Research and capacity building Eastern Mediterranean Region

WHO-EM/PHP/036/E
Research and capacity building
in trade in health services in the
Eastern Mediterranean Region
Rabat, Morocco, 30 May– 1 June 2006

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Printed by El Balagh, Cairo
Document WHO-EM/PHP/036/E/12.06/300

Contents
1. Introduction .......................................................................................5
2. Globalization, trade and health.....................................................11
2.1 Globalization, trade and health: WHO perspective.........11
2.2 Understanding commitments in health services
under GATS ...........................................................................14
2.3 GATS application to health services...................................17
2.4 Trade and health: a tool kit for analysis and
assessment
of countries............................................................................18
2.5 Discussion on presentations ................................................19
3. Regional experience in trade in health services ..........................22
3.1 Methodological framework for assessing trade
in health services ..................................................................22
3.2 Challenge of assessing trade in health services:
experience from the Eastern Mediterranean Region.......25
3.3 Egypt.......................................................................................30
3.4 Jordan......................................................................................32
3.5 Lebanon ..................................................................................35
3.6 Morocco ..................................................................................36
3.7 Oman ......................................................................................38
3.8 Pakistan ..................................................................................39
3.9 Sudan .....................................................................................40
3.1 0 Syrian Arab Republic............................................................42
3.11 Tunisia ....................................................................................44
3.12 Yemen .....................................................................................45
3.13 Discussion on the country studies......................................46
4. Working groups...............................................................................48
5. Recommendations...........................................................................52
Annexes
1. Programme .............................................................................................54
2. List of participants.................................................................................56

1. Introduction
Globalization represents a challenge to health systems, both in
the Eastern Mediterranean Region (EMR) of the World Health
Organization (WHO) and worldwide. The opening up of trade in
health services will create new opportunities for health systems while
also putting pressure on them and creating new challenges for them.
Health systems are expected to benefit in particular from
developments in information technology, which will facilitate access
to up-to-date biomedical technology and skills for large segments of
the population. At the same time, concerns have been expressed
about the potential negative impacts of free trade in health services
on access to essential health services, on the existing “brain drain” of
qualified professionals from the Region and on overall equity with
respect to health care.
Over the past two years the WHO Regional Office for the
Eastern Mediterranean (EMRO), International Development Research
Centre (IDRC) of Canada and United Nations Population Fund
(UNFPA) Egypt, have undertaken a joint Concerted Action for
Research and Capacity Building in Trade in Health Services in the
Eastern Mediterranean Region to comprehend the influence of trade
on the efficient and equitable provision of health services. While
international trade in health services has grown globally in recent
years, the General Agreement on Trade in Services (GATS) has been
instrumental in stimulating current thinking on the implications of
globalization and the opening up of trade in health services for
creating new opportunities and challenges for health systems.
The Regional Office has been intensively involved in assessing
the status of trade in health services in 10 countries of the Region:
Egypt, Jordan, Lebanon, Morocco, Oman, Pakistan, Sudan, Syrian
Arab Republic, Tunisia and Yemen. The results of these studies were
shared with national policy-makers during the Regional Consultative
Meeting on Research and Capacity Building in Trade in Health
Services in the Eastern Mediterranean Region, held in Rabat,
Morocco, from May 30 to June 1 2006 (for the programme see Annex

6 Trade in health services in the Eastern Mediterranean Region
1). The participants included country researchers, national health and
trade policy-makers, multilateral trade and health agencies,
international development agencies, members of academia and civil
society, and WHO staff (for the participants list see Annex 2).
The Minister of Health of Morocco, His Excellency, Dr
Mohamed Cheikh Biadillah, welcomed participants. He observed that
it was a time of frontiers falling in the face of market-driven financial
and trade flows, and the establishment of intellectual property laws.
These events gave rise to various important questions of public
concern: was it possible to protect ourselves in some areas of activity,
were health services also going to be liberalized and what would
become of hospitals, pharmacies and clinics?
Trade liberalization had many effects on health, he noted. The
lowering of custom tariffs improved access to medical technology
and made medication available at reduced prices. However,
modification of international regulations governing patents affected
access to essential medicines, and national health regulations and
standards impacted on multilateral trade.
He pointed out that GATS would have implications for the
health sector on at least four levels: transnational supply of services
(e.g. telemedicine); consumption of services abroad (treatment in
another country); commercial presence (creation of health services in
another country); and the brain drain of human resources.
The involvement of countries in the management of these areas
and in measures adopted in response would be beneficial, he said.
Ministries of health should develop their capacity for analysis and
their knowledge of trade issues and their relation to health services.
Collaboration should be strengthened with ministries of commerce
and finance in order to anticipate and predict the impact of WTO
measures.
He congratulated WHO for according priority to the subject
and for having established mechanisms of consultation with the Food
and Agriculture Organization of the United Nations (FAO), United
Nations Conference on Trade and Development (UNCTAD), World
Intellectual Property Organization (WIPO), World Trade

Organization (WTO), etc. Since the Fifty-sixth World Health
Assembly in 2003, WHO had been following developments and the
implementation of the Doha Agreement, especially where they
concerned public health and trade-related aspects of intellectual
property rights (TRIPS).
He pointed out that the meeting came at the right time to help
health services decision-makers, managers and providers to find
answers to their many questions in this field. He concluded by saying
that he looked forward to the thoughts and comments of participants
on the subject, and wished them full success in their work.
UNFPA Representative in Egypt, Dr Faysal Abdel Gadir,
speaking on the occasion, remarked that UNPFA Egypt was pleased
to be part of this collaborative effort and was particularly interested
in seeing progress in this field in Egypt. It was for this reason that
UNFPA had supported a strong team that included Dr Mohammed
Tag El Din, the former Minister of Health and Population of Egypt.
Dr Abdel Gadir stated that UNFPA’s mandate was in the area
of reproductive health and it was interested to see how the
liberalization of international trade in health services would impact
on reproductive health services in Egypt. In addition, UNFPA Egypt
was interested in looking into the broader area of international trade
and health and in being able to assess how other trade agreements
could influence reproductive health policies, such as on access to
contraception, in the country. Finally, Dr Abdel Gadir thanked the
WHO Regional Office for inviting UNFPA Egypt and wished the
meeting complete success.
Dr Raouf Ben Ammar, WHO Representative, Morocco,
delivered a message by Dr Hussein A. Gezairy, WHO Regional
Director for the Eastern Mediterranean.
The objective of the workshop was to share the main policy
findings of 10 country case studies on liberalizing trade in health
services in the Eastern Mediterranean Region within the framework
of GATS, he said. This research-to-policy workshop was the
concluding activity of the Concerted Action for Research and
Capacity Building in the Eastern Mediterranean Region, initiated as a

