Trade in Health Services & the General Agreement on Trade in Services (GATS)

Trade in Health Services & the General Agreement on Trade in Services (GATS) IMPLICATIONS FOR HEALTH POLICY Nick Drager M.D., Ph.D. Senior Adviser World Health Organization

Trade in Health Services and trade in health services understanding the GATS agreement managing the GATS negotiation process key issues for policy makers GATS 2

Co-contributors Julia Nielson- Senior Trade Policy Analyst, OECD David Fidler Professor of Law, Indiana University Richard Smith Senior Lecturer Health Economics, University of East Anglia Rolf Adlung and Mireille Cossy WTO Secreteriate 3

Growth of goods and services exports 1980/2000 Goods Services Percentage (1980=100) 400 300 200 100 0 GDP growth Services growth Goods growth 12000 10500 9000 7500 6000 4500 3000 1500 0 Billion $ 1980 82 84 86 88 90 92 94 96 98 2000 4

10 largest cross-border M&A deals concluded in health services, 2000 Transaction Acquired Host Home Value ($ company Industry country Acquiring company Industry country million) medical and Kuwait Invest Off- surgical United General medical and Hospitals(3) hospitals Kingdom Columbia/HCA Healthcare Corp surgical hospitals United States 151 medical and St Martins surgical United General medical and Healthcare Ltd hospitals Kidney Kingdom HCA-Healthcare Co surgical hospitals United States 150 Electromedical and Total Renal Care dialysis United electrotherapeutic Hldgs-Intl centers States Fresenius AG apparatus Germany 145 g p, Medical except diagnostic ImmGenics Inc SHL Telemedicine laboratories Canada Abgenix Inc Home health substances United States 77 Household audio and Ltd Undisclosed Long care services Israel Koninklijke Philips Electronic Skilled United video equipment Netherlands 40 Real estate investment Term Care nursing care Home health States United CPL Long Term Care Real Estate trusts Canada 39 Home health care Clinovia Ltd care services Kingdom LVL Medical Groupe services France 39 (Serologicals allied United Health and allied Corp) services, nec States Aventis SA services, nec France 21 medical and Clinica San Camilo surgical hospitals Spain United Surgical Partners Intl General medical and surgical hospitals United States 16 5

Trade in Health Services Globalization of Health cross border delivery- telemedicine; e-health consumption abroad- patients travelling across borders for diagnosis and treatment commercial presence- establishments of hospitals, clinics through FDI, joint ventures, alliances, mergers movement of personnel- doctors and nurses practising in other countries 6

Health implications of cross border delivery of services mode 1 Opportunities enable health care delivery to remote and underserviced areas - promoting equity alleviate some human resource constraints enable more cost -effective surveillance of diseases improve quality of diagnosis and treatment upgrade skills, disseminate knowledge through interactive electronic means Risks given lack of telecommunications and power sector infrastructure -telemedicine may not be cost effective capital intensive, possible diversion of resources from basic preventive and curative services hurt equity if it caters to a small segment of the population- urban affluent 7

Health implications of consumption abroad mode 2 Opportunities for exporting countries generate foreign exchange earnings to increase resources for health upgrade health infrastructure, knowledge, standards and quality for importing countries overcome shortages of physical and human resources in speciality areas receive more affordable treatment Risks create dual market structure may crowd out local population -unless these services are made available t local population diversion of resources from the public health system outflow of foreign exchange for importing countries 8

Opportunities generate additional resources for investment in upgrading of infrastructure and technologies reduce the burden on public resources create employment opportunities raise standards, improve management, quality, improve availability, improve education (foreign commercial presence in medical education sector) Health implications of commercial presence mode 3 Risks large initial public investments needed to attract FDI if public funds/subsidies used - potential diversion of resources from the public health sector two tier structure of health care establishments internal brain drain from public to private sector crowding out of poorer patients, cream skimming phenomena 9

