Posted by WTO Watch Qld on February 6, 2003 at 21:08:47:
QUOTES OF THE WEEK
“The United States is of the view that commercial opportunities exist along the entire spectrum of health and social care facilities including hospitals, outpatient facilities, clinics, nursing homes, assisted living arrangements, and services provided in the home.”
Kuttner, R. (1999) “The American Health Care System: Wall Street and Health Care”, New England Journal of Medicine, 340: 664-68.
“We believe we can make much progress in the [GATS] negotiations to allow the opportunity for US businesses to expand into foreign health care markets . . . Historically, health care services in many foreign countries have largely been the responsibility of the public sector. This public ownership of health care has made it difficult for US private-sector health care providers to market in foreign countries.” The US Coalition of Service Industries (CSI) Website: www.uscsi.org.
1) COMING EVENTS
2) CALLS TO ACTION
a) Submission to DFAT Discussion paper on GATS
b) Submission to Senate Inquiry into GATS
c) Get-out-of-GATS campaign update
3) FOCUS ON HEALTH AND GATS
a) Australia's GATS commitments on Health
b) Government Health Insurance (Medicare) and GATS
c) Medicare Fact Sheet
d) GATS:The End of Public Health?
e) Healthcare and GATS in Kenya
f) Some good news from Uganda
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1) COMING EVENTS
Put your foot down - Walk against Want - Sunday February 23
Oxfam Community Aid Abroad believes all people have the right to a
livelihood, to health and education, to safety, to be heard and to equal treatment.
Join 20,000 people around Australia and walk against want, raising money to
stamp out poverty and injustice.
We are looking for people to register or organise a group from their
community or workplace to walk against want on February 23, 2003. As a team
leader we would ask you to motivate interest in your group or workplace,
choose a fundraising goal to aim for and encourage group members to get
sponsored for walking!
Then simply come along on the day and walk. It's fun, easy and a great
social activity for your family, friends or work group!
We would love your support! For more information log onto www.caa.org.au/walk
or contact Rowena Aberdeen on (07) 3857 6888 (Brisbane)or email rowenaa@caa.org.au
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2) CALLS TO ACTION
a) RELEASE OF DFAT DISCUSSION PAPER ON GATS
In a belated response to community concern and pressure, and the recent announcement of a senate Inquiry into GATS, the Department of Foreign Affairs and Trade has released a discussion paper on GATS, with submissions due on Monday 24th February. (See details below) This paper summarises requests made to Australia by other countries, and the requests made of Australia by other countries, but the information provided lacks enough detail to be very helpful. It does, however, confirm that that there are requests to increase Australia's GATS commitments on health, education, postal and audio visual services and to include water services in the definition of environmental services (which would make water a tradeable commodity, instead of a human right.) It does not include the request which we know was received from the EU to Australia to list water services.
The closing date for submissions to the DFAT discussion paper is just one month before the closing date for submissions into the Senate Inquiry into GATS.
It is VITAL that as many people as possible put in submissions to both DFAT and the Senate Inquiry. WTO Watch Qld would suggest that the submission you send to DFAT will do very well for the Senate Inquiry.That gives us all just over three weeks to prepare our submission!
The discussion paper is available on the DFAT website at http://www.dfat.gov.au/trade/negotiations/services.
Hard copies are also available from the DFAT Office of Trade Negotiations.
Comments on the discussion paper are invited by 24 February 2003, to The Director, Services Trade Negotiations, Office of Trade Negotiations, Department of Foreign Affairs & Trade, Barton, ACT 0221 or by e-mail to: services.negotiations@dfat.gov.au.