8 Trade in health services in the Eastern Mediterranean Region
pioneer regional initiative in February 2004 in partnership with IDRC
and UNFPA.
GATS was one of the key agreements of the WTO and had
brought trade in services for the first time within a multilateral
framework. The Agreement aimed to gradually liberalize trade in
services, including health services, carrying significant implications
for the health care sectors of WTO member countries. To date, 10
Member States of the Region were also members of the WTO, with an
additional 6 countries maintaining observer status. While the process
of services trade liberalization had been underway since 1995, much
was yet to come on the health services front, he noted. Liberalization
measures in this sector had been “back-loaded” or postponed, with
the “wait-and-see” negotiations strategy reflecting concern over the
potential impact of liberalization within the multilateral framework
on the health care sector.
Most countries had taken a conservative approach to the
liberalization of trade in health services and the opening up of the
health sector to the forces of globalization. One of the reasons behind
this conservative approach was that the precise impact of
globalization on the health services sector, in terms of efficiency,
access and equity was difficult to evaluate. The need for a rigorous
methodology to capture the impact of this phenomenon was,
therefore, pertinent.
One of the core components of the Concreted Action Plan was
to develop a research methodology, which had been applied over the
last two years in 10 countries of the Region. The policy messages of
these studies should be instrumental in advising negotiators and
policy-makers on where to go next, and on how fast to advance on
the liberalization front. Of no less importance, these country case
studies had been able to provide key guidelines regarding the nature
of the regulatory measures that should accompany the liberalization
process, if it proceeded further.
Trade in health services was not a new phenomenon, he noted.
Traditional modes of trade whereby patients, physicians and students
of medical sciences had been moving between countries in pursuit of

etter services, more prosperous livelihoods or education of higher
quality had long been recorded and documented. More novel modes
of trade such as cross-border supply of health services and foreign
commercial presence were relatively new phenomena. Cross-border
supply of health services had advanced in parallel with advances in
communication and information technologies, and had become
highly prolific, cutting down substantially on the cost of some
medical services. Foreign direct investment (FDI) in the domain of
health services was also on the rise, mainly due to the opening up of
opportunities for the private sector to become an active player in the
provision of health care services, especially in countries where this
sector had traditionally been government dominated.
There was an increased level of interest in assessing the impact
of trade in health services, particularly in relation to public health
considerations. Moreover, the question regarding the merits of
liberalization within a multilateral framework versus unilateral
liberalization, governed by national legislation, had been posed in
most of the studies undertaken. The answers to these two questions
would be debated over the coming few days, and it was hoped that
by the end of the workshop clear policy messages would be available
to policy-makers.
He added that the liberalization of trade in services did not and
should not mean the absence of government regulatory control.
Trade liberalization had its merits, as demonstrated by the case
studies, yet in the absence of regulatory measures that ensured
equality in the provision of health services as well as accessibility in
the aftermath of liberalization, gains from trade may not accrue
equally to all. It was the responsibility of policy-makers to ensure that
gains from trade did not create a duality of health care systems or
create shortages (“brain drain”) that would jeopardize the provision
of essential health services.
He concluded by describing some of the impediments that had
been faced by researchers during their investigations. Data on trade
in health services in the Region was sparse. The fragmented nature of
data on trade in health services had been a key constraint on the

10 Trade in health services in the Eastern Mediterranean Region
evaluation of the impact of liberalization. Further, communication
between health and trade officials over issues regarding trade and
health had not been systematic. Reaching coherency between policies
adopted at both levels was instrumental to a successful negotiations
process, he said. These two issues needed to be addressed by policymakers
so that the liberalization process did not fall short of ensuring
equitable access to health care services, the quality of health care and
the efficient use of resources.
Dr Belgacem Sabri, Director, Division of Health Systems and
Services Development, stated that globalization represented a
challenge to health systems, both in the Region and worldwide. The
opening up of trade in health services provided new opportunities
for health systems while creating new challenges. The Regional
Office, IDRC and UNFPA Egypt had been engaged in the Concerted
Action for Research and Capacity Building in Trade in Health
Services in the Eastern Mediterranean Region since 2004. The purpose
of this joint initiative was to:
• build capacity of researchers and institutions in countries of the
Eastern Mediterranean Region for undertaking research on
trade in health services;
• advance and refine the research methodology for assessing the
impact of trade in health services for countries of the Region
and beyond;
• undertake case studies in countries of the Region to document
trade in health services;
• disseminate the research results among concerned policymakers
and stakeholders to create awareness and elicit
appropriate responses from countries.
Dr Sabri then updated the participants on the main activities of
the project so far, including recruitment of a study coordinator,
refinement of the research methodology and survey instruments,
holding of a research methodology workshop on trade in health
services and the carrying out of 10 country case studies.

Dr Sabri outlined the objectives of the meeting as follows:
• to create increased awareness among national health and trade
policy-makers of the public health implications of trade in
health services;
• to share and debate the findings of the country studies
undertaken on the subject with relevant policy-makers and
stakeholders;
• to review the methodological aspects of undertaking country
studies in trade in health services;
• to develop a shared understanding and a regional strategy and
planned response for liberalization of trade in health services.
The Chairmen of the meeting were Dr Mohammed Tag El Din
(Day 1) and Dr Walid Ammar (Day 2 and 3). The Rapporteurs were
Kevin Eisenstadt, Azza El Shinnawy and Ahmed Mokhtar.
2. Globalization, trade and health
2.1 Globalization, trade and health: WHO perspective
Dr Nick Drager
GATS is one of the most important trade agreements to emerge
from the Uruguay Round negotiations that created the WTO. Services
are one of the fastest growing areas for many economies and services
of many kinds play important roles in the protection and promotion
of health. GATS, therefore, creates numerous challenges for people
working in public health, particularly since it is a complex legal
agreement that borrows from existing international trade law to
create new rules for services. The Agreement has become the subject
of significant controversy, especially with respect to how it will affect
health-related services and health policy.
The debate about the impact of GATS on health policy has
created a “tale of two treaties”. From one perspective, GATS is
regarded as one of the worst of treaties since it is seen to undermine
the exercise of national sovereignty. From another perspective, GATS
is the best of treaties, since it respects health sovereignty through its
flexibility, which allows each WTO member to shape its obligations

12 Trade in health services in the Eastern Mediterranean Region
according to its national needs and interests. This “tale of two
treaties” problem has made it difficult for the health policy
communities to understand how GATS may or may not affect their
work. Risks and opportunities associated with trade in health services
under the four GATS modes of supply are outlined in Table 1.
Table 1. Health opportunities and risks
Mode Opportunity Risk
Mode I
Increased care to remote Diversion of resources from
Cross border
supply of
services
and underserved areas other health services
Mode 2
Consumption
abroad
Mode 3
Commercial
presence
Mode 4
Presence of
natural persons
Generates foreign
exchange earnings for
health services
Creates opportunities for
new employment and
access to new
technologies
Economic gains from
remittances of health care
personnel working
overseas
Crowding out of local population
and diversion of resources to
service foreign nationals
Development of two-tiered
health system with an internal
brain drain
Permanent outflows of health
personnel, with loss of
investment in educating and
training such personnel
It is important to assess the impact of liberalized trade in health
services on access to, cost and quality of health services. Policies and
regulations should be in place to ensure that trade in health services
increases equity in health and is in the interest of those in greatest
need.
The need for progressive liberalization within the GATS
framework means that WHO members face decisions about whether
or not to liberalize trade in services through market access and
national treatment commitments, including trade in health-related
services. In relation to this, the GATS round of liberalization
negotiations will potentially affect health policy in two areas:
evaluating requests from other countries for, and offers to other
countries of, specific commitments for market access and national
treatment; and negotiations on GATS rules.

From the point of view of WHO, managing the GATS process
from a health policy perspective should ensure that:
• liberalized trade in health-related services leads to an optimal
balance between preventive and curative services;
• there is involvement of both private industry and civil society to
ensure that liberalization of health-related services promotes
participatory health policy;
• improving access and affordability of health-related services is
a goal of liberalization of trade in health-related services;
• developing countries, and least-developed countries in
particular, receive special consideration in the process of
liberalizing trade in health-related services;
• the status of health as a human right informs and guides
proposals to liberalize trade in health-related services.
The following set of key questions also needs to be addressed:
• To what extent is the sector already open to foreign service
providers, and what have been the regulatory concerns posed
by existing foreign competition?
• Do the commitments fit the strategies and directions identified
by national health policy?
• What effects will the commitments have on governmentprovided
health services?
• What regulatory burdens will the commitments create for the
government in health-related sectors?
• Will the commitments eliminate or weaken regulatory
approaches necessary for the protection and promotion of
health?
• What evidence and principles can be used to analyse the
possible effect of the commitments?
• Can the commitments be crafted to both protect health policy
and liberalize trade progressively?
Managing the GATS process from a health policy perspective
requires that health principles and criteria should drive policy
decisions on trade in health-related services in the GATS
negotiations. It is worth remembering “who owns the house”: GATS

