Introduction
The Doctors Reform Society (DRS) was formed in 1973 to support the introduction of universal health insurance in Australia, then called Medibank, now Medicare. The DRS has fought long and hard to improve equity and access to healthcare for all members of Australian society. There is sound international evidence that universal health insurance schemes, such as Medicare, with risk pooling across society in both funding and service delivery, provide the most effective and efficient health systems. The situation seen in the USA indicates the failure of market provision of health services backed with government subsidies.
The DRS believes the General Agreement on Trade in Services (GATS) threatens the existence of public healthcare, the Pharmaceutical Benefits Scheme (PBS) and mandatory universal health insurance schemes such as Medicare. The DRS is concerned about the effects of unregulated free-market globalization.
The DRS believes economic globalisation widens the gap between the rich and poor causing increasing inequalities both within and among nations. Increasing socio-economic inequity results from diminished government regulation and resource distribution through socio-economic policies and delivery of public services. This contributes to poor health outcomes. Good health is a prerequisite for human development and for maintaining peace and security, without which economies cannot thrive.
Globalisation and Inequality
As practised by the World Trade Organization (WTO), globalisation is an economic process synonymous with corporatisation. The process is geared towards ever-increasing market liberalisation, profits for large corporations and reducing government involvement. The benefits of economic growth go to the top of the hierarchy. Measurements of benefit by Gross Domestic Product (GDP) do not take into account the costs of economic growth and the distribution of the benefits.
This form of economic globalisation has been promoted by claiming that the free market will generate wealth by stimulating economic growth and thus both poorer nations and poorer people within nations will be better off. Poverty is claimed to be best reduced through growth-orientated rather than distributive policies. This is based on assumptions that the distributive impact of policies is neutral, that income inequality within countries is stable and that there is no strong association between growth and inequality.
Studies by the United Nations University/ World Institute for Development Economics Research (UNU/WIDER) and the United Nations Development Programme (UNDP) have indicated that benefits and costs of market liberalisation reforms have not been clear cut (Cornia 1999, Jha 2000, Singh & Dhumale 2000, Taylor 2000). Evidence suggests that for most countries, the last two decades have brought about slow growth and rising inequality (Beyer et al 1999, Braun 1997, Cornia 1999, Harrison & Hanson 1999, Shen et al 1997).
In a report on eighteen transitional and developing countries, evidence indicated that few, if any, found a sustainable growth path, that employment growth was slow to poor and that increasing income inequality was the rule (Taylor 2000). Analyses have indicated that, compared to the two earlier decades of 1960-1980, economic growth over the last two decades of increasing trade liberalisation (1980-2000) has slowed dramatically, especially in the less developed countries. Two exceptions were India and China where the increase in growth began a decade before their opening to trade (Weisbrot et al 2000). Real GDP per capita in sub-Saharan Africa has halved in relative terms and in Latin America has fallen by 30 per cent from 1971 to 1996 (Woodward 1996).
According to the United Nations (UN), the gap between the rich and poor has been growing over the last 50 years and the rate of growth has been greatest during the economic liberalisation of recent decades. There has been growing inequality both between and within countries (Cornia 1999).
The ratio between the average income of the world’s top five per cent of people and the bottom five per cent increased from 78:1 to 123:1 in the five years from 1988 to 1993 (UNDP 1999). The ratio between the income of the richest 20% of the world’s population to the poorest 20% has increased from 30:1 in 1960 to 78:1 in 1994 (UNDP 1999). World Bank evidence from poorer countries undergoing structural adjustment points to stagnating per capita income, rising poverty and or declining life expectancy (World Bank 1999).
In Australia, a report by St Vincent de Paul “Two Australias - Addressing Inequality and Poverty 2001” highlights growing inequalities. Benefits from wealth generated in recent decades has gone largely to the wealthiest in society. A comparison of data between the 1993/4 and 1998/9 Household Expenditure Surveys by the Australian Bureau of Statistics (Docs 6530.0) shows Australians in the lowest quintile of household incomes in the five year period received an average weekly increase of $9 - that is a 5% increase to $160 per week. In contrast, the top 20% of income earners over that same period received an average weekly increase of $343 - a 23.4% increase to $1,996 per week.
