In September, Europe will return to the negotiating table to discuss a far-reaching trade and investment agreement on services, called ‘TISA’. By further opening up the health sector to private investments, health inequalities will be exacerbated in both Western and developing countries.
Depending on your income, you will or will not have access to health care
What is TISA?
In 2012, the EU and the US initiated the multilateral negotiations for ‘TISA’ (Trade in Services Agreement). Services include every aspect of daily life; the train that takes you to work, mortgages, pension savings, hospitalisation insurances, internet, electricity and water supply, education, etc. The governments’ key role is to ensure that important services are sustainable and accessible for everyone.
When a service sector is opened to trade, public providers will compete with private providers. While commercial providers primarily focus on the maximisation of profit, public services aim to provide for the population’s basic needs. Public services are not in a good position to compete, because -in principle- they should also provide services to the people that have the highest needs and the least purchasing power, e.g. the poor, the disabled, the elderly, the unemployed, migrants; in short, people that have a harder time in society. This increases the cost of services. That is why public services are based on the solidarity principle. Everyone pays taxes, which generally serve to provide a safety net in times of need, illness, old age or bad times. Commercial services on the other hand focus on the people that can afford them; what you pay is what you get. This applies to private hospitalisation insurances, private hospitals, bank loans or private education. Everything goes well as long as you have the money, but what will happen when you encounter setbacks? What will happen when you are ill and the treatment is too expensive, or when you grow older and your pension is not high enough to pay for a retirement home?
Which countries participate in the TISA-negotiations?
Participants in the negotiations are all EU-countries, Australia, Canada, Chile, Chinese Taipei, Hong Kong, Iceland, Israel, Japan, Liechtenstein, New Zealand, Norway, Republic of Korea, Switzerland, the US, Colombia, Costa Rica, Mexico, Panama, Peru, Turkey, Pakistan and Paraguay. The majority of the participating countries are rich countries, whose economy largely depend on services. Together, they are responsible for 70% of the global trade in services.
The European Commission aims for a maximal number of countries to sign the TISA agreement, that will and consequently push other countries in the World Trade Organisation to accept the same terms.
What are the risks for the health sector?
The TISA agreement involves substantial risks to public health. Commercialization of health is made irreversible by the TISA agreement. The TISA agreement also automatically implies privatization of future services, that do not yet exist today. This smothers the future public policy space in the bud. The biggest risk of health care commercialisation would be the creation of a two-tier health system. People with a higher income would be able to enjoy private, high tech and specialised health care while the poor would have to turn to the public health care. In short, depending on your salary, you will or will not have access to health care. This will lead to unequal health outcomes, even though everyone should be entitled to good health, regardless of status or background.
The TISA-agreement will also have an impact on the migration of health personnel. Commercial care providers would import more health workers from other countries, because this is a ‘cheaper’ strategy than to invest in education and employment of local health personnel. The loss of health workers to this ‘brain drain’ can entirely destroy fragile health systems in developing countries. People that live in rural areas and in poor regions will remain behind without access to quality health care.
What impact will TISA have on the policy space for public health?
Since 1994 countries that are part of the World Trade Organisation can open their services to the free market through the GATS-agreement (General Agreement on Trade in Services). They can choose which specific sectors they export or open to foreign investment. The GATS-agreement includes clauses that allow countries to prioritise public health over commercial interests. This means that the government can limit commercial activities when she considers it necessary to protect the population. Therefore commercial lobbies now pressure US and EU governments to sign the TISA-agreement that do not include these protection mechanisms and that includes all services unless explicitly excluded. TISA will have, therefore, even more far reaching consequences than GATS already had.
So isn’t there any democratic participation?
The TISA-agreement is being discussed in secret, preventing the possibility of a public debate. Civilians in a democratic political system are entitled to be involved in decisions, all the more so because the signing of this agreement carries a high degree of risk. We have to pressure our governments to publish the entire contents of the negotiations and protest against any agreement with major risks for public health and public policy space for health.