14 Trade in health services in the Eastern Mediterranean Region
provides countries with choices and does not force them to make
liberalization commitments that are not in their best interests. If a
country is unsure about the effects of making specific commitments,
it is fully within its rights to decline to make legally binding
commitments to liberalize, or to liberalize unilaterally without
making binding commitments.
2.2 Understanding commitments in health services under GATS
Dr Sameen Siddiqi
The purpose of GATS is to: create a credible and reliable system
of international trade rules; ensure fair and equitable treatment of all
participants; stimulate economic activity through guaranteed policy
bindings; and promote trade and development through progressive
liberalization. Liberalization of trade in health services has important
public health implications, with both risks and benefits. Trade
agreements can be multilateral such as GATS, regional (e.g. an Arab
free trade agreement), or bilateral between two countries.
There are certain threshold issues relating to GATS and
national health systems that need to be considered. These include: the
extent of public or private financing in provision of health services;
the extent to which the health system makes a distinction between
national and foreign suppliers; the distinction between trade within
and outside trade agreements; and the need for strong regulation in
the face of liberalization of trade in health services. Most importantly,
and despite some controversy, Article 1.3 of GATS ‘excludes services
in the exercise of government authority’ as they are non-commercial
and non-competitive.
It is important to understand how the health sector is defined
under GATS . Member States can use their definitions, follow the UN
Provisional Central Product Classification (UN CPC), or use WTO
Services Sectoral Classification List (W 120), which has 12 Classes of
Service Sectors. Box 1 shows how the health sector is defined under
W 120. Members can define the scope of the sector and need not
commit the entire sector.

Box 1. How the Health Sector is defined under GATS
Class 8: Health Related and Social Services
Hospital Services
Other Human Health Services
Social Services and Others
Class 1: Business Services
Professional Services
(h) Medical and dental services
(j) Services provided by midwives, nurses and paramedics
Class 7: Financial Services
All Insurance and Insurance Related Services
Life, Accident and Health Insurance Services
The four modes of supply under GATS are: cross-border supply
(when only services cross the border); consumption abroad (when a
consumer crosses the border to receive a service in another country);
commercial presence (when there is FDI in a country to set up a
facility to provide a service); and the movement of natural persons
(when a provider moves to another country to provide a service).
All WTO members have certain General Obligations, the most
important of which is the Most Favoured Nation (MFN) status, which
means treating all WTO members as you would treat your most
favoured nation. Some exceptions to the MFN status are regional
trade agreements, sectoral exemptions and recognition of
qualifications, which has implications for the health sector.
Additional obligations include transparency, review procedures for
administrative decisions and certain basic competition disciplines.
In addition, WTO members make certain modal commitments
under GATS. When these cover a single mode of supply across all
service sectors listed in the schedule, it is called a horizontal
commitment. Sector-specific commitments for each mode can be
made either as “market access” or “national treatment”. A
commitment is a guaranteed minimum treatment to foreign service
suppliers. A commitment under GATS means specifying the extent of

16 Trade in health services in the Eastern Mediterranean Region
market access and national treatment for each service sector and
mode of supply. GATS commitments are binding once locked into.
Countries have choices when making commitments with
regards to the extent of commitment:
• None or full: provides full market access and/or national
treatment for a particular mode (no restrictions)
• Partial commitment: provides market access and/or national
treatment, with restrictions
• Unbound: provides no commitment at all on market access
and/or national treatment for a particular mode.
Countries also have flexibility on the level of liberalization
under GATS, which could be kept at the current level of access, or set
at a more liberal or more restricted level.
Developing countries are not obliged to liberalize trade in
health services and have the flexibility to open fewer sectors,
liberalize fewer transactions, progressively increase market access
and attach conditions in line with national policy objectives. GATS
recognizes the right to regulate, but certain disciplines apply
depending on whether the measure is non-discriminatory (foreign
suppliers and nationals) or discriminatory (foreign suppliers only). If
commitments are made for any mode, discriminatory measures need
to be listed in the national treatment schedule.
GATS allows members to recognize the qualifications of some
members and not others (which breaks the MFN rule), but members
mutually recognizing qualifications need to inform WTO and give
others the opportunity to demonstrate that they also meet the
required standards. Under GATS, members are free to set their own
standards.
Before making any commitment in the health sector, WTO
members should thus consider whether GATS can help achieve any
of the health policy outcomes being sought, how to regulate trade in
health services to achieve the best health outcomes once commitment
is made, and the level of national capacity required to regulate trade
in health services and the measures necessary to improve it.

It is essential to have policy coherence between ministries of
health and trade and other stakeholders before committing. For this
to happen, a mechanism for policy coordination needs to be evolved.
In addition, a solid evidence base is critical in order to understand the
public health implications of GATS and to ensure that these are not
compromised.
2.3 GATS application to health services
Dr Rudolf Adlung
Liberalization (of market access and national treatment) with
respect to GATS should not be taken to be synonymous with
deregulation. GATS recognizes the right of WTO member countries
to regulate and to introduce new regulations to meet national policy
objectives, particularly in the health care sector. Liberalization
through reciprocal exchange of concessions within the GATS
framework is deeper and gains an important element of credibility
through binding commitments.
While GATS is far wider in coverage then conventional trade
agreements, it is extremely flexible in application. Countries have
three possible scenarios. They can opt for having specific sectors not
covered, such as in the case of governmental services and air traffic
control. These sectors are excluded from coverage on the basis that
they are ‘services provided in the exercise of governmental authority’
which, in turn, are defined as services that are supplied ‘neither on a
commercial basis, nor in competition with one or more service
suppliers’ (Article 1:3). They can also opt for specific sectors being
covered with no access obligations. In this case, minimum
(“unconditional”) obligations include MFN treatment, transparency
requirements and some other “good governance” provisions
(availability of legal remedies, etc.), but there is no obligation to open
markets. Governments can also opt for access obligations (“specific
commitments”), which denotes three basic concepts: “market access”
(absence of quota type and similar restrictions), “national treatment”
(non-discrimination with regard to all measures affecting the supply
of a service) and “additional commitments” (plus “unconditional”

18 Trade in health services in the Eastern Mediterranean Region
and '”conditional” obligations). Any limitations must be inscribed in
the Schedules under the relevant modes. Scheduling a sector does not
imply that trade must be liberalized across all modes. Specific
commitments may vary across a spectrum between “unbound” (no
commitment) and “none” (no limitation/full commitment). Specific
commitments can be in a selection of sectors in which limitations are
inscribed as less than status quo, the status quo or more liberal than
the status quo.
Of the 10 country studies: Lebanon, Sudan, Syrian Arab
Republic and Yemen are not WTO members; Egypt, Morocco and
Tunisia are members without commitments on Medical and Hospital
Services; and Jordan, Oman and Pakistan are members with
commitments, Jordan and Oman in Medical and Hospital Services,
and Pakistan in Hospital Services.
The time-frame regarding trade in services negotiations is as
follows: initial offers were submitted on 31 March 2003; revised offers
on May 2005; and plurilateral requests on 28 February 2006. The
second round of revised offers is to be submitted by 31 July 2006 and
the final draft schedules by 31 October 2006.
2.4 Trade and health: a tool kit for analysis and assessment of
countries
Dr Nick Drager
For a country analysis of the trade and health situation it is
important to identify: the priority trade and health issues, including
the policy and regulatory framework; any trade in health goods and
health-related services; any trade agreements and ongoing
negotiations; the institutional capacity to manage trade liberation;
and the elements of domestic policy coordination.
Country experiences in ensuring national policy coherence with
respect to trade liberalization in the domain of health services include
establishing inter-ministerial committees, appointing dedicated staff
in ministries of health to work on trade issues and in ministries of
trade/commerce to work on health issues, consultation with
stakeholders, developing the research and evidence base, and
technical cooperation with international organizations.