Increasing inequality is the most powerful factor affecting population health. Socio-economic inequalities in mortality rates are observed in almost every country for which data is available. These inequalities are seen for over 75% of all causes of deaths and are found for all age groups (Najman & Davey Smith 2000). There is a linear effect rather than a threshold effect (Adler et al 1993). Income inequality within a population is an important determinant of both individual and population mortality (Davey Smith 1996, Wilkinson 1996). Cross-national research shows that the greater the degree of socioeconomic inequality within a society, the steeper the gradient of health inequalities (Daniels et al 1999). In other words, inequality causes ill-health.
Economic globalization and the free market are not concerned with wealth distribution or inequality. Governments have usually had that responsibility. Resources generated through economic growth do not automatically help the poor or disadvantaged. The argument that free markets are welfare-enhancing by ensuring more efficient production ignores the fact that there are vast multitudes of people with little or no ability to participate in market processes. Social factors such as education and health influence economic participation. The basis of public services is redistribution. Risks are pooled across society and entitlement is based on need not the ability to pay. Government action is required to direct resources towards public social services.
The GATS
The GATS is one of the “free trade” agreements of the WTO that deals specifically with services. Social equity and democracy are not identified as goals. The agreement is dedicated solely to strengthening the ability of the private market system to generate wealth. Large corporations take over responsibilities which were formerly those of governments. Citizens’ rights are reduced to those of merely consumers. An example of this way of thinking in Australia is in Victorian hospitals, where patients have been designated as “RRUs - revenue raising units”.
The goal of the GATS is to remove barriers to trade in services. Under the GATS, governments are required to remove regulations on services which are deemed to be barriers to trade. The GATS is thus more than just an economic trade agreement, it is explicitly political as it influences how a government regulates within its borders. The WTO has stated of the GATS -
The GATS has a set of general obligations and a set of specific obligations. Nation members of the WTO are committed to the full range of general obligations across 160 service sectors including healthcare. Each nation has a schedule of specific commitments to which they commit particular service sectors they are prepared to open up to competition from overseas services providers. Nations will come under increasing pressure to commit more of their service sectors to specific obligations. The European Commission admits that the pressure to liberalise key service sectors is a “fact of life” and has argued that all sectors should be included in the GATS.
The GATS aims to remove barriers to trade in services through “progressive liberalization”. WTO members are committed to progressively liberalise their service sectors. The process involves regular rounds of negotiations where governments progressively negotiate away their regulatory authority. The GATS mandates WTO members to return to the negotiating table on a regular basis and expand their GATS commitments. Article XIX in Part IV, “Progressive Liberalization” clearly sets the agenda on liberalisation:
“Members shall enter into successive rounds of negotiations, beginning not later than five years from the date of entry into force of the WTO Agreement and periodically thereafter, with a view to achieving a progressively higher level of liberalization.” (Article XIX.1.)
“The process of progressive liberalization shall be advanced in each such round through bilateral, plurilateral or multilateral negotiations directed towards increasing the general level of specific commitments undertaken by Members under this Agreement.” (Article XIX. 4.)
“Committing governments to repeated efforts to enlarge opportunities for international trade in services, ….. Article XIX is a guarantee that the present GATS package is only the first fruit of a continuing enterprise .…” (WTO Secretariat, 1999 An Introduction to the GATS, 1.2: 9)
“Each government’s schedule of liberalization commitments to trade in services is only a first step ..… Among the most important elements in the GATS package is the promise that successive further rounds of negotiations will be undertaken to continue opening up world trade in services.” (WTO Secretariat, 1999 An Introduction to the GATS, 1.1)
The DRS is concerned that public control is progressively undermined with “free trade” the ultimate goal.
GATS and Health Care
The full implementation of the GATS would have direct effects on the delivery of healthcare along with other public services. Despite reassurances from some quarters to the contrary, health services would not automatically be exempt from the GATS.