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b) SENATE INQUIRY INTO GATS
The Senate has decided on the terms of the Inquiry into the GATS and the US/Australia Free Trade Agreement
Senate Foreign Affairs, Defence and Trade Committee
General Agreement on Trade in Services and Australia/US Free Trade Agreement
Terms of reference
On 12 December 2002, the Senate referred the following matters to the Foreign Affairs, Defence and
Trade References Committee for inquiry and report by 27 November 2003:
1. The relevant issues involved in the negotiation of the General Agreement on Trade in Services
(GATS) in the Doha Development Round of the World Trade Organisation, including but not limited to:
(a) the economic, regional, social, cultural, environmental and policy impact of services trade liberalisation
(b) Australia’s goals and strategy for the negotiations, including the formulation of and response to requests, the transparency of the process and government accountability
(c) the GATS negotiations in the context of the ‘development’ objectives of the Doha Round
(d) the impact of the GATS on the provision of, and access to, public services provided by government, such as health, education and water
(e) the impact of the GATS on the ability of all levels of government to regulate services and own public assets
2. The issues for Australia in the negotiation of a Free Trade Agreement with the United States of
America including but not limited to:
(a) the economic, regional, social, cultural, environmental and policy impact of such an agreement
(b) Australia’s goals and strategy for negotiations including the formulation of our mandate, the transparency of the process and government accountability
(c) the impact on the Doha Development Round
Submissions
The Committee invites individuals and organisations with knowledge and information relevant to the inquiry's terms of reference to lodge submissions by Friday, 21 March 2003 with: The Secretary
Senate Foreign Affairs, Defence and Trade References Committee
Suite S1.57
Parliament House
CANBERRA ACT 2600
or Email: fadt.sen@aph.gov.au
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3) GET-OUT-OF-GATS CAMPAIGN
The GET-out-of-GATS campaign success hinges on your decision to act NOW.
This campaign was kicked off by Joe (see details below) in Sydney and is taking off around the country.
The campaign involves making an appointment to see your local member and/or local senator during the last two weeks of February. With submissions to two GATS inquiries due around that time, it is a great opportunity to let your Parliamentary representatives know how you feel about the GATS. It you would like materials about the GATS to take with you, please let me know at gumbus@powerup.com.au
The VERY best way to participate in the campaign is to personally visit your federal member and/or senator. But, for many people, this is difficult. WTO Watch Qld therefore suggests that you phone (second best option) or write (least preferred option) during that period.
Do not sit on your hands, NOW is your last chance to Get-out-of-GATS and the Free Trade Trap.
For further information contact Joe Bryant PO box 270 St Marys NSE 2760. Fax: 02-9826-1670
Ph: 02-9826-1337. Email: info@gats.com.au Web: www.gats.com.au
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3) FOCUS ON HEALTH
a) Australia's GATS Commitments in Health
In 1995, Australia made the following commitments in health. At that time there was no public consultation, and very few people, apart from a few trade lawyers and trade bureaucrats, had even heard of the GATS. These commitments are binding, and can be reversed only by negotiating compensation with all other WTO member countries. Australia's commitments are more extensive than DFAT and the government would have us believe, because of the way some health services are classified in the GATS agreement.
Health Insurance ( Health Insurance is classified in the GATS agreement under 'Financial Services' and thus DFAT is able to technically omit including health insurance in the list of 'health' commitments made under GATS.) Health Insurance includes Medicare.
Dental services ( Dental services are classified in the GATS under 'Business and Professional Services' and so once again, DFAT is able to technically exclude it from the list of 'health' commitments under GATS.)
Podiatry and Chiropody services (except where performed in a hospital).
Veterinary services
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b) The following media release is from Canada, but it applies equally to Australia, as both countries have Medicare-type health insurance schemes and both countries have made full commitments in Health Insurance. I would urge you to read the full document at the site indicated below. If you had visions of Medicare being extended in the future to cover areas such as dental services, physiotherapy or other allied health services...forget it. Our GATS commitments make that very unlikely. Queensland is now the only state with a free dental service and that service may be at risk in the future from the GATS.
FOR IMMEDIATE RELEASE
FEBRUARY 19, 2001
GOVERNMENT EXPOSED HEALTH CARE TO TRADE CHALLENGE AT THE WTO--STUDY
OTTAWA--Contrary to repeated assurances from the Minister of International Trade and other federal government officials that Canada's health care system is protected from trade challenge under the WTO's General Agreement on Trade in Services (GATS), a new study released today shows that the government has, in fact, recklessly exposed health care to the GATS commercial rules.