WHO and WTO collaboration to support successful policy
coherence has included high-level policy consultations, governance
meetings, research and analysis, country missions, regional/national
meetings, training courses and informal consultations.
To achieve trade and health policy coherence for human
development, governments need to: develop a common
understanding of the key trade and health policy issues through
ongoing dialogue; have a clear commitment and ministry of health
leadership to work towards trade and health policies that mutually
support human development objectives; create sustainable
institutional mechanisms to enhance coherence and use innovative
instruments and appropriate incentives; ensure early and effective
stakeholder involvement, build trust and recognise the importance of
transparency; get the evidence right, develop costing and financing
options, and propose alternatives; measure, track and evaluate
progress, and make course corrections; and develop negotiation
skills. The WHO website on globalization, trade and health
(www.who.int/trade/) can support countries in these challenges.
2.5 Discussion on presentations
There was discussion about the possible conflict between
liberalization and the ability to regulate the provision of health
services at the national level. Globalization poses a credible threat to
national health care systems, it was felt. So far there has been very
little analysis of the costs associated with liberalization. The ‘right to
health’ should be a guiding ‘lens’ to govern the liberalization process.
The liberalization of health services can be looked at from two
perspectives, the economic perspective and the health perspective,
that are completely different in terms of the challenges and
opportunities posed. What should concern policy-makers is the
health outcome of liberalization, and this should take precedence.
It was felt that WHO should provide assistance to countries in
the process of acceding to the WTO. There is a need to identify a few
indicators by mode in order to evaluate the nature of the impact of
liberalizing trade in health services on national health care systems.

20 Trade in health services in the Eastern Mediterranean Region
Other important issues include dispute settlement mechanisms and
how to operationalize them.
The right to health should be a guiding principle with regards
to the impact of globalization on health services, it was felt. However,
so far the evidence has not been encouraging. The issue of human
resources and the scarcities created as a result of the movement of
health care professionals has become increasingly important. There is
a possibility that governments’ are reducing their investment in
medical services, in parallel to increased reliance on the private
sector, both foreign and local. It was also noted that no country had
scheduled commitments in the domain of health for a long enough
time period to properly evaluate the nature of the impact created.
The impact of former liberalizing efforts such as structural
adjustment has shown that the costs may well be high and this calls
for caution. A concise assessment of the benefits for a country of
joining the WTO is needed. There is also a need for a more focused
methodology with regards each particular mode of supply. The
identification of priority areas in relation to trade and health services
is required. When discussion of trade and health services takes place,
the focus tends to be only on tertiary services, rather than on primary
and secondary health care, the services that help the poor. There is
therefore a need to evaluate how trade in health services can improve
both primary and secondary health services. There is also a need to
integrate the provision of these services at the regional level.
Developing countries may be best advised to ‘wait and see’
what the outcome of liberalization will be before committing.
However, some felt that developing countries are best advised to
schedule their commitments to reflect the status quo. That developed
countries are refraining from opening up their health services sectors
to the forces of globalization, should be taken as an indicator of the
risks that may even go beyond the abilities of these countries.
Negative examples have been seen of privatization in the social
sectors. The health care sector has a different status to other of
economic or social sectors, and this special status almost always
negates free trade.

The nature of the assistance WTO is providing to developing
countries in the domain of services trade liberalization was discussed.
Apart from multilateral trade agreements, bilateral free trade
agreements (FTAs) are also booming, so WTO advice to countries
negotiating on FTAs is needed. It is important that countries are
informed on rules-based negotiations.
Commitments in services have proven to be positively linked to
FDI flows and the quality of services, particularly for sectors such as
telecommunications. However, in the case of health services, the
situation has proven to be different, because of the sensitivity of the
sector.
When countries decide to schedule their commitments in any of
the services sectors this ‘locks’ these commitments for increased
credibility. WTO has seem some 100 trade disputes, but only two
concerned services, indicating that GATS has worked more smoothly
than any other agreement. However, small countries still have
problems translating autonomous liberalization into commitments
under the GATS framework, and this is where technical support is
needed. WTO is just an umbrella organization, and the decision to
commit is in the hands of governments, with WTO being more like a
notary. WTO can however provide technical assistance through
various missions and seminars. The Aid for Trade initiative adopted
at the Hong Kong ministerial meeting is meant to help institutionbuilding
in developing countries.
It was pointed out that regional and bilateral trade agreements
should be notified to WTO. In these agreements countries give more
than in the MFN approach and with no safeguards. The extent to
which bilateral and regional trade agreements take countries away
from the GATS agenda was noted. However, FTAs have become an
important foreign policy issue.
The WTO negotiations process was discussed from an equity
perspective. The role of government in the health care sector in
relation to both globalization and liberalization was raised, because
the market has been shown to fail in the health sector. Countries
should not rush to liberalize as there is no conclusive evidence

22 Trade in health services in the Eastern Mediterranean Region
regarding impact. There is a need to carry out more studies on trade
and health in relation to liberalization under the multilateral
framework and a need to analyse these results within the context of
national policy objectives. Countries need to ensure that the benefits
from trade in health services trickle down to the poor. At this early
stage it is not possible to describe clear benefits.
However, countries are under increased pressure to liberalize,
and therefore may not be able to ‘wait and see’. There is therefore a
need to feed the results of the country studies undertaken by the
Regional Office into the policy debate through national policy forums
on trade and health.
3. Regional experience in trade in health services
3.1 Methodological framework for assessing trade in health
services
Azza El Shinnawy
The lack of information regarding the nature and extent of trade
in health services and the risks and opportunities associated with
each of the modes of supply, as well as the limited research capacity
in academic institutions for undertaking research on trade in health
services, was the driving force behind the WHO, IDRC and UNFPA
Concerted Action for Research and Capacity Building in Trade in
Health Services in the Eastern Mediterranean Region.
The core components of the methodological approach included
a review of the overall macroeconomic and trade environment and
the domestic health system to provide the contextual basis for the
assessment of trade in health services. Among the key issues
investigated were: whether trade liberalization is part of the country’s
development strategy; the trends and regulation of FDI; the
organization and financing of the health care system; the major health
care challenges of the country; and possible sources of information.
Under each of the supply modes, detailed questions were posed
addressing the current status of trade in the mode, existing and
proposed GATS commitments in the mode, national policy in relation

to the mode and the regulatory regime for the mode. For example, for
mode 1, questions addressed the current status of trade in mode 1,
existing or proposed GATS commitments under mode 1 in health
services, national policy on e-Health, the nature of the infrastructure
and regulatory capacity, the regulatory regime for e-Health and the
situation of information technology (IT) infrastructure. A note about
data availability and sources of information for each mode was also
included.
An important part of the methodological approach was the
review of national legislation and the regulatory framework
governing trade in health services under the four modes of supply in
order to identify the market access conditions that are in place as well
as exemptions to national treatment. The methodological framework
also presented a list of possible sources from which to collect
information and data regarding estimates of the value and direction
of trade in health services with respect to the four modes of supply
under GATS.
One of the core components of the methodological framework
was the analysis and assessment of the level of country commitments
for providing and/or seeking market access to health services, as well
as an assessment of the challenges and opportunities posed by the
liberalization of trade on the provision of health services and options
for national policy-makers.
The matrix of challenges and opportunities presented in the
methodological framework was the basis for the analytical part of the
country case-studies. The matrix presented a check list of possible
implications of liberalising trade in health services which formed the
basis for advising policy-makers on the pace and scope of
liberalization under the GATS framework.
Some key questions considered include:
• How will GATS legally affect the country’s health policy?
When, and how best, might negotiations be undertaken?
• What is the single most important issue in determining whether
to commit under GATS?

