status. The results show that in 2010 the unmet care needs of both poor and rich Americans exceeded those of the poor in several industrial countries. The number of Dutch adults experiencing financial obstacles to health care quadrupled between 2007 and 2013, and 22% of Swiss adults reported skipping needed care in a 2016 survey. The most negative impacts of "managed care" on care quality are its tight constraints on physicians' professional autonomy; a large reliance on the physicians' material motivation; health service fragmentation; and the tendency to apply evidence-based medicine too rigidly. Countries with a commercial insurance monopoly generally remained above the maternal, infant, and neonatal mortality rates versus the health-spending regression line. We conclude that the most inefficient system is where the insurance market has achieved its maximal development and that care industrialization contributes to the comparatively poor performance of the U.S., Dutch, and Swiss health systems.

International Trade and Health Care in Brazil: An Unpredicted Tale Threatening Health Care Entitlement?

The General Agreement on Trade in Services (GATS), established in 1994, has been a key element of market liberalization of health care services. Brazil had the provision of health care services partially protected from international competition until 2015, when a constitutional change opened the national health care market to international provision. We performed a retrospective and prospective policy analysis based on a systematic policy document review, general literature review, and secondary data analysis mapping, describing and analyzing the international trade agreements signed by Brazil with the World Trade Organization (WTO) and the available legislation relevant to health care services. The provision of health care services was not included in the WTO commitments signed by Brazil during the analyzed period (1994–2018). Financing of private health insurance was part of the agreement since 1994. There was a mild liberalization of the private health insurance sector, while provision of health care services was forbidden to foreign investors until 2015. The mode 3 of GATS presents the greatest potential impact as it exposes health care provision to international competition. The international liberalization of the provision of health care services in Brazil is now legal and an observable consequence of the pressure to gradually lift trade barriers in the health and health care sector.

Psychiatry and the pharmaceutical industry: who pays the piper?

There is increasing concern about the relationship between medicine and the pharmaceutical industry. In July the BMJ devoted a themed issue to this, and critical discussions have featured in other leading medical journals recently. The industry has grown in profitability and influence over the past 20 years, and is now second only to armaments in the US economy (Public Citizen, 2002). Its influence is enhanced through its control of research, and it employs sophisticated and wide-reaching marketing strategies. This level of influence is concerning because the private investment necessary to enable drug development demands ever more vigorous struggles to maintain and expand market presence. In other words, commercial rather than clinical or scientific demands are becoming the dominant driving force for ‘innovation’. This leads to the popularity of developing cheaper ‘me too’ options, and the promotion of new ‘disease concepts' to allow the re-badging of old products to expand markets without major development costs.

The GATS: Impacts of the international “services” treaty on health-based alcohol regulation

There is an underlying incompatibility between public health-focused alcohol regulation and the World Trade Organization's “services” treaty. This treaty, the General Agreement on Trade in Services (GATS), is very broad, extending beyond border measures to reach into many areas formerly considered purely matters of legitimate domestic regulation. Essentially unknown to the public, the GATS is currently being re-negotiated to broaden the number and types of services it covers and to place greater restrictions on the scope of governments' regulatory ability. All services, including services relating directly and indirectly to alcohol, are on the negotiating table. These negotiations can be expected to affect most adversely those alcohol policies that are considered to be the most effective in protecting public health. The European Commission and the United States are strong advocates for expanding the GATS and formally propose that countries liberalize their distribution systems, including systems for distributing alcohol. If adopted, this proposal would preclude many health-based policy options in developing countries and is likely to place increased pressure on alcohol policy in Europe, when other countries request reciprocal commitments from the EC. The paper ex-amines threats that the treaty and its proposed expansion pose for alcohol monopolies, advertising restrictions, governments' control over availability and access to alcohol, international health-based alcohol initiatives, and alcohol policy in developing countries. Alcohol researchers and public health advocates are encouraged to play a more proactive role in international treaties to achieve more balanced results, rather than acceding to ratchet-like constraints that make the adoption of an ever-greater number of public policy options increasingly difficult.