Health implications of movement of personnel mode 4 Opportunities from the sending country promote exchange of knowledge among professionals upgrade skills and standards (provided service providers return to the home country) gains from remittances and transfers from host country meet shortage of health care providers, improve access, quality and contain cost pressures Risks From sending country permanent outflows of skilled personnel -brain drain loss of subsidised training and financial capital invested adverse effects on equity, availability and quality of services 10

Implication of Globalization of Health Services impact of liberalised trade in services on the access to, cost, quality of services what policies, regulations should be in place to ensure that trade in health services increases equity in health and is in the interest of those in greatest need what collective action across countries, at regional and global level is needed to take advantages of emerging global opportunities and mitigate potential risks work towards policy coherence 11

General Agreement on Trade in Services (GATS) GATS is one of the most important trade agreements to emerge from the Uruguay Round negotiations that created the World Trade Organization (WTO) Services are one of the fastest growing areas for many economies Services of many kinds play important roles in the protection and promotion of health GATS provides the multilateral legal framework for liberalizing international trade in services GATS creates numerous challenges for people working in public health GATS is a complex legal agreement that borrows from existing international trade law to create new rules for services GATS has become the subject of significant controversy, especially with respect to how the Agreement will affect health-related services and health policy 12

Tale of Two Treaties Problem Debate about GATS impact on health policy has created a tale of two treaties problem for health policy communities GATS is the worst of treaties GATS undermines the exercise of national sovereignty for health purposes GATS is the best of treaties GATS respects health sovereignty through its flexibility, which allows each WTO member to shape its obligations according to its national needs and interests The tale of two treaties problem makes it difficult for the health policy communities to understand how the complex law of GATS may or may not affect their work 13

Legal Architecture of GATS Does a health-related service fall within the scope of GATS? GATS rules that apply to health-related services within GATS scope General Obligations Specific Commitments Progressive Liberalization Institutional Framework 14

Scope of GATS GATS scope Measures Affecting Trade in Services 15

What is covered by the Agreement Measures affecting trade in services: measures related to production, distribution, marketing, sale and delivery of a service and can take any form : laws regulations, rules, procedures, decisions, administrative actions GATS also applies to measures taken by central, regional or local governments and to NGOs where they are exercising delegated powers 16

Trade in Services Consumption of services abroad (Mode 2): hospital treatment overseas Cross-border supply of services (Mode 1): telemedicine Trade in services Commercial presence (Mode 3): establishment of health facilities abroad Presence of natural persons (Mode 4): nurses working in other countries 17

GATS and Health Sovereignty: Significant Overlap Scope of GATS Health Professional Environmental Distribution Financial Business R&D Scope of health sovereignty Health-related services 18

Controversial Question: Does GATS Apply to Government-Provided Services? Significant controversy about whether GATS applies to government-provided services GATS excludes services supplied in the exercise of governmental authority The GATS and health controversy involves disagreement among experts about how broad or limited the exclusion for services supplied in the exercise of governmental authority is This controversy has not yet been authoritatively determined, meaning the scope of this exclusion is ambiguous no interest so far in narrowing this exclusion 19

Is the health-related service supplied by the government? Yes Is the health-related service supplied on a commercial basis? No Is the health-related service supplied in competition with one or more service providers? No S T A R T Threshold Question: Does GATS Apply? No Yes Yes Is the health-related service supplied by a private actor pursuant to delegated governmental authority? Yes No GATS applies to measures of WTO members that affect trade in health-related services GATS does not apply 20

Unfinished Business More time needed to undertake negotiations to determine whether or what type of discplines are necessary ongoing negotiations Government procurement- some provisions (MFN, MA/NT in sector commitments) do not apply e.g. hiring of temporary foreign nurses by a government department of health to address shortages in public hospitals Subsidies- no specific disciplines to datenegotiations on disciplines to avoid trade distortive effect of subsidies 21

Entering the House of GATS GATS (Services) Health Sovereignty 22

The House that GATS Built Trade Liberalization Preservation of the Right to Regulate Services Multilateral Framework of Rules GATS (Services) 23