24 Trade in health services in the Eastern Mediterranean Region
• How might a country best obtain the information necessary to
inform policy?
Discussion
The idea that trade in health services is a governance issue of
national security was discussed, as was the concept of global health
governance and the leading role of WHO within this. The need for
health systems to put their “house in order” in order to mitigate the
bad effects of trade in health services was also discussed.
The costs and benefits of joining or not joining the GATS were
discussed. It was noted that the status of newly acceded members’
(like Oman and Jordan) is different from that of the older members.
However, while commitments may be made under pressure and
countries have to “pay” a lot, non-members are excluded from tariff
reductions except through bilateral/regional agreements. It was
explained that GATS allows countries to specify what they want to
commit on and that health services can be excluded. It was noted that
there are also bilateral/regional agreements that exist outside the
WTO framework and it was clarified that Sudan and Yemen are
currently under accession to WTO.
The methodology used in the country case-studies was
discussed and it was felt that there is a need to investigate trade in
health services in terms of its impact on health services as well as on
the determinants of health (including poverty and economic growth).
It was noted that there has not yet been enough time to assess the
impact on health, which could take many years to measure.
It was felt that the focus should be on obtaining evidence that
trade liberalization is good for health and that in the absence of such
evidence it would be best for countries to adopt a “wait and see”
approach to GATS. However, it was pointed out that trade in health
services was already happening before GATS and therefore there is
no new impact issue. A key question to address, it was suggested, is
whether “open” or “non-open” health systems perform better. To
measure this, indicators are required (by Mode) for openness and

performance. There is a need to focus on the impact in specific areas
of concern; in this regard, a country-focus on different areas could be
useful.
It was explained that the methodology book had been refined
and adapted for the Region from a WHO headquarters version, and
included a set of questions on health context, trade and health policy.
The methodology was defined to encourage analysis and
interpretation, as well as policy recommendations, not just data
collection. It was observed that the issue was not just one of asking
the right questions but is also about identifying the right sources for
the answers, of which there are many, often outside the Ministry of
Health. There is no single source or nodal point, and this necessitates
initiative.
It was felt that the methodology needed to take into account the
position of he different stakeholders, including hospitals, consumers,
health insurance, physicians etc. It was noted that some countries,
such as Malaysia, have done this and that some have set up websites
to support the process. There are also conceptual issues that need to
be further addressed, such as under which Mode to categorize some
health services (for instance, visiting medical teams in Sudan). A
concept workshop could help to improve the conceptual basis of the
methodology. It was acknowledged that the methodology is a
working methodology and will be further refined.
3.2 Challenge of assessing trade in health services: experience from
the Eastern Mediterranean Region
Dr Sameen Siddiqi
The Eastern Mediterranean Region covers 22 countries and has
a population of approximately 500 million. The proportion of the
population aged less than 15 years is 40% and the dependency ratio is
79%. Overall, the Region is a low middle-income region with a GNP
per capita of US$ 1700 and contains five of the least developed
countries. The Region faces several challenges in the area of trade in
health services:
• a lack of understanding and information on the nature and
extent of trade in health services;

26 Trade in health services in the Eastern Mediterranean Region
• limited research capacity of institutions;
• the need to place trade in health services on the health policy
agenda and evolve a planned response;
• the need to assess the implications of trade in health services on
public health;
• the need for countries to develop strategies to both protect the
public health interest and maximize the benefits of trade
liberalization.
Pakistan, Sudan and Yemen are low-income countries. All
three, by and large, promote market-driven policies, liberalization
and deregulation and favour an open trade regime. All have liberal
laws to encourage foreign investment and all underwent World Bank
and International Monetary Fund-led stabilization and structural
adjustment programmes in the 1990s. For the middle and upper
middle-income countries of Egypt, Jordan, Morocco, Oman, Syrian
Arab Republic and Tunisia there has been a progressive shift from an
over-regulated to a market-oriented economy since the 1980s,
progressive trade liberalization, encouragement for FDI, free trade
agreements with other Arab countries and neighbours, and a reliance
on services sectors, especially tourism and foreign remittances. In the
Syrian Arab Republic there have been trade protectionist policies
with strong central planning. Lebanon has long had a liberal trade
regime, promoting extensive privatization, even in the social sectors,
and banking and tourism are the leading services sectors.
Table 2 provides an overview of the state of the domestic health
sector in the countries studied, while table 3 gives a summary of their
membership status and schedule of commitments to GATS in the
health sector.

Table 2. State of health sector in country studies
Areas Low income countries Lower middleincome
countries
Upper middleincome
countries
Governance Limited capacity for evidence-based policy formation and strategic
planning
Inadequate capacity to legislate, regulate and enforce rules and
regulations
Financing Inadequate allocation
to health
High share of out-ofpocket
payment
Absence of social
health insurance
programmes
Human
resource
development
Service
provision
Health
information
Poor capacity for
human resources
planning
Inappropriate skill mix
Lack of trained health
and hospital managers
Accreditation system
not functional
Primary health care not
universally accessible,
basic package of health
services absent
Weak district health
system, poorly
functioning drug
supply/referral systems
Inadequate recognition
of private sector role
Poorly functioning
management
information systems
Burden of
disease/national health
account not assessed
Limited capacity for
health services research
Absence of
universal coverage
High share of outof-pocket
payment
Inefficient social
health insurance
programme
Poor capacity for
human resources
planning
Inappropriate skill
mix
Deficient cadre of
health managers
Accreditation
system not fully
functional
Inadequate
scheme for
universal coverage
of expatriates
Heavy reliance on
expatriate human
resources
Policies that
promote national
health workforce
Inadequate focus of primary health care
programmes on quality, responsiveness
to changing burden of disease and
needs of aging population
Escalating costs of health care/
medicines
Weak regulation of investment in
complex centres, inappropriate use of
technology
Management information systems
needs strengthening
Burden of disease/national health
account not institutionalized
Limited capacity for health services
research

28 Trade in health services in the Eastern Mediterranean Region
Table 3. WTO membership status and schedule of commitments to
GATS in health sector
Country Medical and
dental services
Nurses,
midwives,
etc.
Hospital
services
Other
human
health
services
Egypt X
Jordan X X X X X
Lebanon In process of accession to WTO/observer status
Morocco No commitment in health sector
Oman X X
Pakistan X X
Sudan In process of accession to WTO/observer status
Syrian Arab
Republic
Not a WTO member
Tunisia No commitment in health sector
Yemen In process of accession to WTO/observer status
Notes X = commitments made
∗ = includes heath insurance, professional services
Other
relevant
health
sectors∗
In terms of the overall status of the trade in health services for
the four modes of supply in the case-study countries, none of the
countries had a well developed tele-health services programme under
mode 1 (cross-border supply). However, the Ministry of
Communication and the Ministry of Health and Population in Egypt
have recently launched a large initiative to develop the first telemedicine
network.
Mode 2 (consumption abroad, popularly called “medical
tourism”) is important in the Region with many countries being net
exporters and others net importers of health services. For instance,
patients travel in large numbers from Yemen and Sudan to consume
health care aboard, while Jordan is the leading promoter of medical
tourism in the Region; 120 000 patients sought medical services in
Jordan in 2002, generating an estimated revenue of US$ 620 million.