The GATS: Impacts of the international “services” treaty on health-based alcohol regulation

There is an underlying incompatibility between public health-focused alcohol regulation and the World Trade Organization's “services” treaty. This treaty, the General Agreement on Trade in Services (GATS), is very broad, extending beyond border measures to reach into many areas formerly considered purely matters of legitimate domestic regulation. Essentially unknown to the public, the GATS is currently being re-negotiated to broaden the number and types of services it covers and to place greater restrictions on the scope of governments' regulatory ability. All services, including services relating directly and indirectly to alcohol, are on the negotiating table. These negotiations can be expected to affect most adversely those alcohol policies that are considered to be the most effective in protecting public health. The European Commission and the United States are strong advocates for expanding the GATS and formally propose that countries liberalize their distribution systems, including systems for distributing alcohol. If adopted, this proposal would preclude many health-based policy options in developing countries and is likely to place increased pressure on alcohol policy in Europe, when other countries request reciprocal commitments from the EC. The paper examines threats that the treaty and its proposed expansion pose for alcohol monopolies, advertising restrictions, governments' control over availability and access to alcohol, international health-based alcohol initiatives, and alcohol policy in developing countries. Alcohol researchers and public health advocates are encouraged to play a more proactive role in international treaties to achieve more balanced results, rather than acceding to ratchet-like constraints that make the adoption of an ever-greater number of public policy options increasingly difficult.

Physicians' job satisfaction and motivation in a public academic hospital

BACKGROUND

Physician shortage is a global issue that concerns Brazil's authorities. The organizational structure and the environment of a medical institution can hide a low-quality life of a physician. This study examines the relationship between the hospital work environment and physicians' job satisfaction and motivation when working in a large public academic hospital.

METHODS

The study was restricted to one large, multispecialty Brazil's hospital. Six hundred hospital physicians were invited to participate by e-mail. A short version of the Physician Worklife Survey (PWS) was used to measure working satisfaction. Physicians were also asked for socio-demographic information, medical specialty, and the intention to continue working in the hospital.

RESULTS

Data from 141 questionnaires were included in the analyses. Forty-five physicians graduated from the hospital's university, and they did not intend to leave the hospital under any circumstance (affective bond). The motivating factor for beginning the career at the hospital and to continue working there were the connection to the medical school and the hospital status as a "prestigious academic hospital"; the physicians were more satisfied with the career than the specialty. Only 30% completely agreed with the statement "If I had to start my career over again, I would choose my current specialty," while 45% completely agreed with the statement "I am not well compensated given my training and experience." The greater point of satisfaction was the relationship with physician colleagues. They are annoyed about the amount of calls they are requested to take and about how work encroaches on their personal time. No significant differences between medical specialties were found in the analysis.

CONCLUSIONS

The participants were satisfied with their profession. The fact that they remained at the hospital was related to the academic environment, the relationship with colleagues, and the high prestige in which society holds the institution. The points of dissatisfaction were inadequate remuneration and the fact that work invaded personal time. Routinely, there is a need for organizations to examine the impact of their structures, policies, and procedures on the stress and quality of life of physicians.

Privatization and Trade in Health Services: A Review of the Evidence

Health care provision, like other areas of welfare, has increasingly been subject to processes of privatization and contracting out, leading in some cases to an increased involvement of for-profit corporations. Such processes are likely to interact with processes of liberalization at the international level in ways that we would expect to lead to a growth in the international trading of such services. However, health service provision is usually deeply embedded in state structures at the national level, and the form of such structures varies greatly. The degree and type of private involvement allowed for or facilitated by national-level systems defines the scope for the potential development of international trade in health services. The author reviews existing sources of data on the levels of private provision across advanced capitalist countries, countries in transition from Soviet-type systems, and developing countries, and highlights processes of change that are likely to increase such provision. Private provision is growing slowly but steadily in most countries. While levels of international trade in health services are difficult to ascertain, the interaction between national processes of reform and international processes of liberalization is likely to increase such trade.

