Public health implications of world trade negotiations.

Sir

We agree with the main sentiments of Allyson Pollock and David Price (Sept 27, p 1072). Moreover, the effect of world trade negotiations on the general agreement of trade and services (GATS) could have serious implications for developing countries, where healthcare systems are characterised by weak administrations and the coexistence of public and private sectors. Since 1990, the aid policies of industrialised countries has tended to restrict the public sector's functions to mere disease control. On the grounds of the private sector's supposed higher efficiency, this policy recommends marketing of curative care together with prioritisation of disease control within the public sector. GATS article 1.3.c. makes this recommendation compulsory: “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”. It could be invoked by powerful health services companies in countries with a weak bargaining position, to prevent publicly oriented services from receiving government subsidies or oblige subsidised public services to limit their activities to disease control.

As a consequence, access to general care will further suffer in areas where private providers are scarce (60% of the population of low-income developing countries live in rural areas), or will become too expensive for most (82·6% of south Asians live on less than US$2 per day).

Article 1.3.c. could also hamper disease control—the paradigm of contemporary international aid in health. It provides the legal basis to preclude integration of disease control with general practice. Nevertheless, many commentators stress the convenience of integrating programmes into health facilities to achieve a reasonable prospect of successful disease control. Such integration requires structures with patients, as journalists noticed while analysing causes of the severe acute respiratory syndrome (SARS) epidemic in China. These patients, consulting for various symptoms, represent a pool of users that disease control programmes need for early case detection and sufficient coverage.

Subsidies to publicly oriented services owned by ministries of health, city councils, and non-governmental organisations could be barred on the ground of GATS article 1.3.c. Politicians who endorse it carry a heavy moral responsibility.