For mode 3 (foreign commercial presence), in 2004, foreign
direct investment in Jordan’s hospital sector reached US$ 8.6
million. Foreign investors are treated equally with Jordanians in
terms of all rights and privileges awarded, except that non-
Jordanians need to deposit bank drafts of no less than JD 50 000.
Examples of FDI are also common in Egypt, such as the Dar-El-Fouad
Hospital, which has a large foreign equity holding, and the Al-
Maghraby hospitals and centres. In Pakistan, the Shifa International
Hospital in Islamabad is an investment by Pakistani Americans.
There was no evidence of FDI in health so far in Morocco, Oman,
Sudan and the Syrian Arab Republic.
In mode 4 (movement of natural persons) Egypt, Jordan,
Pakistan, Sudan and Tunisia are net exporters of health workforce,
while Oman, like all Gulf Cooperation Council countries, is a net
importer.
There is lack of policy coherence between ministries of trade
and ministries of health in most countries. The Ministry of Commerce
in Pakistan has a special WTO wing but collaboration with the
Ministry of Health is weak. Oman has established a Higher
Committee for WTO issues and the Ministry of Health is a permanent
member, while in Jordan the Ministry of Health works closely with
the Ministry of Industry and Trade and the Ministry of Tourism and
Antiquities to promote medical tourism.
The lessons learnt from undertaking the case-studies can be
summarized as follows: public health professionals need to learn the
trade jargon and understand trade and health issues before
embarking on studies; the methodological framework is a useful
guide to undertaking trade in health services studies, but innovation
is required while collecting data; it is critical to share trade in health
services messages with national policy-makers; and analysis of trade
in health services should address how to ensure that public health
interests are not compromised in favour of trade liberalization.
In conclusion, most countries of the Region have an explicit
trade liberalization policy which impacts on health services. Modes 2
and 4 are currently the most important modes of trade in health

30 Trade in health services in the Eastern Mediterranean Region
services in the Region. However, it is important to note that most
trade in health services in the Region takes place outside GATS. It is
essential that there is policy coherence among the ministries of health
and ministries of trade in partnership with civil society. Finally,
despite the limited data, health policy-makers now have greater
awareness of the public health implications of trade in health services
and GATS.
3.3 Egypt
Azza El-Shinnawy
Egypt is the second largest economy in the Middle East and
North Africa after Saudi Arabia, with a GDP of 594 billion Egyptian
Pounds (LE) (US$ 104 billion). It is classified as a lower middleincome
economy and is one of the most densely populated countries
of the Region. Egypt is a labour surplus economy, and is a major
exporter of labour services to the Region. Some 1.9 million Egyptians
are working abroad as temporary migrants. The Egyptian economy is
also a service dominated economy, whereby services account for
close to 47% of GDP.
Despite Egypt’s commitments in several of the services sectors
under the framework of the GATS, significant liberalization in the
services sector has yet to materialize. Given the low sector coverage
of commitments, and the relatively restrictive measures which apply
to foreign commercial presence and natural persons in the scheduled
sectors, a commitment to full service liberalization is not evident.
Under the current stage of liberalization within the GATS
framework, Egypt did not schedule health services in the Revised
Conditional Offer. In the previous offer, only the health insurance
sector was opened.
It is difficult at this stage to quantify the exact magnitude of
trade in health care services under mode 1. However, many hospitals
surveyed had contracts with medical centres aboard to provide
consultations through electronic mediums.
With regards to mode 2, medical tourism is estimated to
account for 2.5% of all incoming tourists to Egypt (4.3 million). As for
Egyptian patients treated aboard (at government expense), the

numbers have gone down from 854 in 1994 at a total cost of LE 57
million, to 240 in 2004, at a total cost of LE 20 million, reflecting an
import substitution policy in this domain.
Medical students studying in Egypt at national universities
account for 8.1% of all foreign students (6000), while dentistry
students account for 3.9% (2001/2002). Students from Arab countries
account for 92% of all foreign students in Egypt. In private
universities, the number of total foreign students has reached 4600,
accounting for 28% of the student body: 25% study dentistry, 16%
study medicine and 5.5% study pharmacy. Arabic studies accounts
for 98% of foreign students in private universities.
With regards mode 3, the current regulatory framework in
Egypt is very liberal. Investment Law 8/1997 provided generous fiscal
incentives to foreign investors to operate within the domain of
hospital services (provided that 10% of capacity is available free).
There is no ceiling on foreign equity share, no restrictions on land
acquisition (except agricultural land) and no ceiling on the number of
foreign employees. The outcome has been a significant inflow of
capital (foreign and local) in Egypt’s hospital sector.
As for mode 4, which is of particular importance to Egypt
according to the Egyptian Ministry of Manpower, Employment and
Immigration, health care services, including physicians and nurses,
are among the most sought-after professions in neighbouring Arab
countries. With regards to foreign professionals practicing in Egypt,
Law 70/1996 regulates the provision of diagnostic and treatment
services by foreigners in Egypt. The law clearly outlines the
conditions under which private and public hospitals or clinics are
allowed to utilize the services of foreign health professionals. Prior
authorization is needed from the Ministry of Health and Population,
based on the precondition that the service provider holds a
distinguished track record in his/her domain and that no such
expertise is available locally. The contract with the service provider
cannot extend beyond three months and he/she cannot have a permit
to work twice in Egypt during a single year. In 2005, 71 foreign
medical experts provided their services in Egypt.

32 Trade in health services in the Eastern Mediterranean Region
3.4 Jordan
Dr Riyad Amin Okour and Dr Ratib Hinnawi
The total population of Jordan is 5.35 million (2004), with a
population growth rate of 2.8%. The proportion of people over 65 has
been increasing and is expected to reach nearly 4% of the total
population by 2015.
Health care services in Jordan are provided by a complex
amalgam of providers, mainly in the public sector, which includes the
Ministry of Health, the Royal Medical Services and two university
hospitals. The Ministry of Health provides primary, secondary and
tertiary services through a network of health centres, maternal and
child health centres, and hospitals. It runs 29 hospitals distributed
throughout the country with 3500 beds, representing a third of
hospital beds in the country.
In 2001, total health care expenditure was estimated to be 598
million Jordanian Dinars (JD), which accounted for 9.6% of GDP:
public health care expenditure was 3.5% of GDP, while private health
expenditure was 5.6% of GDP. Per capita health care expenditure was
JD 115.4. Public sector health expenditure accounted for 45.0% of total
health expenditure, private 48.7%, UNRWA 1.3% and
nongovernmental organizations 5.1%. The total (private) out-ofpocket
expenditure on health was JD 242 million in 2001. The
Ministry of Health is the major provider and financing agent within
the public health system.
With regards to trade in health services, mode 1 is practiced in
Jordan on a limited scale. In the public sector it is not practiced yet,
but the Ministry of Health is planning to utilize telemedicine. The
Ministry has limited programmes on e-health and e-learning in
selected areas of Jordan, but this experience is still in its first stages,
and data are not yet available.
In mode 2, Jordan has a reputable health care system and the
private sector has gained a reputation as a centre of excellence for
many subspecialties including cardiovascular surgery,
transplantation, plastic surgery and cancer treatment. Reliable data
on the extent of movement of Jordanian nationals for health services

abroad is difficult to obtain. Patients are covered by the Ministry of
Health insurance scheme. During 2003, 32 cases were treated abroad
at a total cost of US$ 1 million. These cases were treated mainly in the
USA and UK.
With regards to medical tourism in Jordan, over 100 000 non-
Jordanian Arab patients are treated annually in Jordanian medical
institutions, particularly in the highly advanced fields of coronary
care and kidney, brain and eye surgery. Yearly revenues from visiting
patients varied from JD 450 million to JD 500 million between 2000
and 2005. In terms of the nationality of patients, Yemenis account for
30%, Libyans for 20%– 25% and Sudanese for 20%. Other patients
come from countries such as Algeria, Iraq, Palestine, Saudi Arabia
and other GCC countries, and Tunisia.
The success of Jordan in attracting this large number of patients
in mainly attributed to the health system performance indicators that
reflect a more advanced system with a physicians to population ratio
that is much higher than other neighbouring Arab countries.
Hospitals are also well-equipped with a high level of technology.
Doctors’ fees for most medical procedures and other health care
services are moderate and are cheaper than regional competitors by
about 30%. Jordan also has medical cooperation protocols with
Algeria, Libyan Arab Jamahiriya, Sudan and Yemen.
Jordan's future strategy for medical tourism includes: attracting
140 000 patients by 2010, including more Arab patients and other
patients from Europe and Africa; promoting investment and high
standards in the health care sector (hospitals, specialized health
centres) to maintain the medical tourism industry; and increasing
revenue from medical tourism to JD 1 billion.
For mode 3, the market access limitations on trade in health
services in Jordan include: one of the owners must be a physician
except in a public limited company; at least three-quarters of
physicians in any hospital or nursing/convalescent homes must be
Jordanian nationals and at least half of all staff must be Jordanians;
for other health services, especially medical laboratories, the director
must be a Jordanian national; external investors are treated the same