Medical Students' Opinions About the Commercialization of Healthcare: A Cross-Sectional Survey

There are serious concerns about the commercialization of healthcare and adoption of the business approach in medicine. As market dynamics endanger established professional values, healthcare workers face more complicated ethical dilemmas in their daily practice. The aim of this study was to investigate the willingness of medical students to accept the assertions of commercialized healthcare and the factors affecting their level of agreement, factors which could influence their moral stance when market demands conflict with professional values. A cross-sectional study was conducted in three medical schools in Turkey. The study population consisted of first-, third-, and sixth-year students, and 1,781 students participated in total. Students were asked to state if they agreed with the assertions of commercialized healthcare. Of all students, 87.2 per cent agreed with at least one of the assertions, and one-fifth (20.8 per cent) of them agreed with more than half of the assertions. First-year students significantly agreed more with some assertions than third- and sixth-year students. Being female, having mid-level family income, choosing medicine due to idealistic reasons, and being in the third or sixth years of medical study increased the probability of disagreement. Also, studying in a medical school that included integrated lectures on health policies, rights related to health, and health inequities, along with early field visits, increased the probability of disagreement. This study suggests that agreement with the assertions of commercialized healthcare might be prevalent among students at a considerable level. We argue that this level of agreement is not compatible with best practice in professional ethics and indicates the need for an educational intervention in order to have physicians who give priority to patients' best interests in the face of market demands.

A abertura da saúde nacional ao capital estrangeiro: efeitos do mercado global no Brasil

A saúde é um direito constitucional no Brasil. Este ensaio debate a abertura do mercado da saúde, em seu subsistema privado, ao investimento estrangeiro (Foreign Direct Investment), sancionada pelo governo brasileiro (Lei 13.097/2015). Busca evidências na literatura que demonstrem experiências semelhantes em outros países, assim como contextualiza o mercado da saúde nacional na conjuntura global de investimento em serviços. Tal lei, carecendo de mecanismos regulatórios e de discussões prévias nas instâncias de controle social, falhará na promoção de maior competitividade entre provedores e acarretará, como consequência de longo termo, a inviabilidade do subsistema público de saúde nacional.

Needs in health care: what beast is that?

Need is a pivotal concept within health systems internationally given its driving force in health care policy, development, and delivery at population and individual levels. Needs assessments are critical activities undertaken to ensure that health services continue to be needed and to identify new target populations that demonstrate unmet need. The concept of need is underpinned by varied theoretical definitions originating from various disciplines. However, when needs are assessed, or health interventions developed based on need, little, if any, detail of the theoretical or conceptual basis of what is being measured is ever articulated. This is potentially problematic and may lead to measurement being invalid and planned health services being ineffective in meeting needs. Seldom are theoretical definitions of need ever compared and contrasted. This critical review is intended to fill this gap in the literature. Interpretations of the concept of need drawing from areas such as psychology, social policy, and health are introduced. The concept and relevance of unmet need for health services are discussed. It is intended that these definitions can be used to operationalize the term "need" in practice, theoretically drive needs assessment, and help guide health care decisions that are based upon need.

"Trade policy, not morals or health policy": the US Trade Representative, tobacco companies and market liberalization in Thailand

The enforced opening of Thailand's cigarette market to imports in 1990 has become a cause celebre in debates about the social and health impacts of trade agreements. At the instigation of leading US-based cigarette manufacturers, the US Trade Representative (USTR) threatened trade sanctions against Thailand to compel the government to liberalize its domestic cigarette market. Thailand's challenge to the USTR led to referral to General Agreement on Tariffs and Trade (GATT) arbitration. While GATT ruled in favour of the USTR on market access, it also found that Thailand could subsequently enact non-discriminatory tobacco control regulation without contravening the GATT agreement. This paper contributes to existing literature via its analysis of tobacco industry documents that highlight not only USTR responsiveness to lobbying from tobacco corporations, raising concerns about the drivers of globalization and the limited protection afforded to public health concerns in trade agreements. Significantly, the documents also indicate that USTR support of the tobacco industry was not unconditional, being subject to wider pressures of global trade negotiations. Such qualification notwithstanding, however,,ongoing governmental willingness to advance the international interests of tobacco corporations remains a concern from a public health perspective, particularly given the failure of the US to ratify the World Health Organization's Framework Convention on Tobacco Control.

Advancing the business creed? The framing of decisions about public sector managed care

Relatively little research has clarified how executives of for-profit healthcare organisations frame their own motivations and behaviour, or how government officials frame their interactions with executives. Because managed care has provided an organisational structure for health services in many countries, we focused our study on executives and government officials who were administering public sector managed care services. Emphasising theoretically the economic versus non-economic motivations that guide economic behaviour, we extended a long-term research project on public sector Medicaid managed care (MMC) in the United States. Our method involved in-depth, structured interviews with chief executive officers of managed care organisations, as well as high-ranking officials of state government. Data analysis involved iterative interpretation of interview data. We found that the rate of profit, which proved relatively low in the MMC programme, occupied a limited place in executives' self-described motivations and in state officials' descriptions of corporation-government interactions. Non-economic motivations included a strong orientation toward corporate social responsibility and a creed in which market processes advanced human wellbeing. Such patterns contradict some of the given wisdom about how corporate executives and government officials construct their reality.