The House that GATS Built Trade Liberalization Preservation of the Right to Regulate Services Multilateral Framework GATS (Services) Front Wall: General Obligations and Disciplines 24

General Obligations and Disciplines General Obligations and Disciplines Substantive Duties Procedural Duties 25

Substantive Duties Substantive Duties Most-Favored-Nation Principle Duties Affecting Domestic Regulatory Powers Rules not linked to specific commitments Rules that apply only to services covered by specific commitments 26

Rules Affecting Domestic Regulatory Powers: Controversies Rules affecting domestic regulatory powers linked to specific commitments Article VI:5 on domestic regulations requires that licensing, qualification, and technical standards not be applied in manner that is not transparent, is more burdensome than necessary, and could not have reasonably been expected at the time the specific commitment was made Article VIII on monopoly service providers regulates how a WTO member may grant monopoly or exclusive service rights in a sector covered by a specific commitment 27

The Article VI:4 Controversy Article VI:4 requires WTO members to engage in negotiations to develop disciplines on licensing, qualification, and technical standard regulations The disciplines shall aim to ensure that regulations are Based on objective and transparent criteria Not more burdensome than necessary In the case of licensing procedures, not in themselves a restriction on the supply of services No negotiations on disciplines affecting a healthrelated service have occurred or been proposed 28

Procedural Duties Procedural Duties Duties to provide information and to establish government procedures Duties to participate in negotiations and/or consultations Generally applicable provisions Provisions related to specific commitments Duties to negotiate multilateral rules Duties to consult and cooperate 29

Summary on General Obligations and Disciplines Present impact of general obligations and disciplines of GATS on health sovereignty is not significant General obligations that are universally binding are not large in number or worrying from a health-policy perspective Low level of specific commitments made in health-related sectors mitigates the impact of general obligations linked to specific commitments More concerns will arise in the future as the level and nature of specific commitments in health-related sectors may increase and as WTO members negotiate multilateral disciplines on trade in services 30

The House that GATS Built Trade Liberalization Preservation of the Right to Regulate Services Multilateral Framework Side Wall: Market Access Commitments GATS (Services) Front Wall: General Obligations and Disciplines 31

Commitments Liberalizing under the GATS means undertaking specific commitments on market access and national treatment Commitments are recorded in national schedules Members can chose the sectors in which they want to undertake commitments (GATS does not require the liberalisation of health services) Absence of commitments does not necessarily mean absence of trading opportunities 33

Commitments do not Affect Non-discriminatory domestic regulation- (standards, licensing requirements, universal service obligations, etc.) Government procurement decisions Private commercial actions 34

Scheduling and Modifying Specific Commitments National schedules of specific commitments form part of the binding treaty, so the drafting of such schedules is very important In addition, GATS contains rules that make modifying schedules of specific commitments difficult because the rules require compensation for those WTO members adversely affected by the modification(s) 35

Specific Commitments Countries decide which service sectors they want to allow foreign suppliers to enter and under what conditions Commitments (guaranteed minimum treatment offered to other WTO members) in individual schedules -countries free to offer better treatment if they wish but not worse) A list of 12 service sectors (160 subsectors ) was developed (not obligatory to use) Four possible modes 36

Defining the Health Sector Health related and social services: hospital services; other human health services, social services Professional services: medical and dental services; services provided by mid-wives, nurses physiotherapists and para medical personnel 37

Modes of Supply Consumption of services abroad (Mode 2): hospital treatment overseas Cross-border supply of services (Mode 1): telemedicine Trade in services Commercial presence (Mode 3): establishment of health facilities abroad Presence of natural persons (Mode 4): nurses working in other countries 38

Horizontal vs. Sectoral Commitments Commitments can be made for each sector or covering a single mode of supply across all sectors listed in their schedule (unless otherwise specified) Horizontal commitments can be used to include important conditions which apply to all sectors in the schedule 39