Article I.3 of GATS defines the services covered in the agreement:
“3. For the purposes of this Agreement:
(a) “measures by Members” means measures taken by:
(i) central, regional or local governments and authorities; and
(ii) non-governmental bodies in the exercise of powers delegated by central, regional or local governments or authorities;
In fulfilling its obligations and commitments under the Agreement, each Member shall take such reasonable measures as may be available to it to ensure their observance by regional and local governments and authorities and non-governmental bodies within its territory;
(b) “services” includes any service in any sector except services supplied in the exercise of governmental authority;
(c) “a service supplied in the exercise of governmental authority” means any service which is supplied neither on a commercial basis, nor in competition with one or more service suppliers.”
There is ambiguity in I:3(c). The phrases “on a commercial basis” and “in competition with one or more service suppliers” are both open to interpretation. Many government services are on a partial commercial basis and or in competition with commercial service suppliers. The scope for interpretation of I:3(c) has potentially worrying results. A narrow interpretation of “government services” is quite possible.
Health services in Australia involve both commercial provision and competition and therefore would not necessarily be exempt under this article. The presence in Australia of a private sector in competition with the public sector in health service delivery could undermine the “exemption”. The WTO has stated:
“39. The hospital sector in many countries, however, is made up of government- and privately- owned entities which both operate on a commercial basis, charging the patient or his insurance for the treatment provided. Supplementary subsidies may be granted for social, regional and similar policy purposes. It seems unrealistic in such cases to argue for continued application of Article 1:3 and/or maintain that no competitive relationship exists between the two groups of suppliers or services. In scheduled sectors, this suggests that subsidies and any similar economic benefits conferred on one group would be subject to the national treatment obligation under Article XVII.” [italics added] (WTO, Council for Trade in Services, Health and Social Services: Background Note by the Secretariat, S/C/W/50 18 September 1998 : 11)
“The fact that the GATS rules are still necessarily untested, and that the services schedules are much more complex than those for goods, adds to the difficulty of assessing exactly what rights and obligations WTO members have assumed under the services package.” (WTO Secretariat Trade in Services Division An Introduction to the GATS 1999, 1.1:1)
The charging of privately insured and overseas patients in public hospitals in Australia and the government supplying public hospital services through private-for-profit hospitals such as Port Macquarie could be considered to be operating under a commercial basis. The Australian government’s promotion of the private health system in competition with the public system also serves to undermine the exemption (e.g. advertisements showing public versus private hospital beds racing down a road).
The WTO clearly sees healthcare on the bargaining table and open for liberalisation as the following quotes clearly demonstrate:
“.… the health services sector - a domestic economic giant representing, for example, close to 6% of U.S. GDP - has remained a minor contributor to trade …. However, the picture appears to be brightening over time, owing in particular to two complimentary developments: first, regulatory regimes in various countries have been moving towards stronger market orientation - opening space for increased private involvement, domestic and foreign….” [italics added] (WTO, Council for Trade in Services, Health and Social Services: Background Note by the Secretariat, S/C/W/50 18 September 1998, 1.3:1)
“The forthcoming round of negotiations under the GATS offers an opportunity for WTO Members to reconsider the breadth and depth of their commitments on health and social services which are currently trailing behind other large sectors.” [italics added] (WTO, Council for Trade in Services, Health and Social Services: Background Note by the Secretariat, S/C/W/50 18 September 1998, 1.4:1)
“Members drew attention to the variety of policy objectives governing the provision of health and social services, including basic welfare and equity considerations. Such considerations had led to a very substantial degree of government involvement, both as a direct provider of such services and as a regulator. However, this did not mean that the whole sector was outside the remit of the GATS; the exceptions provided in Article 1:3 of the agreement needed to be interpreted narrowly.” [italics added] (Minutes of a WTO Council for Trade in Services meeting from Sanders 2001)
Also of concern is article IV of the GATS regarding domestic regulation which covers the processes of service delivery that are conceived to be potential barriers or obstacles to trade. These include professional qualifications and licensing, and licensing and accreditation of facilities.
Article IV. 4 states:
“4. With a view to ensuring that measures relating to qualification requirements and procedures, technical standards and licensing requirements do not constitute unnecessary barriers to trade in services, the Council for Trade in Services shall, through appropriate bodies it may establish, develop any necessary disciplines. Such disciplines shall aim to ensure that such requirements are, inter alia:
(a) based on objective and transparent criteria, such as competence and the ability to supply the service;
(b) not more burdensome than necessary to ensure the quality of the service; [italics added]
(c) in the case of licensing procedures, not in themselves a restriction on the supply of the service.”