How is Telemedicine perceived? A qualitative study of perspectives from the UK and India

Background

Improvements in communication and information technologies have allowed for the globalisation of health services, especially the provision of health services from other countries, such as the use of telemedicine. This has led countries to evaluate their position on whether and to what extent they should open their health systems to trade. This often takes place from the context of multi-lateral trade agreements (under the auspices of the World Trade Organisation), which is misplaced as a significant amount of trade takes place regionally or bi-laterally. We report here the results of a qualitative study assessing stakeholders' views on the potential for a bi-lateral trade relationship between India and the UK, where India acts as an exporter and the UK as an importer of telemedicine services.

Methods

19 semi-structured interviews were carried out with stakeholders from India and the UK. The themes discussed include prospects on the viability of a bi-lateral relationship between the UK and India on telemedicine, current activities and operations, barriers, benefits and risks.

Results

The participants in general believed there were good prospects for telemedicine trade, and that this could bring benefits to "importing" countries in terms of cost-savings and faster delivery of care and to "exporting" countries in the form of foreign exchange and quality improvement. However, there were some concerns regarding quality of care, regulation, accreditation and data security.

Conclusions

There is potential for trade in this type of health services to succeed and bring about important benefits to the countries involved. However, issues around data security and accreditation need to be taken into consideration. Countries may wish to consider entering bi-lateral agreements, as they provide more potential to address the concerns and capitalise on the benefits. Finally, this paper concludes that more data should be collected, both on the volume of telemedicine trade and on the impact it is having on health systems, as currently there is very limited data on this.

Health Care Management Training Needs in Pakistan

The management of health care organisations (HCOs) significantly determines the quality and efficiency of health care delivery in developing countries like Pakistan. HCO managers are needed to plan and execute expansion and corporatisation of private HCOs and to transform public sector charity hospitals to self-sustaining efficient organisations and private clinics into profitable ventures. The objective of this study was to assess the need for health care management training in Pakistan using semi-structured interviews of key informants in different cities. We asked experts about the existing HCO management training opportunities, demand for such skills and its impact on the future of health services delivery. Unanimous support for HCO management training emerged in the wake of dissatisfaction with limited opportunities for such training in the country. The participants agreed that trained HCO managers can help introduce modern management practices in health care service delivery, thereby making the HCOs more efficient and effective. We conclude that well-reputed management schools would be performing an important service to the improvement of the health sector in Pakistan if they can design and offer effective management training programmes for HCOs.

Neo-liberal economic practices and population health: a cross-national analysis, 1980–2004

Although there has been substantial debate and research concerning the economic impact of neo-liberal practices, there is a paucity of research about the potential relation between neo-liberal economic practices and population health. We assessed the extent to which neo-liberal policies and practices are associated with population health at the national level. We collected data on 119 countries between 1980 and 2004. We measured neo-liberalism using the Fraser Institute’s Economic Freedom of the World (EFW) Index, which gives an overall score as well as a score for each of five different aspects of neo-liberal economic practices: (1) size of government, (2) legal structure and security of property rights, (3) access to sound money, (4) freedom to exchange with foreigners and (5) regulation of credit, labor and business. Our measure of population health was under-five mortality. We controlled for potential mediators (income distribution, social capital and openness of political institutions) and confounders (female literacy, total population, rural population, fertility, gross domestic product per capita and time period). In longitudinal multivariable analyses, we found that the EFW index did not have an effect on child mortality but that two of its components: improved security of property rights and access to sound money were associated with lower under-five mortality (p = 0.017 and p = 0.024, respectively). When stratifying the countries by level of income, less regulation of credit, labor and business was associated with lower under-five mortality in high-income countries (p = 0.001). None of the EFW components were significantly associated with under-five mortality in low-income countries. This analysis suggests that the concept of ‘neo-liberalism’ is not a monolithic entity in its relation to health and that some ‘neo-liberal’ policies are consistent with improved population health. Further work is needed to corroborate or refute these findings.