Commitments cont'd For each service sector or sub sector and for each mode of supply countries make commitments as to the level of market access and national treatment Informs foreign suppliers about the access they will have to the market and any special conditions that will apply to them as foreigners 40

Commitments 3 Main Choices Full market access and /or national treatment for a particular mode- that is to maintain no restrictionindicated in the schedule by none No commitment to provide anything on MA/NT for a particular mode unbound Partial commitments for MA/NT listing restrictions 41

Market Access Commitments set out the conditions under which foreign suppliers are allowed to enter the market Countries can chose to place no restrictions on market access (none) or to make no commitment (unbound) or to allow access subject to limitations and conditions (partial commitment) 42

Market Access Restrictions Can only be maintained if listed in the schedule. Can apply to both national and foreigners or only foreigners Restrictions on the number of service suppliers- no of hospitals Restrictions on the total value of service transactions or assetsforeign private clinics must not have assets worth more then USD50 million Restrictions on the total number of service operations or the total quantity of service output no. of surgical operations or hospital beds) Restrictions on the total number of natural persons that may be employed in a particular service sector or that a service supplier may employ no. of doctors and nurses employed Restrictions on or requirements for certain types of legal entity or joint venture for the supply of a service- foreign private clinic must enter into a joint venture with a local clinic to enter into the market Limitations on the participation of foreign capital in terms of maximum percentage limit on foreign shareholding or the total value of individual or aggregate foreign investment- foreign private clinic 43 is limited to 30% of the equity in the newly established private clinic

National Treatment Foreign services and service suppliers are granted treatment no less favourable then that accorded to like national services and service suppliers Likeness WTO DU on a case by case basis taking into account consumer perceptions of the degree to which a particular good is like and its substitutability 44

National Treatment Limitations No specific list members must judge whether a measure breaches national treatment and have to be scheduled Measure may not be considered discriminatory if it is genuinely open to both nationals and foreigners to fulfil i.e. language proficiency Examples of the types of measures that need to be listed in the schedule as limitations: eligibility for subsidies reserved to nationals; the ability to own land reserved to nationals, citizenship requirements for certain health professionals 45

How Schedules of Commitments are structured: Singapore Modes of supply: 1) Cross-border supply 2) Consumption abroad 3) Commercial presence 4) Presence of natural persons Sector or subsector Limitations on market access Limitations on national treatment Additional commitments Medical Services 1) Unbound* 1) None 2) None 2) None 3) None, other than the number of new foreign doctors registered each year may be limited depending on the total supply of doctors 3) None 4) Unbound except as indicated in the horizontal section 4) Unbound *Unbound due to lack of technical feasibility 46

How Schedules of Commitments are structured: India Modes of supply: 1) Cross-border supply 2) Consumption abroad 3) Commercial presence 4) Presence of natural persons Sector or subsector Limitations on market access Limitations on national treatment Additional commitments Hospital Services (CPC 9311) 1) Unbound* 2) Unbound 1) Unbound 2) Unbound 3) Only through incorporation with a foreign equity ceiling of 51 per cent 3) None 4) Unbound except as indicated in the horizontal section 4) Unbound except as indicated in the horizontal section *Unbound due to lack of technical feasibility 47

The House that GATS Built Trade Liberalization Preservation of the Right to Regulate Services Multilateral Framework Side Wall: Market Access Commitments Front Wall: General Obligations and Disciplines GATS (Services) Back Wall: Exceptions Side Wall: National Treatmen Commitments 48

The House that GATS Built Trade Liberalization Preservation of the Right to Regulate Services Multilateral Framework Side Wall: Market Access Commitments Front Wall: General Obligations and Disciplines GATS (Services) Floor: Dispute Settlement Back Wall: Exceptions Side Wall: National Treatment Commitments 49

GATS Legal Review: Further Documents and Information Legal Review of the General Agreement on Trade in Services (GATS) from a Health Policy Perspective. Geneva: WHO, 2004. [xxx] pp. Also available at: www.who.int/. The International Legal Implications of GATS for Health Sovereignty, in Handbook on Trade in Health-Related Services and GATS. Geneva: WHO, 2004, at pp. []-[]. Also available at www.who.int/. GATS and Health-Related Services: Managing Liberalization of Trade in Services from a Health-Policy Perspective. Geneva: WHO, 2004, 7 pp. Also available at www.who.int/. 51 WHO web site on GATS and health: www.who.int/.