(GATS Article IV.4.)
Member nations would have to show that regulations were “not more burdensome than necessary”. Further interpretation by the WTO in relation to health and social services states that this is not clear and would be open to interpretation:
“42. Three types of regulation seem to be particularly relevant as they may directly affect supply or demand of medical and health services. These are, first, qualification and licensing requirements for individual health professionals; second, approval requirements for institutional suppliers such as clinics or hospitals; and, third, rules and practices governing reimbursement under mandatory (public or private) insurance schemes. …. Since health-related quality criteria may differ significantly between individual activities, Member’s scope for operating qualification and licensing requirements under these provisions would need to be assessed case-by-case.” (WTO, Council for Trade in Services, Health and Social Services: Background Note by the Secretariat, S/C/W/50 18 September 1998, 42: 12)
Australia’s Specific Commitments on Health-Related Services
A document from the WTO Council for Trade in Services (Health and Social Services: Background Note by the Secretariat Table 3: p25, 18 September 1998 S/C/W/50) summarises specific commitments on medical, health-related, social and health insurance services of member nations. In these categories, the Australian Government has already made commitments to liberalise dental services, veterinary services, podiatry and chiropody services and health insurance.
According to GATS Australia Schedule of Specific Commitments 15 April 1994 GATS/SC/6, Australia has committed to liberalise dental services with no limitations on market access and national treatment for cross-border supply, consumption abroad and commercial presence. The ramifications of this are wide-ranging.
Article XVI. 2 on Market Access in relation to specific commitments states:
“2. In sectors where market-access commitments are undertaken, the measures which a Member shall not maintain or adopt either on the basis of a regional subdivision or on the basis of its entire territory, unless otherwise specified in its Schedule, are defined as:
(a) limitations on the number of service suppliers whether in the form of numerical quotas, monopolies, exclusive service suppliers or the requirements of an economic needs test;
(b) limitations on the total value of service transactions or assets in the form of numerical quotas or the requirement of an economic needs test;
(c) limitations on the total number of service operations or on the total quantity of service output expressed in terms of designated numerical units in the form of quotas or the requirement of an economic needs test;
(d) limitations on the total number of natural persons that may be employed in a particular service sector or that a service supplier may employ and who are necessary for, and directly related to, the supply of a specific service in the form of numerical quotas or the requirement of an economic needs test;
(e) measures which restrict or require specific types of legal entity or joint venture through which a service supplier may supply a service; and
(f) limitations on the participation of foreign capital in terms of maximum percentage limit on foreign share-holding or the total value of individual or aggregate foreign investment.”
Article XVII on National Treatment in relation to specific commitments states:
Article XV on Subsidies states:
Articles XVI, XVII and XV, quoted above, apply to Australia’s commitment to liberalise dental services. This puts present and future public dental programs in jeopardy. Subsidies to public dental services are threatened as governments are not allowed to discriminate between government and overseas service providers.
Governments could be required to match support of public dental services with support for dental services offered by overseas corporations. Implementation of articleXVI would mean government regulation of dental care is lost to market forces. This takes no account of distribution of services, access or equity issues. The DRS is alarmed this has occurred without appropriate community debate.
Decisions regarding those qualified to practise in dental care is open to interpretation and possible legal challenge. The United Nations Central Product Classification (CPC) used in the GATS describes dental services as involving the “diagnosis and treatment services affecting the patient’s teeth…” with no reference made to the qualification of the professionals involved (UN Statistical Papers, Series M No.7). This is in contrast to general and specialised medical services which specify diagnosis and treatment by “doctors of medicine”. (WTO Council for Trade in Services: Health and Social Services: Background Note by the Secretariat 18 September 1998 S/C/W/50 footnote 27: 12)
Australian health insurance has also been committed to liberalisation. Fundamental protection for public health insurance is undefined and may be open to interpretation. These commitments made by Australia expose Australia to the threat of trade challenges that restrict options for health reform. The GATS rules restricting monopolies (Article VIII.4) could expose to challenge any future expansion of Medicare coverage to encompass health services currently covered by private health insurance such as dental and allied health services. The DRS is concerned the risk of high compensation costs or lengthy legal challenges could deter any such policy initiatives.