Estratégia de Saúde da Família no Sistema de Saúde Suplementar: convergências e contradições

Pesquisa qualitativa que evidencia as convergências e contradições na implementação da Estratégia de Saúde da Família no Sistema de Saúde Suplementar no município de São Paulo. Identifica o conceito de saúde da família de profissionais da saúde de nível superior de uma empresa de autogestão; identifica as possibilidades e limites vivenciados pelos profissionais na implementação da ESF na empresa. Foram realizadas entrevistas com 14 profissionais e feita análise de conteúdo. O conceito de saúde da família parece transitar entre o modelo hegemônico, curativo, e o modelo idealizado de atenção integral à saúde com bases nas ações de promoção da saúde, porém vinculadas sempre à prevenção de doenças, ao trabalho multidisciplinar, à lógica da diminuição dos custos do sistema. Foram identificadas contradições que dificultam a implementação de propostas baseadas na Promoção à Saúde. São necessários investimentos de ordem política, organizacional, financeira e, fundamentalmente, na formação e educação permanente dos profissionais.

Trade in health-related services

The supervision of a domestic health system in the context of the trade environment in the 21st century needs a sophisticated understanding of how trade in health services affects, and will affect, a country's health system and policy. This notion places a premium on people engaged in the health sector understanding the importance of a comprehensive outlook on trade in health services. However, establishment of systematic comparative data for amounts of trade in health services is difficult to achieve, and most trade negotiations occur in isolation from health professionals. These difficulties compromise the ability of a health system to not just minimise the risks presented by trade in health services, but also to maximise the opportunities. We consider these issues by presenting the latest trends and developments in the worldwide delivery of health-care services, using the classification provided by the World Trade Organization for the General Agreement on Trade in Services. This classification covers four modes of service delivery: cross-border supply of services; consumption of services abroad; foreign direct investment, typically to establish a new hospital, clinic, or diagnostic facility; and the movement of health professionals. For every delivery mode we discuss the present magnitude and pattern of trade, main contributors to this trade, and key issues arising.

[Marketizing of the State, erosion of democracy and impoverishment of citizenship: global tendencies?]

This article analyses the advance of the neo-liberal regime, in order to contextualise the international formulation of policies focussed on poverty reduction. In recent debates, terms such as 'citizenship' and 'democracy' have been subject to critical scrutiny, revealing changes in the relations between citizens and the State which accompany the hegemony of economic criteria that put financial considerations at the centre of national states. We argue that analyses of such global processes require an ample political economy perspective, capable of illuminating how the substance of democracy and the legitimacy of state authority have been conditioned by the advance of new global entities that represent the interests of capital, favouring the concentration of wealth and the increase of poverty, inequality and exclusion, and installing a state of vital insecurity that affects the majority of the world's population.

"Profits before people"? A systematic review of the health and safety impacts of privatising public utilities and industries in developed countries

Debates on government privatisation policies have often focused on the alleged effects of privatisation on health and safety. A systematic review (through Quality of Reporting of Meta-analysis) of the effects of privatising industries and utilities on the health (including injuries) of employees and the public was conducted. The data sources were electronic databases (medical, social science and economic), bibliographies and expert contacts. Experimental and quasi-experimental studies were sought, dating from 1945, from any Organisation for Economic Cooperation and Development member country (in any language) that evaluated the health outcomes of such interventions. Eleven highly heterogeneous studies that evaluated the health impacts of privatisation of building, water, paper, cement, bus, rail, mining, electric and gas companies were identified. The most robust study found increases in the measures of stress-related ill health among employees after a privatisation intervention involving company downsizing. No robust evidence was found to link privatisation with increased injury rates for employees or customers. In conclusion, public debates on the health and safety implications of privatisation have a poor empirical base, which policy makers and researchers need to address. Some evidence suggests that adverse health outcomes could result from redundancies associated with privatisation.

Globalization and social determinants of health: The role of the global marketplace (part 2 of 3)

Globalization is a key context for the study of social determinants of health (SDH): broadly stated, SDH are the conditions in which people live and work, and that affect their opportunities to lead healthy lives. In the first article in this three part series, we described the origins of the series in work conducted for the Globalization Knowledge Network of the World Health Organization's Commission on Social Determinants of Health and in the Commission's specific concern with health equity. We identified and defended a definition of globalization that gives primacy to the drivers and effects of transnational economic integration, and addressed a number of important conceptual and methodological issues in studying globalization's effects on SDH and their distribution, emphasizing the need for transdisciplinary approaches that reflect the complexity of the topic. In this second article, we identify and describe several, often interacting clusters of pathways leading from globalization to changes in SDH that are relevant to health equity. These involve: trade liberalization; the global reorganization of production and labour markets; debt crises and economic restructuring; financial liberalization; urban settings; influences that operate by way of the physical environment; and health systems changed by the global marketplace.