34 Trade in health services in the Eastern Mediterranean Region
as Jordanians in terms of rights and privileges, although non-
Jordanians should have bank draft of not less than JD 50 000; and in
the hospital sector, foreign investors can have 100% property
ownership.
With regards to mode 4, there are no general restrictions on the
temporary movement of labour from Jordan to other countries.
However, due to recent concerns of labour shortages in public health
care, especially in nursing and specialized medicine, the Ministry of
Health has placed temporary restrictions on these groups moving
abroad. There is concern about a permanent “brain drain”, especially
given large incentives to work in countries such as the UK. It is
difficult to assess the flow of money into Jordan as a result of
remittances made by Jordanian professionals working abroad.
It is recommended that Jordan: establishes units within the
Ministry of Health to tackle the issues of trade in health services and
to strengthen the capacity of all professionals concerned; carries out
more in-depth situation analysis for various aspects of trade and
investment in health services, preferably a survey at the national
level, and secures the needed human and financial resources for this;
ensures policy development, strategic planning, regulations and
legislation to manage and empower trade in health services;
strengthens and promotes partnership among stakeholders, including
the private sector, academia, nongovernmental, organizations, UN
agencies (especially WHO) and other sectors such as commerce and
industry; raises awareness among health professionals, mid-level
mangers and community leaders; benefits from opportunities offered
by trade in health services such as generation of foreign exchange
earnings for health services, creating opportunities for new
employment and access to new technologies and economic
remittances of health care personnel working abroad; and avoids or
minimizes risks such as brain drain and diversion of resources from
other health services through better regulation and wise decisionmaking.
It is also recommended that the Regional Office initiates a
regional forum on trade and health for the provision of guidance,

capacity building, regional networking and supporting different
activities undertaken within the trade and health framework.
3.5 Lebanon
Dr Nabil Kronfol
Lebanon has a population of 4 million, with an annual growth
rate of 1.7%. There is an 89% literacy rate and a 15% unemployment
rate. Total health expenditure is US$ 2 billion (12.3% of GDP), and
there is a per capita health expenditure of US$ 500. Public sources
account for 18% of the total, households 70% and pharmaceuticals
25%. Public providers include National Social Security Fund (26%),
the Cooperative of Civil Servants (4.4%), the military (11.2%) and
Ministry of Health as the insurer of last resort/safety net (43%).
With regards to trade in health services under mode 1, the
following initiatives exist: World Care, MedNet, e-learning (Arab
Open University, courses, conferences) and e-commerce (Euro-Med
initiative to develop the legal and regulatory framework and to
promote development of e-commerce).
For mode 2, there are no restrictions on travelling abroad. In the
past, a trend existed to seek care in the Syrian Arab Republic (tests,
dental care). Active steps have been taken to support medical tourism
by both the government and the private sector. The flow increased
after September 2001 and there has been active marketing by
hospitals. About 5% of patients are foreigners, mainly Syrian Arab
Republic nationals and citizens of GCC countries.
In relation to mode 4, there is a serious problem of nursing staff
shortages and a lesser one for doctors. There are restrictions on
medical doctors moving to Lebanon due to professional requirements
that need to be met in order to practice. There is a moderate inflow of
nurses from the Philippines.
Recommendations for mode 1 include: improving the
telecommunication infrastructure and internet access; promoting egovernment;
establishing the legal framework for e-commerce;
responding to security concerns; raising business awareness of the
benefits of e-commerce; provision of academic programmes on ecommerce
law; establishing programmes to assist in capacity

36 Trade in health services in the Eastern Mediterranean Region
building, encourage internet usage, improve IT skills and improve
knowledge of customers/suppliers; health institution cooperation in
the development of telemedicine and e-learning both nationally and
regionally; and health insurance involvement through development
of telemedicine-based second medical opinions.
Under mode 2, medical tourism has been encouraged in many
countries of the Region, giving rise to health competition. It is
recommended that there should be provision of quality medical care
at competitive prices and recognition of the importance of pricing
(flat rates, prospective payment modalities) to encourage the flow of
patients and students to educational establishments in Lebanon.
In terms of mode 3, FDI in the health sector has been small,
unlike other sectors, and health insurance in the Region is still in the
development stage. It is therefore recommended that government
oversee good practices in this sector to protect the consumer.
International competition ought to be encouraged to protect patient
interests and FDI encouraged to enter into partnership with (or buy
into) existing family-owned facilities. Listing establishments on the
Beirut stock exchange should be considered.
For mode 4, it is recommended that Lebanon should recognise
that restrictive measures have not been helpful in any country. There
is a need to produce a greater number of nurses, and to retain them
through provision of better job opportunities and work conditions to
minimize the “push" factors. However, new employment
opportunities exist in the Region and human resources should be
viewed as “movable assets”.
3.6 Morocco
Professor Lahcen Achy
Morocco is a middle income country, where GDP per capita is
less than US$ 1700 (2004). The population is more than 30 million, life
expectancy at birth is almost 70 years, the maternal mortality ratio is
227 per 100 000 live births and the under-five mortality rate is 48 per
1000 live births. Total expenditure on health is almost US$ 60 per
capita (more than 5% of GDP), while out-of-pocket payments
(household direct payments) stand at 52% of total health expenditure.

Between 30%–35% of the population are covered by mandatory
health insurance.
Under mode 1, substantial efforts are needed to improve
training about, and access to, electronic resources for health care
professionals. Cross-border supply of health services is still in the
experimental stage and the regulatory regime for e-commerce is
currently in preparation. However, a draft law has been prepared to
deliver full-scale e-commerce transactions. Morocco’s comparative
advantages under mode 1 are largely based on geographical
proximity with Europe, close linguistic and cultural ties with some
European countries and the emerging “call centre” sector that is a
good starting point for other IT-related services including e-health.
Under mode 2, National Fund of Social Protection
Organizations (CNOPS) data indicates that in 2001, 500 patients were
sent abroad for specialized health care and surgical treatments;
transfers to cover their health expenses amounted to US$ 2.25 million.
Consumption of health services abroad declined between 1993 and
2002, with the share in total reimbursements by CNOPS declining
from 32% in 1993 to 4% in 2002. France is the main destination of
Moroccan patients seeking health care services abroad. Foreign
exchange worth US$ 4.8 million has been legally transferred by
institutions and individuals for health purposes (medical insurance
amounting to 50% and the rest being mainly out-of pocket money).
With regards to mode 3, the health sector is currently not open
to FDI. Only physicians who have fulfilled the requirements for
practicing medicine in Morocco may establish private clinics and
comparable medical facilities. Morocco has no commitment under
foreign commercial services in health services. Insurance is an
exception, but commitments were made under financial and
insurance services.
Under mode 4, Morocco has made no commitments on the
movement of health professionals. However, for foreigners to be able
to practice in Morocco, they have to have permanent residency in
Morocco, be the spouse of a Moroccan national or have a bilateral
agreement with one, or have government authorization.