Matthew Sanger, the researcher who conducted the 143 page study for the Canadian Centre for Policy Alternatives, made the startling discovery that health insurance has already been included in the list of Canadian services which are subjected to the full force of the GATS rules.
"It's astonishing the government would have done this. Now all future measures are exposed to challenge," said Sanger. "So, for example, any extension of public health insurance to cover pharmaceuticals or home care would almost certainly be challenged by the multinational drug giants and US for-profit home care companies. They would be able to demand stiff compensation, and the added cost would be a huge deterrent to implementing such policies." He stated.
The federal government must act immediately, according to Sanger, to fix the problem and safeguard our health care system from trade challenge.
Sanger proposes a number of concrete measures the government must take including:
"insist on a self-defining general exception for health care which applies to all WTO members and will not be targeted in future rounds."
"exclude health care from the scope of the agreement, negotiate explicit exceptions and limitations to all Canada's GATS commitments which may affect healthcare services. "
"invoke GATS article XXI to modify Canada's schedule of commitments in health insurance, and enter a limitation which shields public health insurance and ensures that Canadians can expand medicare in the future."
The CCPA study comes at a time when the Government is finalizing its negotiating position for a new stage of services negotiations set to begin in Geneva in late March.
Matthew Sanger is an independent trade consultant specializing in health and social policy issues. The study is called "Reckless Abandon: Canada the GATS and the Future of Health Care," It is part of the ongoing work of the Trade And Investment Research Group which is coordinated through the CCPA.
A summary of the study is available from the CCPA web site: http://www.policyalternatives.ca
For further information and a list of experts and organizations to comment on this study, contact Bruce Campbell at 613-563-1341 ext. 302.
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c) Medicare Fact Sheet No 6......How Australia's Health Service Compares Internationally
This fact sheet is one of a series of 10 prepared by the Friends of Medicare in 1999. The full series is available on the Doctor's Reform Society's website www.drs.org.au
Four indicators are often used to compare health services in different countries. These are: universal coverage; level of satisfaction among the population with the health system; health status and overall cost to the economy. On each of these Australia rates well.
Health status
Australians enjoy a high overall level of population health status on almost every criterion. Most measures of death and illness show Australia ranks in the middle range of developed countries.
Age-standardised death rates take into account the different age distributions across countries. Comparing the number of deaths per 100,000 people provides a comparison of a nation’s overall health status.
In 1992, Australia had the fifth lowest rate among 19 comparable developed countries (AIHW, 1998), bettered only by Japan, Hong Kong, Sweden and Canada. Australia’s death rate was 16% lower than the rates for the USA and New Zealand, which ranked 15th and 16th respectively.
Life expectancy in Australia in 1996 was 78.2 years, one year greater than the OECD median and 2.1 years more than the USA - while infant mortality was equal to the OECD median of 5.8 per 1000 live births (Anderson 1998).
In 1995, a comparison of eight developed countries recently ranked Australia second only to Japan in achieving the lowest potential years of life lost for all causes except suicide for people under the age of 70 in 1995 (Anderson 1998).
Spending on health care
Australia’s total spending on health care, as a proportion of GDP and in the proportion coming from the public sector, ranks in the middle of the developed countries for which data are available.
Note that the USA, with only 46.7% of its health care expenditure in the public sector spends 67% more than Australia as a proportion of GDP and 2.3 times as much per capita. Yet despite this additional spending, the USA reports a worse population health status and has 40 million people without any form of health insurance. Most of it’s highest spending simply goes in higher costs.
Every OECD nation’s health spending has risen since 1970. However, where the public sector dominates the market, such as Australia and the UK, cost rises have been slower and more controlled. In Australia the cost of health care has been relatively stable for the last 10 years.
Australia’s proportion of GDP on health went from 5.2% to 8.4% between 1970 and 1995; while the USA rose from 7.4 to 14.5% over the same period (AIHW 1996). The USA rate has only plateaued in the 1990s, mainly as a result of bureaucratic “managed care” restrictions on the supply of medical services, something Australia has so far avoided.