La opacidad de los acuerdos generales de bienes y servicios en España

OBJECTIVE

To explore the intensity of the debate in the Spanish Parliament on the General Agreement on Trade in Services (GATS) developed by Spain and the World Trade Organization, and to compare it with the debate on the General Agreement on Tariffs and Trade (GATT).

METHODS

A systematic search and content analysis were performed of all parliamentary initiatives on GATS and GATT undertaken from 1979 to 2004 in the Spanish Parliament and Senate. The frequency and percentages of initiatives on both issues were calculated, and the final result and kinds of initiative were analyzed.

RESULTS

A total of 185 initiatives were presented in the Spanish Parliament on these agreements, of which 120 were on GATT, 8 were on GATS and 57 were on both agreements. Most of these initiatives were not discussed in parliament (GATT, 71%; GATS, 55.4%) or were the subject of political debate with low participation among parliamentary groups.

CONCLUSIONS

Despite the implications of the GATS for Spanish health policy, the agreement was developed with little prior political debate, which was even less intense than that on GATT. The parliamentary function of controlling the government should be reaffirmed in Spain.

Psychiatric drug promotion and the politics of neo-liberalism

The pharmaceutical industry has popularized the idea that many problems are caused by imbalances in brain chemicals. This message helps to further the aims of neo-liberal economic and social policies by breeding feelings of inadequacy and anxiety. These feelings in turn drive increasing consumption, encourage people to accept more pressured working conditions and inhibit social and political responses.

Strengthening the health claims of the poor: promoting social inclusion and redistribution in the health sector

The problems for poor people generated by 'disorganised health care markets' in the developing world have grave consequences for their health. In many countries, processes of liberalisation and commercialisation have generated a number of dilemmas for policy-makers, non-governmental organisations and individuals seeking health care. Complex markets for health care provision and financing exist, regulation is lacking and rates of exclusion are high due to the effects of prices and a lack of concerted efforts to make health systems more accessible to the poor. Analysis of health systems and the problems they create for the poor should lead to responses that protect and enhance the rights of poor people to health.

Health care or health trade? A historic moment of choice

During the 20th century, medical care evolved from a notional economy of trying to a real economy of doing. Care systems can therefore usefully be measured and evaluated as production systems. Whether they will succumb to the pattern of competitive commodity production for profit in the market, or will succeed in developing their own new gift economy for human needs, will become a dominant political and economic issue in the 21st century. Health care is now becoming industrialized in essentially the same way as textile manufacture was industrialized in the 19th century, with corresponding loss of control by skilled workers over their work processes. The outcome of the struggle between skilled handloom weavers and their industrializing employers was determined by the huge rise in productivity associated with machines. The outcome of current struggles between public service and state-subsidized corporate care for profit will be decided likewise by superior productivity. Evidence suggests that in terms of health outcome, democratized public care with a much expanded and diversified workforce could be far more productive than industrialization.

The public health implications of world trade negotiations on the general agreement on trade in services and public services

Trade ministries from the World Trade Organization's (WTO's) 144 member states are presently deciding which public services to open to foreign competition under the complex liberalisation rules of the general agreement on trade in services (GATS). A frequent criticism of the WTO system is that it reduces national autonomy over public policy. However, respect for national sovereignty is asserted in the GATS treaty. Here, we examine claims made by the WTO and others that GATS exempts public services and does not require their privatisation. We discuss trade treaty processes that can subject public services to commercial rules, the treaty's flexibility with respect to national autonomy, and the effect of GATS in situations in which national autonomy is not protected. We conclude that national autonomy over health policy is not preserved under GATS, and that accordingly, there is a role for international standards that protect public services from the adverse effect of trade and market forces.

