Gats and equity in health services in Pakistan : opportunities, concerns and limitations

The World Trade Organization\u27s agenda shall be enforced within the member countd.es on 1 January 2005 but lack of preparedness may delay the process. The main provisions governing the services sector are dealt in General Agreement on Trade in Services (GATS) that claims to enhance economic activity. Critics negate this international trade agenda and consider it to be a threat to their health system in the welfare perspective. Several developing countries at the same time have adopted strategies to Promote trade of health services with focus on improving the quality of domestic health infrastructure. The trade in health services has probable implications on equity, efficiency and quality of health services albeit not much is known. For Pakistan the issue of equity in health becomes relevant when the country\u27s social indicators are rather depressed and reveal large regional, urban/rural and gender disparities. This study attempts to examine impact of GATS on equity in health services in Pakistan and provide recommendations to facilitate policymakers in making commitments in GATS in health services from the perspective of equity in health. The study adopts policy perspective for critical analysis of GATS exploring equity issues in health services applying a policy analysis tool and employing qualitative research methods for further inquiry and support. Benchmarks of Fairness\u27 were adapted and applied to study the implications of issues related to equity in health services with the introduction of GATS and enhanced trade in health services. Scoring criteria was developed to examine each mode of health service under GATS on equity in health. When examined against different criteria of Benchmarks of Fairness, trade in different modes of health services could only be scored highly on the scale developed for the purpose. Moreover, none of the criteria could be scored with direct and specific evidence and inferences from different studies were used to validate scoring. Lack of data relevant to trade in health services in Pakistan came up as the most striking limitation to comment on each benchmark criteria. None of the criteria in any mode of service could indicate through direct or indirect evidence that it may improve equity in any or all related variables. Key informant interviews conducted for an in-depth inquiry revealed that there is considerable lack of knowledge about GATS and interviewees were generally unable to comment on equity in health in relation to GATS. In its schedules of commitments related to health, Pakistan has rightly been cautious in liberalizing market access and national treatment so far since it has not gained sufficient experience on the issue. There has also been lack of reliable, comprehensive, and internationally comparable data in Pakistan to understand the implications of trade in health services on equity in health system. It might be too early to arrive at firm conclusions regarding the impact of GATS on equity in health services in the country. Research in the country must be encouraged to provide information needed to strengthen the development of policies. There is also need for advocacy and awareness raising within the health sector, and for coordination between different sectors, in order to mitigate the potential negative impact of the liberalization of health services on vulnerable groups