US Style Health Care For Australia
The free market system of providing healthcare is failing in the USA. The US healthcare industry is being destabilised by falling profits (Levit et al 1998) and is intent on expanding its markets. Australia’s healthcare sector would provide a lucrative market.
The Coalition of Service Industries (CSI), a coalition of US service corporations, is a powerful lobby group that has been intensively pushing the USA and other government representatives to decrease barriers in trade in services and delivery of services. In relation to healthcare, the CSI’s 1998 submission to US trade representatives before the Seattle meeting stated:
“Three general objectives are to encourage more privatization, to promote pro-competitive regulatory reform, and to obtain liberalization. Specific objectives are:
• Transparent licensing of health care professionals and facilities, which do not place unnecessary or discriminatory burdens on US providers.
• Obtain market access and national treatment commitments allowing provisions of all health care services cross border.
• Allow majority foreign ownership of health care facilities.
• Obtain a commitment for the cross border provision and transfer of health care information.
• Seek inclusion of health care in WTO government procurement disciplines.
• Strengthen international cooperation to promote pro-competitive reform across countries.
• Negotiate Mutual Recognition Agreements (MRAs) for licensing of professionals and cooperative agreements on regulation of facilities.
• Develop principles to guide regulators so as to minimize unnecessary costs on trade and investment in the health care sector.
• Simplify regulations and provide transparency for the movement of personnel, both professionals and patients”
Under the full implementation of the GATS, the Australian government would be required to provide the same subsidies and grants to US and other foreign private interests that Australia already provides to Australian public institutions. The Australian government would no longer have control of health and social services.
Ultimately, Australia would have a US-style free market health system. The USA’s healthcare system is an example of failure of free market delivery of healthcare with limited government regulation and involvement. It is more expensive, less efficient, less equitable and has worse health outcomes.
The public sector has generally been the main contributor in the delivery of healthcare services. There are strong reasons for this. These include market failure in the healthcare sector and that the competitive market does not deal adequately with issues of public interest and equity. In the delivery of healthcare there are often overriding benefits of public interest that bring about a common good. These factors are not taken into account in the private competitive market. The government has been considered to be the best provider in these circumstances to ensure access and equity.
Market failure occurs in the healthcare market due to special features on both the demand and supply side that differ significantly from conditions required for the competitive market model. Market failure is an imbalance in supply and demand with market prices not reflecting efficient allocation of resources.
The USA’s system is widely considered to be more costly and less efficient than other OECD nations (Himmelstein & Woolhandler 1986, Pearson 1994, Woolhandler & Himmelstein 1991). Comparisons of administrative and other costs between OECD countries such as the USA, Canada and the UK support this view (Anderson & Poullier 1999, Fuchs & Hahn 1990, Goldberg & White 1995, Himmelstein & Woolhandler 1986, Woolhandler & Himmelstein 1991).
A study in the USA found administrative costs of for-profit hospitals 23% higher than not-for-profit hospitals and 34% higher than public hospitals (Woolhandler & Woodlander 1997). The USA’s fragmented health care funding arrangements, with numerous insurers as opposed to a universal health insurance scheme, is considered to be contributory to their rising healthcare expenditure (Goldberg & White 1995, Pearson 1994).
The US is the ‘richest country’ in the world, but it is not the whole country that is rich only the one per cent of the population who own 40 per cent of the wealth (Bezruchka 2000). Of fifteen OECD nations, the USA has the highest level of income inequality (Atkinson et al 1995 as cited in Anderson & Poullier 1999) and worse health outcomes. In the USA, life expectancy has consistently been lower and infant mortality higher than other developed nations in the OECD. In ranking for life expectancy of nations in 1997 the USA was 25th, behind all other rich nations and some poor nations (UNDP 1999).