International trade, law, and public health advocacy

Public Health Science and practice expanded during the course of the 20th century. Initially focused on controlling infectious disease through basic public health programs regulating water, sanitation and food, by 1988 the Institute of Medicine broadly declared that “public health is what we, as a society, do collectively to. assure the conditions for people to be healthy.” Commensurate with this definition, public health practitioners and policymakers today work on ;in enormous range of issues. The 2002 policy agenda of the American Public Health Association reflects positions on genomics’ role in public health; national health and safety standards for child care programs; sodium in Americans’ diets; the health and safety of emergency rescue workers; and war in Central Asia and the Persian Gulf.

Rejuvenating health systems for aging communities

Nowadays, about the half of Swiss women die after their 84th birthday. This unprecedented proportion of the population reaching an old age, or even a very old age (25% of women die after 89 years, and 5% after 95 years) is a novel aspect of human demographics, and represents the very last stage of the epidemiological transition, a term coined to describe the transformation of the prevailing health burden in the population, shifting from infectious and communicable pathologies to chronic and degenerative diseases. In developed countries, this epidemiological transition has been well documented during the last century; worldwide, a similar transition is taking place, with some countries still at mid or early stages of transition. A striking aspect of the current transition is its speed. In India, the mean duration of life since 1947 has increased from 32 to 62 years. As a result, India, like many other developing countries, is facing a double burden of disease, i.e., an upsurge of degenerative diseases while the burden from the old agenda (i.e., malaria, tuberculosis) still reaches devastating proportions in the population. This double burden is certainly a crucial problem in developing countries, and probably is the most important health challenge for the coming century. A similar accelerated pace of change is observed with the decline of mortality at old age. Worldwide, the current estimate of centenarians is 100000, i.e., ten time more centenarians than the number estimated in 1960. The downward trend in mortality, which is steeper with increasing age, is now the leading factor to Increase the life expectancy in developed countries. In the United Kingdom, life expectancy increased by 2.5 years between 1971 and 1991; this is equivalent to the increase observed between 1851 and 1961. This accelerated increase will influence public health in two different ways. The first will be the absolute increase in the number of older persons, with a corresponding increase in degenerative diseases. A second consequence will be the need for a substantial and rapid adaptation of the health care system. Three selected aspects are addressed below: 1) the increase of resources, 2) the improvement of performance, and 3) the reduction of demand through preventive strategies.

The globalization of capital, the welfare state, and old age policy

A new political economy is shaping the lives of present and future generations of older people. The key change has been the move from the mass institutions that defined growing old in the period from 1945 through the late 1970s to the more individualized structures--privatized pensions, privatized health and social care--that increasingly inform the current period. The authors examine the role of international governmental organizations in promoting this trend, with examples drawn from the work of the World Bank, World Trade Organization, and Organization for Economic Cooperation and Development, and the relationship between international governmental organizations and the state. The article concludes with an assessment of the changes to citizenship that accompany globalization and the implications for political organization among older people themselves.

Globalization and health

Globalization means different things to different people; a general definition is the increasing movement of information, material and people across borders. It can be considered in terms of five conflicting but inter-relating themes, economic transformation; new patterns of trade; an increasing poverty gap associated with widening health inequalities; the revolution in electronic communication; and the growing role of non-state actors, such as non-governmental organizations and transnational corporations, in global governance. Globalization is both an opportunity and a threat, but it is not inexorable. Successful action against its undesirable aspects is possible.

Rewriting the regulations: how the World Trade Organisation could accelerate privatisation in health-care systems

The World Trade Organisation (WTO) is drawing up regulatory proposals which could force governments to open up their public services to foreign Investors and markets. As part of the General Agreement on Trade in Services (GATS) negotiations, the WTO working party on reform of domestic regulation is developing a regulatory reform agenda which could mark a new era of compulsion in international trade law. Article VI.4 of the GATS is being strengthened with the aim of requiring member states to show that they are employing least trade-restrictive policies. The legal tests under consideration would outlaw the use of non-market mechanisms such as cross-subsidisation, universal risk pooling, solidarity, and public accountability in the design, funding, and delivery of public services as being anti-competitive and restrictive to trade. The domestic policies of national governments will be subject to WTO rules, and if declared illegal, could lead to trade sanctions under the WTO disputes panel process. The USA and European Union, with the backing of their own multinational corporations, believe that these new powers will advantage their own economies. Health-care professionals and public-health activists must ensure that this secretive regulatory reform process is opened up for public debate.