Contrary to claims of health cost blow outs, recent trends show that the rate of increase in health care spending was slower in nearly all countries in the 1990s than it had been in the 1960s, 1970s, and 1980s (Anderson, 1998).
Fairness, Access and Choice
National expenditure on health care is only one measure of comparison. Other important areas include; how fairly the costs are shared; how accessible the health care services are and how much consumer choice is available.
Countries with universal health insurance cover, such as Australia, ensure that all people have access to medical and hospital care when they need it.
Countries which rely more on private funding of health care, such as the USA, emphasise the right of individuals to choose how their health care needs are met. But in reality, choice is determined by personal wealth. Around 40 million Americans or 16% of the population remain uninsured. For them, the choice may be limited to using dwindling public services, bankruptcy or going without needed care.
The UK’s National Health Service provides universal health care cover, but offers only limited choice. In international terms, this system is efficient in terms of health outcomes, and fair, because nearly all health care is paid for by progressive taxation.
Getting the balance right
An effective health care system not only recognises health as a public concern, but ensures everyone has a stake in their own and each other’s health. Everyone pays their fair share, according to their capacity. It accommodates the values and rights of the individual and allows for choice and active involvement in decision making about health care. Most importantly, an effective health care system maximises access for all, so that health and health care is seen as a basic right and not a commodity for sale only to those who can afford it.
Australia has managed to walk the thin line between more extreme models by attempting to balance fairness, access and choice as well as maximise health outcomes.
Our health care system is essentially a hybrid of public and private provision. However, one key feature of its public arm is universal health insurance coverage. Universal health coverage is a feature of all OECD countries except for the USA, and means that everyone, rich and poor, is insured against major individual health care costs. Universal health coverage also ensures that all taxpayers contribute to the cost of maintaining the system, according to their capacity to do so.
If the rich were exempt from contributing to the public system via means testing or “opt out” provisions, the diminished tax base would render the public system unworkable. However, the current system ensures all Australians have access to quality care on the basis of need, a choice of GP and the right to choose and pay for private care if they wish.
There is always room for improvement in health care. Australia’s system is not perfect, but by international comparisons it gets the balance right. As Dr Michael Wooldrige, Federal Minister for Health, often states: the choice is clear; what country other than Australia would you like to be sick in?
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d) GATS....The End of Public Health
The following are extracts from and article published in 'New Doctor' issue No 76 Summer 2001-2002. The full article is available on the Doctor's Reform Society website www.drs.org.au
"To establish a trade in services, as GATS aims to do, there has to be a market in services - services have to be bought and sold. Until recently, however, many countries have not had markets in health care, education, water, sewerage or energy. All have, by and large, been provided by government or non-profit organisations. The state has established hospitals and schools, and trained and paid their staff.
Markets are now being created by enabling entities other than the state to provide services. Privatisation of ownership, for instance selling off water supplies, is an obvious means. Other means are more hidden and gradual: privatisation of service provision (by requiring contracting out, leasing or competitive tendering); privatisation of finance (charging users of the service, private capital, private health insurance) and the introduction of internal markets (dividing purchasers from providers of services).
Health care services have not generally been explicitly privatised. Instead, there has been an incremental process of government retraction accompanied by private sector enlargement as the services have been commercialised. Markets - and thus the potential for trade - have crept in through the back door. "
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"The central principle which has underpinned public service provision in Australia is the principle of universalism. Under this all citizens are guaranteed access to public services according to need, not according to their ability to pay. This has been of particular importance to health and education but applies across many other sectors too.
The model of ‘new universalism’ promoted by bodies such as the World Bank and the WTO is based not on state provision but on the free market, with government ensuring a level of market regulation. Instead of risk pooling, the new model is based on capitation (payment on the basis of a head count and individual risk) plus targeted subsidies. Instead of cross-subsidising, the new model of universalism requires the ‘unbundling’ of public services, typically including a separation of the infrastructure (network) from actual service delivery. The effect of this ‘unbundling’ is to render the public service inefficient, as it is no longer able to spread risk across society and subsidise high cost elements of service provision through low cost.
