Assessment of the association of health with the liberalisation of trade in services under the World Trade Organisation.

BACKGROUND: The liberalisation of trade in services which began in 1995 under the General Agreement on Trade in Services (GATS) of the World Trade Organisation (WTO) has generated arguments for and against its potential health effects. Our goal was to explore the relationship between the liberalisation of services under the GATS and three health indicators--life expectancy (LE), under-5 mortality (U5M) and maternal mortality (MM)--since the WTO was established. METHODS AND FINDINGS: This was a cross-sectional ecological study that explored the association in 2010 and 1995 between liberalisation and health (LE, U5M and MM), and between liberalisation and progress in health in the period 1995-2010, considering variables related to economic and social policies such as per capita income (GDP pc), public expenditure on health (PEH), and income inequality (Gini index). The units of observation and analysis were WTO member countries with data available for 2010 (n = 116), 1995 (n = 114) and 1995-2010 (n = 114). We conducted bivariate and multivariate linear regression analyses adjusted for GDP pc, Gini and PEH. Increased global liberalisation in services under the WTO was associated with better health in 2010 (U5M: -0.358 p<0.001; MM: -0.338 p = 0.001; LE: 0.247 p = 0.008) and in 1995, after adjusting for economic and social policy variables. For the period 1995-2010, progress in health was associated with income equality, PEH and per capita income. No association was found with global liberalisation in services. CONCLUSIONS: The favourable association in 2010 between health and liberalisation in services under the WTO seems to reflect a pre-WTO association observed in the 1995 data. However, this liberalisation did not appear as a factor associated with progress in health during 1995-2010. Income equality, health expenditure and per capita income were more powerful determinants of the health of populations.

[Opacity of general agreements on goods and services in Spain]. / 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.

La opacidad de los acuerdos generales de bienes y servicios en España / Opacity of general agreements on goods and services in Spain

Objetivo: Explorar la intensidad del debate parlamentario sobre el Acuerdo General de Comercio de Servicios (AGCS) asumido por España ante la Organización Mundial del Comercio (OMC), y compararla con la del Acuerdo General de Bienes (GATT). Métodos: Búsqueda sistemática y análisis del contenido de todas las iniciativas parlamentarias sobre AGCS y GATT realizadas entre 1979 y 2004 en el Congreso de los Diputados y el Senado. Se calculó la frecuencia y porcentaje de iniciativas parlamentarias de ambos temas, resultado de su tramitación y tipo de iniciativa. Resultados: Se presentaron 185 iniciativas parlamentarias sobre los acuerdos multilaterales de bienes y servicios, de las que 120 se referían al GATT, 8 al AGCS y 57 a ambos acuerdos. La mayoría de las iniciativas no fueron discutidas (GATT, 71%; GATS, 55,4%) o estuvieron sujetas a un debate político en el que apenas se dieron intervenciones por parte de los grupos parlamentarios. Conclusiones: A pesar de las implicaciones del acuerdo multilateral de servicios para la política sanitaria española, éste se ha asumido con escaso debate parlamentario previo, incluso menos que en el caso de su homólogo sobre bienes. Se requiere en este tema una intensificación de la función de control al gobierno

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

El Acuerdo General sobre el Comercio de Servicios y sus implicaciones para la salud pública / General Agreement on Trade in Services and its implications for public health

Debido a la importancia económica del sector servicios y a su potencial comercial, en 1995 entró en vigor el Acuerdo General sobre el Comercio de Servicios (AGCS) de la Organización Mundial del Comercio (OMC), cuyos objetivos son liberalizar el comercio de servicios y establecer las normas y disciplinas que lo rijan. Sin embargo, hasta el momento el acuerdo ha generado poca jurisprudencia sobre sus normas, y algunas de ellas están en proceso de elaboración, lo que le da un carácter ambiguo a la vez que dificulta precisar sus implicaciones. No obstante, algunos analistas consideran que ciertas características y disposiciones representarían una amenaza a los mecanismos de financiación de los servicios públicos, así como a la autonomía reglamentaria gubernamental. Además, el acuerdo llevaría a la formalización de compromisos de carácter irreversible, que impedirían el restablecimiento de condiciones previas, en caso de que fallasen los sistemas de mercado y la participación privada; por otra parte, estaría en oposición a los monopolios y proveedores exclusivos y, en cierto grado, afectaría a los subsidios de los proveedores locales. La capacidad del Tribunal de Justicia de las Comunidades Europeas para forzar la implementación de medidas competitivas en los servicios públicos genera incertidumbre por sus implicaciones para los sistemas sanitarios. El acuerdo de España con la OMC tiene muchos aspectos aún por consolidar, lo que abre una oportunidad política para el debate y la participación desde el sector salud en sucesivas rondas de negociación

Due to the economic importance of the service sector and its trade potential, in 1995 the World Trade Organization (WTO) launched the General Agreement on Trade in Services with the objective of liberalizing trade in services worldwide and of establishing rules and disciplines to regulate it. Until now, the Agreement has produced few case laws on its rules and some of them are in the process of being developed, which makes the Agreement ambiguous and hampers accurate forecasting of its implications. Nevertheless, some analysts consider that certain characteristics and rules represent a threat to the funding mechanisms of public services and to the sovereignty of governments to generate their own rules. Moreover, the Agreement would lead to irreversible formalization of commitments, without the possibility of returning to previous conditions in the case of failure of the market and/or private participation. In addition, the Agreement acts against exclusive monopolies and providers and to a certain extent this will affect subsidies to local providers. The ability of the European Communities Court of Justice to enforce the implementation of competitive measures in public services has produced uncertainty because of the implications for health services. The Spanish Agreement with the WTO contains many questions that remain open, representing an opportunity for the participation of the health sector in the next negotiation rounds

[General Agreement on Trade in Services and its implications for public health]. / El Acuerdo General sobre el Comercio de Servicios y sus implicaciones para la salud pública.

Due to the economic importance of the service sector and its trade potential, in 1995 the World Trade Organization (WTO) launched the General Agreement on Trade in Services with the objective of liberalizing trade in services worldwide and of establishing rules and disciplines to regulate it. Until now, the Agreement has produced few case laws on its rules and some of them are in the process of being developed, which makes the Agreement ambiguous and hampers accurate forecasting of its implications. Nevertheless, some analysts consider that certain characteristics and rules represent a threat to the funding mechanisms of public services and to the sovereignty of governments to generate their own rules. Moreover, the Agreement would lead to irreversible formalization of commitments, without the possibility of returning to previous conditions in the case of failure of the market and/or private participation. In addition, the Agreement acts against exclusive monopolies and providers and to a certain extent this will affect subsidies to local providers. The ability of the European Communities Court of Justice to enforce the implementation of competitive measures in public services has produced uncertainty because of the implications for health services. The Spanish Agreement with the WTO contains many questions that remain open, representing an opportunity for the participation of the health sector in the next negotiation rounds.