Managing the GATS Negotiation Process Threshold issues 10 step flow chart for decision making Intragovernmental coordination 52

Four Policy Issues to Consider Public, private or both? whether and to what extent the private sector can participate in the provision and financing of health services National or foreigners? whether to allow participation by foreign service suppliers Trade vs. trade agreements whether to make GATS commitments/rtas/bilateral Liberalisation is not synonymous with de-regulation regulation should be in place before market opening 53

Threshold Issues Nationals or foreigners? Can have only national private supply Why include foreigners e.g., to increase efficiency via competition, meet key shortages in short-term, access other technologies or skills, increase available services BUT how ensure quality, impact local system. Many issues same for national, as well as foreign private supply. GATS only interested in foreign not privatisation per se. 54

Threshold Issues Trade vs. trade agreements Trade, and the regulatory challenges that accompany it, will be there without GATS Many policies to manage this trade fall outside of GATS Why make GATS commitments? Attract FDI, flexibility vs. certainty Possible regional angle? Global vs. regional interests 55

Threshold Issues Liberalisation and regulation Liberalisation is NOT de-regulation but often re-regulation Harder to regulate liberalised market, but failure also in monopolies Liberalisation must be underpinned by appropriate regulation Huge challenge for some countries Enforcement capacity also 56

Making Commitments under the GATS Agreement: Flow Chart Implications of making commitments/guide to request market opening from other WTO members 10 (not so) easy steps Stop at any stage Do we understand what we are doing? Is this giving us what we want in terms of health policy outcomes? 57

Flow Chart STEP ONE: Work out what is actually what on the table to request or offer Excluded: Governmental services: Unfinished business: nothing at the moment Government Procurement Subsidies STEP 2: Decide if I want to exclude health services from my GATS commitments- what basic obligations still apply? Substantive duties- MFN Procedural duties - Transparency 58

Flow Chart STEP 3: If I want to make or request commitments decide how to define the scope of the health services I want covered by my request or commitment W/120 WTO 12 sectors and 160 subsectors CPC- UN Own definition (some WTO members underline the private commercial- not public- nature of the services for which access is being offered) STEP 4: Decide if I want to include all ways of delivering health services in my request or commitment or not- or whether any existing or new horizontal commitments might be relevant Modes of supply Horizontal vs. sectoral commitments 59

Flow Chart STEP 5: Decide what kind of commitment I want to make and what sort of conditions I want to place on foreign suppliers. What does market access mean? Monopolies? What does national treatment mean Subsidies for nationals but not foreigners Is a commitment necessarily liberalisation? Do commitments start now? As a developing country, do I have to liberalise? 60

Flow Chart In summary, you can: Exclude all or some health services Exclude some modes of supply Limit market access Put additional conditions on foreign suppliers Treat some foreign suppliers better than others (If RTA or MFN exemption) Commit to less than current access Commit to liberalise in the future Developing countries can open fewer sectors and attach conditions 61

Flow Chart STEP 6: Do other general obligations kick in once a commitment is made on health services? -procedural Transparency. notify new or changed measures annually to WTO Timely decisions on authorisations Reasonable, objective, impartial administration of measures For professional services, adequate procedures for verifying competence. 62

Flow Chart STEP 7: What about the impact on how I regulate health services? GATS recognises the right to regulate and to introduce new regulations- regulatory framework still applies Additional regulatory requirements can be put in place for foreigners foreign doctors can be required to undertake an additional year's training before being permitted to practice When no commitments are made - general obligations re transparency and MFN apply, and additional general ones where commitments made Certain types of measures (non-discriminatory, not market access, licensing and qualification requirements and procedures, technical standards) possibly be subject to additional disciplines developed under VI.4 63