The trend is toward something like the United States’ health care system, which has become dominated by for-profit organisations over the past decade and where up to 55 million Americans cannot afford health insurance. In the US, tacit cross-subsidies are being eliminated and hospitals treated more and more as businesses. Researcher Robert Kuttner observes:
“Temporary losses are defensible only as investments in future profits, so cross-subsidy must be avoided ... There is no place for uncompensated care, unprofitable admissions, research, education, or public health activities - all chronic money losers from a strictly business viewpoint”.
A revised GATS could not only reduce equitable access to health care services. It could also undermine mechanisms for containing the costs of public sector health care. It could override national regulations governing health care and affect the kind of services provided, restricting rather than enlarging people’s choice of services and of the places in which they are provided. With reduced public expenditure on health and social services, families will increasingly have to take up the slack and nurse the sick who cannot find or afford health care. Via GATS, private companies could prise open for themselves public funding for services. In the Organisation for Economic Cooperation and Development (OECD) countries, public expenditure on health services and education accounts for more than 13 per cent of gross domestic product. Much of this spending now goes to public or voluntary bodies but could end up being channelled to for-profit groups. Nearly Nearly 50 per cent of UK tax revenue now goes to profit-making companies."
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e) While the GATS promotes the commercialisation and privatisation of heath services in the developed world, the World Bank and the International Monetary Fund have long been busy dismantling public health systems in the developing world. The GATS is likely to finish them off!
John Kinuthia, Trading in Healthcare Services in Kenya, are we prepared? Case study on the implications of committing healthcare services in Kenya under GATS. Consumer Information Network Kenya, Nairobi, Kenya.
20th January 2003
The health care sector and foreign health care providers in Kenya
Current Policy
The government of Kenya is gradually decreasing its active role in providing health care. Under pressure from the International Monetary Fund (IMF) and the World Bank, it cut its budget in the late ’80s and early ’90s in order to deal with the economic crisis and pay back large foreign debts. As a result, the Kenyan government transformed its role from that of provider of health services to that of policy maker and regulator of health service provision. Its goal is to restructure the health care system, making it more effective, affordable and accessible, while improving the health of the Kenyan people. In this scenario, private companies and NGOs are gradually taking over health care provision.
The Kenyan government has in all business sectors been actively working to attract foreign investors. Although the market for foreign-owned hospitals in Kenya has not yet been permanently opened under the GATS agreement, in this and other sectors the government has placed very few restrictions on what foreign companies and organisations may do, in order to make foreign investment as attractive as possible. For example, foreign-owned hospitals are not required to treat poor and uninsured patients. The market for insurance, including health insurance, has already been opened according to GATS rules.
According to the International Covenant on Economic, Social and Cultural Rights (CESCR), every person has the right to the enjoyment of the highest possible standard of health. Non-discrimination is one of the covenant’s basic principles (see introduction). Governments are expected to protect, respect and fulfil CESCR rights, such as by providing accessible and high-quality health care services.
Discriminatory practices in commercial hospitals
Until 1989, all Kenyans received free health care. After 1989, in order to reduce government health care costs, user fees were introduced and uninsured patients were required to make out of pocket payments. The quantity and quality of public health services declined. Public health care became much less accessible for most Kenyans, while commercial care remained financially out of reach. Foreign-owned hospitals are located exclusively in cities, as are the offices of foreign insurance companies. But only 20 percent of Kenya’s population lives in the cities. In rural areas, health care services have collapsed since the institution of user fees. Many clinics and health care posts are out of use and there is just one doctor for every 33,000 people. In the city there is a doctor for every 1700 people.
Like all private hospitals, Kenya’s foreign-owned hospitals are often guilty of discriminatory practices that violate the right to the best possible health care for all. For example:
· Patients who have no money for further tests or treatment are sent away before treatment is completed--even in life-threatening situations. Each treatment must be paid for separately and in advance.
· Patients may be chained to their bed until their bill is paid or required to work in the hospital to pay off their debt.
· Accident victims are not automatically admitted to the nearest hospital if that hospital is beyond their means.