Private insurance coverage with only limited safety nets for the ‘poor’ or aged as seen in the USA has resulted in many people not having access to healthcare and many more having inadequate coverage. In 1998, 43 million US citizens had no health insurance coverage (Feyerick 1998). Inability to pay medical bills has been the greatest cause of personal bankruptcy in the USA (Pearson 1994). Only the wealthiest portion of the US population are well served by their health system and the DRS does not want to see this situation reproduced in Australia.
In contrast, Medicare in Australia performs well in relation to overall healthcare costs, outcomes and equity issues (Donato & Scotton 1999: 22-27, Friends of Medicare 1999 Fact Sheets 4, 6). Medicare’s administrative costs are relatively low. As a proportion of total funds, administrative costs of private health funds are around four times those of Medicare through the Health Insurance Commission (HIC) (Friends of Medicare 1999 Fact Sheet 4, Livingstone 1997:28). Studies in Australia have shown public hospitals to be more efficient than private hospitals (Duckett & Jackson 2000).
The situation was different, however, before the introduction of first Medibank and then Medicare. The 1969 Nimmo Report on Australia’s then voluntary private insurance system (the Earl Page Scheme) found many people had no insurance cover, insufficient insurance coverage was widespread and there was hardship for the low-incomed (Report of the Commonwealth Inquiry into Health Insurance 1969:9-15). In 1973 a study in South Australia found failure to pay healthcare bills was the most common cause of imprisonment for debt (Scotton 1978 in Gray 1996).
Advantages of a public system are ability to deal with equity and access issues; more effective control of expenditure limits; monopsonic buying power; low administrative costs; and the ability to better serve population and public health needs as well as individual needs (Chernichovsky 1995, Webster 1995). Government intervention is needed to protect individual and public interest and to pursue equity and efficiency. A UN report found a comparatively high level of government involvement is required to ensure that health services are accessible, efficient and adequately funded (Saltman & Figueras 1998).
Co-operation is important in the delivery of healthcare. It is necessary for quality of care, appropriate information sharing and preparation in emergencies. If the core rules between various players in healthcare system are based on price and competition then any cooperation would be dictated by commercial rather than health interests.
National governments must take responsibility for ensuring equity in health and access to health care in the 21st century. This is the only way to adequately ensure accountability to citizens when health systems and services involve a multitude of players such as private companies, non-governmental organizations and the public. The free market notion that health is merely a commodity and, as such, has a price and can be traded off against other commodities threatens public health strategies, universal healthcare delivery and the belief that health is a human right.
The looming crisis in international health, with increasing inequities and worsening access to health care for the world’s most vulnerable populations requires global solutions. The DRS believes an international organisation such as the World Health Organization (WHO), rather than the World Trade Organization (WTO), is more appropriate to take a leadership role in coordinating international health initiatives and in setting the direction of international health policy. The world needs a strong body to take the lead in health matters, to act as an advocate for equity in economic and social development, to set priorities for the use of limited resources, to provide neutral territory for debating sensitive issues and to give technical advice and support (Sterky et al 1996).
Conclusion
The Doctors Reform Society (DRS) is an organisation of doctors. Daily, we deal with health problems caused by inequality and grapple with the issue of providing quality care for our patients at a price they can afford. The effect on health services of the full implementation of the GATS can only worsen the plight of many of our patients and the population as a whole. It threatens the existence of successful health schemes like Medicare and the Pharmaceutical Benefits Scheme.
The DRS urges the Australian government to reconsider its position and reject any agreement that can harmfully impact on our community.