Recognition GATS does not require recognition of the professional qualifications of other members nor does it require any particular standards to be applied GATS allows members to recognise the qualifications of some WTO members and not others i.e. permits countries to break the MFN rule in relation to recognition WTO members free to recognise the qualifications of some members and not others - must notify recognition agreements they are negotiating and give other interested WTO members the opportunity to prove that they meet the same standards. 64

Flow Chart STEP 8: What if I change my mind? What if I no longer want to keep a commitment? Renegotiation of commitments - compensation Suspend commitments for balance of payments difficulties; emergency safeguards- under negotiation Exceptions to justify and defend its actions if challenged by another WTO member- necessary to protect human, animal or plant health 65

Flow Chart STEP 9: What happens next? Progressive liberalisation, not inexorable march to a free market remain free to keep service sector closed to foreign suppliers Flexibility for developing countries to extend market access progressively in line with their development situation and when granting market access to attach conditions to fulfil development objectives. 66

Flow Chart STEP 10: A final thought Dialogue, consultation, coordination Can the GATS help us to achieve any desired health policy outcomes? How might we need to regulate that trade to achieve our objectives? And do we have the regulatory capacity to do it? 67

Domestic Policy Coordination What is the mechanism for coordination? Working groups, contact points Is the health authority involved in discussions on all sectors or just the health sector? How good is the mutual understanding and what steps have been taken to improve it? Meetings, seminars, papers, joint consultations Follow up mechanisms Data collection, monitoring Role of international organisations Including WB and IMF Involvement of other groups nationally? 68

Services Negotiations Mandated by the GATS - started in 2000 Achieve progressively higher level of liberalization Due respect for national policy objectives and levels of development Flexibility for developing countries Negotiating guidelines and procedures adopted in March 2001 No a priori exclusion of any sector or mode No change to the structure and principles of the GATS 69

Negotiating Timetable DOHA MINISTERIAL DECLARATION Submission of initial requests by end of June 2002 Submission of initial offers by end of March 2003 Stock taking - Cancun 2003 Conclusion not later than 1st January 2005 as part of DDA single undertaking: unlikely to be met- General Council decision Aug 2004 intensify negotiations on rules and revised offers review progress and full report for purpose of Sixth Ministerial meeting (Hong Kong - 2005) 70

Sector Focus of Current Commitments (Developed/Developing Country Members, August 2003) 160 140 120 100 80 Developed Developing 60 40 20 0 71

Progressive Liberalization and Health Policy WHO members will face decisions whether to liberalize trade in services through market access and national treatment commitments, including trade in health-related services GATS 2000 round of liberalization negotiations potentially affects health policy in two areas: Evaluating requests from other countries for, and offers to other countries of, specific commitments for market access and national treatment Negotiations on GATS rules 72

Managing the GATS Process from a Health Policy Perspective: Principles Liberalized trade in health-related services should lead to an optimal balance between preventive and curative services Involvement of both private industry and civil society is important to ensure that liberalization of health-related services promotes participatory health policy Improving access and affordability of health-related services should be a goal of liberalization of trade in health-related services Developing countries, and least-developed countries in particular, deserve special consideration in the process of liberalizing trade in health-related services The status of health as a human right should inform and guide proposals to liberalize trade in health-related services. 73

Managing the GATS Process from a Health Policy Perspective: Key Questions To what extent is the sector already open to foreign service providers, and what have been the regulatory concerns posed by existing foreign competition? Do the commitments fit the strategies and directions identified by national health policy? What effect would the commitments have on government-provided health services? What regulatory burdens would the commitments create for the government in health-related sectors? Would the commitments eliminate or weaken regulatory approaches necessary for the protection and promotion of health? What evidence and principles can be brought to bear to analyze the possible effect of the commitments? Can the commitments be crafted both to protect health policy and to liberalize trade progressively? 74