The cost per day for a foreign-owned hospital may be ten times as high as the cost for the subsidised general wing of the national hospital in Nairobi. Even there, patients must pay almost 4 American dollars a day--despite the fact that 56 percent of the population lives below the poverty line and has no more than 1 dollar a day to spend. The poor who are turned away from the commercial hospitals end up in the public sector, which is then burdened with the poorest patients.
In order to cut costs, the government-run national hospital in Nairobi has set up a private wing alongside the subsidised wing. This has made the double standard highly visible. In the subsidised wing, patients share beds and there is no pharmacy, while the private wing has enough beds and medicines. Doctors prefer to devote their time to the patients from their private practice, rather than to public health care.
Relationship to GATS
Kenya has not yet liberalised the hospital sector according to the rules of GATS, but during current negotiations, Kenya may permanently open the commercial health care market to foreign corporations. Research into the practices of foreign-run hospitals shows that they do not respect the principle of equal care for all, particularly for the poor. In this way they violate Article 12 of the International Covenant on Economic, Social and Cultural Rights. The GATS agreement does give WTO member states the right to regulate sectors that are subject to GATS provisions (within the limits of the GATS rules), in order to discourage abuses and excesses. But during GATS negotiations and in the GATS agreement, little attention is paid to the ability of a country like Kenya to make complementary regulations to protect its health care system. In addition, countries like Kenya are under pressure from the international financial institutions not to stand in the way of foreign interests--a pressure that is increased by the GATS rules for equal treatment for national and international corporations.
The practices of foreign health insurance companies increase the double standard
Wealthy, healthy Kenyans can increasingly spread risks and contract out their health costs by purchasing commercial insurance policies or joining Health Maintenance Organisations (HMOs). These companies tailor their services to the wealthy city-dwellers who were already able to pay their hospital bills. Some private insurance companies, such as the British/Kenyan AAR, charge between 190 and 344 American dollars a year.
Private, foreign insurance companies refuse to accept patients who suffer from illnesses such as HIV/AIDS. This is in sharp contrast to the government’s public health insurance system, which is obligated to accept all patients. Private hospitals and commercial insurers are profit-driven and often transfer their profits abroad.
It is extremely difficult to collect data on foreign insurance companies and their practices. The Kenyan government has no such data. There is a suspicion that foreign insurance companies and HMOs work closely together, exchanging information on clients’ health and finances. In turn, HMOs work closely with certain hospitals to ensure that patients who can no longer pay for their health care are turned away. At this moment there is no Kenyan legislation whatsoever covering health care or insurance that applies to HMOs.
Relationship to GATS
During the previous GATS negotiations Kenya chose to liberalise its financial services without fully realising that it was also subjecting the health insurance sector to the rules of GATS. Article XVI prohibits governments from taking six specific kinds of measures to place limitations on companies, such as restricting the number of service suppliers. During the negotiations governments can limit these prohibitions but Kenya made only one limitation to complete market access under Article XVI. The Kenyan government could have required foreign insurers to insure poor patients, but did not take that opportunity during previous negotiations. The government can now require foreign companies to insure poor and vulnerable (HIV-positive or terminal) patients only if it also sets the same requirement for Kenya-based insurers, according to the GATS principle of non-discrimination and national treatment (Article XVII). If the Kenyan government sets the requirement only for foreign insurance companies, then other WTO member states can begin or threaten a trade dispute. If Kenya issues licenses to health insurers or sets standards of quality, then according to GATS Article VI.4-5, these measures must not be more burdensome to trade than necessary. It is feared that the discipline that GATS demands of governments will put pressure on their ability to protect human rights, because these protections can be seen as limitations on trade.
According to the GATS agreement (Article XI), countries are not permitted to apply restrictions to international transfer of profits in sectors that they have liberalised under GATS. Foreign health care providers and insurers earn a good profit from wealthy Kenyans. It is distressing that the profit from foreign insurers is not required to remain in Kenya, while the Kenyan health care system suffers from a chronic shortage of capital.