The DRS calls for the Australian government to:
• affirm that safeguarding Australia’s public service sector including healthcare will take precedence over free market agreements and securing market access for Australian exports;
• support research into the impact of free trade agreements on population health and public health infrastructure;
• conduct a systematic and comprehensive assessment of the health impact of our existing commitments under the GATS agreement;
• support the incorporation of objectives such as equity, democracy and well-being, rather than only wealth creation, into trade agreements along with minimum standards in relation to human rights, labour conditions, democratic practice and environmental protection;
• pursue the issue of the “governmental authority” exclusion in Article I.3 at the GATS negotiations so that its meaning is clarified and made fully effective. If the intention of Article I:3 is to exclude public services from the GATS, steps should be taken to ensure that there is less discretion for interpretation. This may involve an amendment of GATS or the adoption of an authoritative interpretation by the WTO Ministerial Conference and the General Council (on the recommendation of the Council on Trade in Services). This should ensure that mixed public-private services, including healthcare, are fully excluded from the GATS (adapted from Sanger);
• voice Australia’s opposition to the extension of GATS commitments over healthcare services. Insist on a general exception for healthcare in the GATS negotiations applying to all WTO members and for healthcare not be targeted in future rounds of negotiations. The diversity of national healthcare systems means that the exception must be self-defining (as is the existing general exception for national security measures). This should be a precondition for agreeing to any further commitments (adapted from Sanger);
• take steps to reverse Australia’s commitment on liberalisation of dental services and prevent its application;
• enter a limitation to Australia’s GATS schedule which explicitly shields public health insurance from any commitments to health insurance;
• support efforts to build international mechanisms for addressing health as a “global public good” such as: recognition of the role of the World Health Organization (WHO) in coordinating international health initiatives and in setting the direction of international health policy; support the role of the WHO in determining legitimate health risks involved in WTO trade disputes; and
• support efforts to build a more balanced international economic order in which commercial interests no longer take precedence over human rights, environmental protection, wealth redistribution and other health-determining factors.
The Doctors Reform Society is concerned that there has been limited community consultation and input surrounding these issues. Community interests and concerns need to be taken into account as there will be profound long-lasting consequences for Australian society. We welcome this opportunity to contribute our views and hope that the best interests of both the Australian and world population are taken into account at the negotiations.
References
• Adler NE, Boyce WT, et al (1993) ‘Socioeconomic inequalities in health: no easy solution’ in Journal of the American Medical Association, 269(24): 3140-3145
• Anderson GF and Poullier JP (1999) ‘Health spending, access, and outcomes: Trends in industrialized countries’ in Health Affairs, 18(3): 178-192
• Andes N (1992) “Institutional contexts and mortality: the case of Peru” in Social Focus: 25: 295-309
• Beyer H, Rojas P and Vergara R (1999) ‘Trade liberalization and wage inequality’ in J Dev Economics, 59: 103-123
• Bezruchka S (2000) ‘Is globalization good for our health?’ in West J Med, 172: 332-334
• Braun D (1997) The Rich Get Richer: The rise of Income Inequality in the United States and the World. Chicago: Nelson-Hall
• Chernichovsky D (1995) ‘Health system reforms in industrialised democracies: An emerging paradigm’ in The Milbank Quarterly, 73, (3): 339-372
• Cornia GA (1999) Liberalization, Globalization and Income Distribution UNU/WIDER Working Papers No. 157. Helsinki
• Daniels N, Kennedy BP and Kawachi I (1999) ‘Why justice is good for our health: the social determinants of health inequalities’ in Daedalus, 128(4): 215-251
• Davey Smith (1996) ‘Income inequality and mortality: why are they related?’ in British Medical Journal, 312: 987-988
• Donato R, Scotton R (1999) ‘The Australian health care system’ in G Mooney, R Scotton (eds) Economics and Australian Health Policy, Allen and Unwin, St Leonards: 22-27