Managing the GATS Process from a Health Policy Perspective: Check List Identify a focal point for trade in health-related services within the Ministry of Health Establish contacts and systematic interactions with trade and other key ministries and with representatives from private industry and civil society Collect and evaluate information on the effect of existing trade in health-related services within the country Obtain legal advice on GATS and other international agreements that may affect trade in health-related services Develop a sustainable mechanism for monitoring the impact of trade in health-related services Utilize the assistance provided by the WHO on matters concerning trade in health-related services Subject all requests for, and offers of, liberalization of trade in health-related services, to a thorough assessment of their health policy implications 75

Managing the GATS Process from a Health Policy Perspective: WHO Recommendations Get Your House in Order: National stewardship of the health system in the context of GATS requires a sophisticated understanding of how trade in healthrelated services already affects and may affect a country s health systems and policy. Know the Whole House Not Just Select Rooms: The GATS process can affect many sectors that related to health, which places a premium on health ministries understanding the importance of a comprehensive outlook on trade in health-related services. 76

Managing the GATS Process from a Health Policy Perspective: WHO Recommendations Remember Who Owns the House: GATS provides countries with choices and does not force them to make liberalization commitments that are not in their best interests. If a country is unsure about the effects of making specific commitments, it is fully within its rights to decline to make legally binding commitments to liberalize, or to liberalize unilaterally without making binding commitments. Home Improvement Means Health Improvement: Health principles and criteria should drive policy decisions on trade in health-related services in the GATS negotiations. 77

Trade in Health Services and GATS Implications for Health Policy risks and opportunities of trade liberalisation/restriction international rules and national health sovereignty government carve out - to what extent does it apply general exception to health - what flexibility in implementation potential new disciplines- domestic regulations, government procurement, emergency safeguards and subsidies new commitments in health and other sectors - insurance, telecommunications, transport, water 78

Informing the Negotiation Process Elements of Country Assessment amount/value of exports and imports of health services in each mode existing barriers to this trade the objectives or interests (whose) served by these barriers current national policies governing this trade: multilateral, regional and bilateral commitments potential gains/losses resulting from changes in health services trade : (changing barriers to the import or export of health services) 79

Elements of Country Assessment cont'd import/export goals- how deep to liberalise/restrict; to which countries - gain market access, lower barriers what complementary domestic polices/regulations are needed to mitigate adverse effects and take advantage of opportunities - more opening /privatization- stronger regulatory system liberalisation in other sectors affecting healthfinancial, professional, education, telecommunications, environmental services what should be legally bound 80

Macroeconomic and Trade Environment Macroeconomic and trade environment State of domestic health care system Mode 1 Mode 2 (as mode 1) Mode 3 (as mode 1) Mode 4 (as mode 1) Current status Infrastructure & regulatory capacity Current data/info & evidence TIHS GATS Health Policy Capital infrastructure Human resources Impact of current trade Data sources and availability GATS TIHS 81

Mode 4 Receiving Benefits Possible costs Possible flanking measures GATS options Meet key shortages Gain additional expertise Reduced pressure to address underlying reasons for shortages Loss for needy countries Potential for exploitation Require training programs for nationals Equal pay and conditions facilitate recognition Negotiate bilateral agreements/codes of conduct Permanent migration issue Most fall outside happening anyway 82

Mode 4 Sending Possible benefits Possible costs Possible flanking policies GATS options Enhanced skills on return Remittances Risk of permanent loss Short term loss of scarce skills Loss of investment Return of service requirements Training levy or bond Enhanced opportunities at home Negotiate agreements with receiving countries Problem of permanent migration Some outside GATS Seek additional commitments on good regulatory practices 83

Scope of Analysis National treatment Market access Cross-industrial commitment 1. CB 2. CA 3. CP 4. PN 84 Stewardship Resource generative Service provision Financing specific commitments Business Telecommunication Construction Distribution Environment Finance Education Health & Social services Culture & sport Tourism/Courier Transportation Others 4 1 2 3 4 1 23