Certain provisions of GATS require complete transparency of government regulations and decisions, to help industry guard against loss of profits. But the GATS agreement does not require the business practices of foreign investors to be equally transparent. This case study has made clear that the government has little power to obtain answers to questions such as who is the owner of a company, what its policies and practices are with regard to poor patients, salaries, etc. The operations of foreign-owned hospitals and health insurance companies are anything but transparent.
Mobility of medical personnel and patients44 See note 1, modes 2 and 4.
More and more wealthy patients from neighbouring countries are coming to Kenya for treatment in Kenya’s private hospitals. This leaves fewer beds for Kenyans, particularly poor Kenyans. In turn, those Kenyans who can afford it prefer to travel to other, often distant countries for treatment. The best-trained medical personnel tend to abandon the public for the private sector, where the pay is better. Anyone who can seeks work abroad. As a result, public health care suffers from brain drain and lack of personnel. Meanwhile, commercial hospitals attract foreign specialists, but they do not pass on their knowledge to local personnel.
Relationship to GATS
The member states of the WTO also negotiate within the GATS agreement about the supply of health care services to foreign patients and the admission of foreign service personnel. Wealthy patients from neighbouring countries who come to Kenyan hospitals yield cash, but at the expense of poor Kenyan patients. In the current round of negotiations, the Kenyan government is considering asking the North to open its market for medical personnel, so that Kenyan doctors and nurses can practice in the European Union. Kenyan nurses working abroad supply hard currency to support their families at home. Kenyan negotiators are inclined to focus on the economic advantages at the expense of their own people’s right to universal health care.
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f) Elimination of User Fees brings big increase in clinic utilization rates in Uganda
Buried in the depths of Uganda's official Ministry of Health Annual
Performance Report for 2001/02 (page 61) are some startling statistics about
the results of Uganda's decision to go against World Bank advice and abolish
health user fees: in one year there has been a spectacular increase in
utilization of services totaling a 40% increase in attendance for
outpatients and an increase from 48 to 63% for DPT3 immunizations.
"This is a massive good news story which needs to get out," says Mr. Rob
Yates of the Ugandan Health Ministry. Although the Ugandan Finance Ministry
and in-country representatives of the IMF and World Bank are not exactly
"singing this from the roof tops," President Museveni is quite happy with
the outcome. Museveni, who went against World Bank policy advice on the
issue, and joined Tanzania and other countries in unilaterally dropping the
much-maligned "user fees", went out of his way to criticize the World Bank
for "imposing user fees" (his words) at the recent Commonwealth Health
Minister's meeting and was now proudly showing the results of having got rid
of them. The result is that millions of Ugandans are now accessing health
care services that the fees had blocked them from receiving.
In the course of the in-depth surveys taken as part of the Uganda
Participatory Poverty Assessment Programme (UPPAP), President Museveni
became aware of just how tremendously unpopular were the fees, and sought to
eliminate them despite World Bank pressure to retain the fees.
It is very important for readers and others to spread the word about this Ugandan good news story in advance of
the World Bank's upcoming World Development Report 2004, which is going to
be a classic effort to argue against increasing support for public health
services - even suggesting that it is not worth investing more money in
them. The upcoming WDR is an attempt to rebut the important conclusions
reached by World Health Organization's recent report of the Commission on
Macroeconomics and Health. This report turned neoliberal and free market
logic on its head: for years the IMF and World Bank have been telling
governments to cut state spending in an effort to decrease budget deficits,
keep inflation low and raise overall economic growth rates; only after
economic growth rates materialize could governments then increase spending
on health & education. Yet the Commission on Macroeconomics & Health
concluded the very opposite: vast increases in public health and education
spending now will lay the social foundation necessary for future higher
economic growth rates.
Fighting the spread of HIV/AIDS, increasing literacy rates and improving
overall prospects for real development will require many things; one
important component will be eliminating the harmful and regressive "user
fees" so that, as this vital Ugandan evidence suggests, poor people can more
easily access critical health services.
Rick Rowden
Researcher
RESULTS Educational Fund
Washington DC
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Terrie Templeton WTO Watch Qld gumbus@powerup.com.au