• Duckett SJ and Jackson TJ (2000) ‘The new health insurance rebate: an inefficient way of assisting public hospitals’ in Medical Journal of Australia, 172: 439-442
• Feyerick D (1998) ‘More Americans without health insurance’ CNN Report Nov 13 1998 http://cnn.com/HEALTH/9811/13/no.health.insurance/index.html
• Friends of Medicare Alliance (1999) Friends of Medicare Information Kit Fact Sheets 4, 6, Public Health Association of Australia Inc. Curtin ACT
• Fuchs V R and Hahn A B (1990) ‘How Does Canada Do It?’ in New England Journal of Medicine, 323(13): 884-90
• Goldberg M A and White J (1995) ‘The Relation between Universal Health Insurance and Cost Control’ in New England Journal of Medicine, 332(11): 742-744
• Gray G (1996) ‘Reform and Reaction in Australian Health Policy’ in Journal of Health Politics, Policy and Law, 21(3): 587-615
• Harrison A and Hanson (1999) ‘Who gains from trade reform? Some remaining puzzles’ in J Dev Economics, 59: 125-154
• Himmelstein D U and Woolhandler S (1986) ‘Cost without benefit: administrative waste in U.S. health care’ in New England Journal of Medicine, 314: 441-445
• Jha R (2000) Reducing Poverty and Inequality in India: Has Liberalization Helped? UNU/WIDER Working Papers No. 204. Helsinki
• Levit K, Cowan C, Branden B, et al (1998) ‘National health expenditures in 1997: more slow growth’ in Health Affairs, 17: 99-111
• Livingstone C (1997) ‘Private Health Insurance: a triumph for market ideology’ in Health Issues, 51: 27-29
• Najman J and Davey Smith G (2000) ‘The embodiment of class-related and health inequalities: Australian policies’ in Australian and New Zealand Journal of Public Health, 24(1):
• Pearson G (1994) ‘The Single-Payer Solution A Physician’s View’ in Minnesota Medicine, 77: 17-21
• Report of the Commonwealth Inquiry into Health Insurance (Nimmo Report) (1969) Government Printer Canberra
• Saltman R and Figueras J (1998) ‘Analyzing the evidence on European health care reforms’ in Health Affairs, 17 (2): 85-108
• Sanders R (2001) ‘GATS: the end of democracy?’ in The Australian Financial Review Friday 15 June 2001
• Sanger M Reckless Abandon: Canada, the GATS and the Future of Health Care Executive Summary Canadian Centre for Policy Alternatives
• Shen C and Wiliamson JB (1997) ‘Child mortality, women’s status, economic dependency, and state strength: a cross-national study of less developed countries’ in Social Forces, 76: 667-700
• Singh A and Dhumale R (2000) Globalization, Technology, and Income Inequality: A Critical Analysis UNU/WIDER Working Papers No. 210. Helsinki
• Sterky G, Bidwai P, Trung TT, et al (1996) Global health cooperation in the twenty-first century and the role of the UN system. Uppsala: Dag Hammerskjold Foundation
• St Vincent de Paul (2001) Two Australias - Addressing Inequality and Poverty
• Taylor L (2000) External Liberalization, Economic Performance and Distribution in Latin America and Elsewhere UNU/WIDER Working Papers No. 215. Helsinki
• United Nations Development Program (UNDP) (1999) Human development Report 1999 New York; Oxford University Press
• United Nations Statistical Papers, Series M No. 77 Provisional Central Product Classification (ST/ESA/STA/SER.M/77)
• Webster I (1995) ‘Private Provision of Public Health’ in New Doctor No. 64: 9-12
• Weisbrot M, Naiman R and Kim J (2000) The Emperor Has No growth: Declining Economic Growth Rates in the Era of Globalization Center for Economic and Policy Research (CEPR) Briefing Paper
• Wilkinson RG (1996) Unhealthy societies: The afflictions of Inequality. London: Routledge
• Woodward D (1996) ‘Effects of globalization and liberalization on poverty: concepts and issues’ in UNCTAD. Globalization and liberalization: effects of international economic policies on poverty. New York: United Nations
• WTO (1998) Health and Social Services document S/C/W/50, 18 September 1998
• WTO Secretariat (1999) An Introduction to the GATS, October 1999
• Woolhandler S and Himmelstein DU (1991) ‘The Deteriorating Administrative Efficiency of the U.S. Health System’ in New England Journal of Medicine, 324(18): 1253-1258
• Woolhandler S and Woodlander D (1997) ‘Cost of care and administration at for profit and other hospitals in the United States’ in New England Journal of Medicine, 336(11)
• World Bank (1999) Inequality: Trends and Prospects, The World Bank Group
[ Doctors Reform Society of Australia
home page]
[ About DRS ]
[ Site Index ] [ Search ] [ What's New ]
[ Policies ] [ Media Releases ] [ Published Letters ]
[ Current Issues: online articles ]
[ New Doctor: Journal of the DRS
]
[ Discussion
Board ] [ Contacting DRS ] [
Joining DRS ]
[ Jobs] [ Links ] [ Archives ]