38 Trade in health services in the Eastern Mediterranean Region
Morocco is committed to the opening up of trade in health
services and hence legislation should evolve to support this. Building
capacity and fully understanding GATS provisions and the
implications of any form of liberalization on the national health
system are crucial prerequisites. A national forum on trade and
health is recommended to be established to provide an opportunity
for all stakeholders to voice their interests and concerns, and identify
areas of possible gains or losses that may arise with the opening up of
trade in health services.
3.7 Oman
Dr Batool Jaffer Suleiman
Oman is an upper-middle income country with a population of
2 340 000, including 1 782 000 nationals. In 2003, GDP was 8302
million Omani Rials (OR) and per capita GDP was OR 3547. Ministry
of Health expenditure per capita was OR 73.4 and formed 5.4% of
overall government expenditure.
Over 95% of the population have access to the public health
system, and services are free for all Omani nationals, government
employees and some other categories. There is an annual registration
charge of US$ 2.58 and a nominal outpatient department visit fee of
US$ 0.52. Most private hospitals and clinics are local ventures.
Oman became a member of the WTO on November 2000.
Modes 2 and 4 are currently the two active modes of trade in health
services in Oman. There are no commitments in GATS mode 1 which
is in a very nascent stage, although tele-education and tele-medicine
will start soon. However, under mode 2, there is an outward
movement of consumers (students and patients). The government
sponsors Omani patients for treatment abroad; in 2002, the treatment
abroad rate was 22 per 100 000 population. Omani patients may also
go abroad for special treatment at their own expense.
In terms of mode 3, there is no clear evidence of FDI in the
health sector. Foreign suppliers are allowed to establish a presence in
Oman as long as there is an Omani share of at least 30%. Companies
with foreign equity of up to 70% pay the same rate of taxation as
wholly Omani-owned companies. There is a 20% limitation on

foreign personnel. As for mode 4, Oman continues to be a net
importer of qualified health professionals and teachers, and there is
import of health-related materials (drugs, vaccines, medical
equipments, etc.). The attrition rate for Omani doctors stands at 1%.
It is recommended that additional financial resources are
identified to help reduce the burden on the Ministry of Health
through cost-sharing and that the salaries of Ministry of Health staff
are improved in order to maintain a high quality health care system.
Incentives should be provided to attract FDI and human resources to
remote areas.
The Ministry of Health should maintain data for all patients
sent for treatment abroad (sponsored and non-sponsored) and the
volume of FDI should be identified by maintaining information about
the true owners of private sector health institutions. Research should
be done on the value and volume of the current and expected modes
of trade in health services.
3.8 Pakistan
Dr Zafar Mirza
Pakistan is a low income country in which the share of trade in
GDP is 15.5%. In 2004, more than 65% of exports were manufactured
goods. Pakistan is one of the founding members of the GATT and
WTO, and the current trade policy formulation is based on marketdriven
policies, liberalization and deregulation.
More than 50% of the population is under 19 years of age and
around 30% people live in absolute poverty. Pakistan has the sixth
largest burden of tuberculosis in the world, 25% of births are low
weight and 65% of women of child-bearing age are anaemic. The ratio
of public : private expenditure on health is 22 : 78.
Pakistan's schedule of commitments under GATS covers 47
activities which fall under 6 service groups, including health-related
and social services.
Pakistan has only made commitments under the hospital
services sub-sector, which means that Pakistan is committed to allow
private hospitals services to be established in Pakistan by foreign
nationals/companies (mode 3). A mix of modes exists in the supply of

40 Trade in health services in the Eastern Mediterranean Region
medical and dental services. There is an overlap between hospital
services, medical and dental services, and movement of natural
persons as in most cases these are interdependent.
Before the GATS commitments there existed an outflow of
students and health professionals going abroad for studies/training
and patients for treatment. A limited number of medical and allied
students came to Pakistan from neighbouring countries, the Middle
East and Africa.
Capacity building needs to be done in the Ministry of Health on
trade issues and in the Ministries of Commerce and Foreign Affairs
on health policy issues. The Ministries of Health and Commerce need
to work together, and national priorities need to be set clearly and
adhered to strongly. Before making any further GATS commitments,
an equity-based impact analysis needs to be done. Further research is
required in this area.
3.9 Sudan
Dr Mounif Babikar
Sudan is in the process of acceding to the WTO. In the domain
of health services, Sudan has offered to open the following services:
• Medical and dental services: specialized medical services where
no limitations were placed concerning national treatment or
market access, except for commercial presence. Commercial
presence is made subject to an economic needs test based on the
availability of services in the location concerned. No
commitments are made concerning the movement of natural
persons.
• Veterinary services: same as above.
• Health related and social services: hospital services (private,
for-profit only). Commitments concerning cross-border supply
and movements of natural persons were not made.
Establishment of hospitals is granted taking into account, inter
alia, the degree of specialization, geographical spread and the
medical needs of the location concerned.
• Other human health services: Sudan has only made
commitments on some and not all services listed under this

sector/sub-sector. No limitations are put on consumption
abroad or commercial presence, but no commitments are made
concerning cross-border supply and movement of natural
persons.
Opening up the health care sector will present the opportunity
for improvement of service quality through increased competition
and retention of trained nationals within the country by offering
better employment opportunities. Savings could be made in the
treatment, travel, accommodation and subsistence expenses that are
presently shouldered by patients who receive treatment abroad and
their accompanying carers.
However, there is the threat that primary health care may be
marginalized if foreign commercial presence (mode 3) concentrates
on private tertiary and secondary care that targets the wealthier
segments of the population. Weak regulatory capacity could hinder
achieving the health and development goals of health for all and
jeopardise poverty reduction. Public counterpart institutions will lose
the protection that may be offered by government through subsidies
and exemptions.
In terms of mode 1, the national laboratory stopped sending
diagnostic test samples abroad in 1994. However, there is high
potential for trade in health services via the internet and electronic
means.
With regards to mode 2, during 2000–2003 total patients sent
abroad for care via the Medical Commission reached 4758, but this
mode has lost its significance mainly due to import substitution.
Egypt and the United Kingdom were the major destinations until the
1980s, but in the 1990s, trade patterns shifted towards Jordan which
became the main trade partner, followed by Egypt and other minor
European and Asian partners.
Under mode 3, two types of institutions are currently present,
Hawwasha (Chinese) hospitals located in Alamaratin, Khartoum,
where 8 private hospitals are located, and Alhasry Hospital, in central
Khartoum, an area burgeoning with private for-profit hospitals. This
indicates that foreign commercial presence through FDI has in fact

42 Trade in health services in the Eastern Mediterranean Region
overcome the limitations placed by Sudan on specialized health
services.
As regards mode 4, the number of Sudanese health
professionals working abroad has increased and their remittances
may support national health expenditures directly through the social
transfers they make to their families and indirectly by stimulating the
economy through their investment and consumption activities. An
indirect impact on the national health system will be the more
diversified professional experience that these workers will bring with
them on their return to Sudan.
Doctors are the largest category of foreigner employed by
public sector institutions; while a few foreign graduate nurses and
technicians are also found, no foreign general workers are employed
in the public health sector. The largest category of doctors come from
Arab countries (111) followed by Africans (41), Asians (18) and
Europeans (12). In the private sector, doctors also head the list, but
the numbers and categories of other health personnel are
proportionately more. Moreover, the private sector also employs
foreign general workers.
The offers that Sudan has made in specialized health services
encourage greater commercial presence, especially given the
favourable regulatory environment. The current status for mode 2
indicates that Sudan may have a deficit in the consumption of
treatment abroad but a surplus in consumption of medical
educational services. An assessment of the import-substitution policy
on consumption abroad needs to be made. Sudan seems to have a
surplus in movement of natural persons; however the data is
deficient, especially in value measurements of trade.
3.10 Syrian Arab Republic
Dr Mahmoud Dashash
Universal health care in the Syrian Arab Republic is guaranteed
by the Constitution, and the Syrian health care system is a mix of
private and public provision. There has been an expansion of primary
health care institutions focusing on preventive services, and medical

procedures are low in cost in comparison with neighbouring
countries.
Major health care challenges include health financing,
reformulating the free health care policy to target free services to the
poor and needy, increasing capacity and improving service quality,
increasing current allocations to health to raise wages, making new
investments, and assuming a strong regulatory role.
Under mode 1, the ICT penetration rate is low (less than 10%),
although a draft law to regulate e-commerce is under deliberation.
There is no government agency with a direct mandate to regulate ehealth
and no data exists on e-health providers. Given low
penetration and the absence of adequate infrastructure, it is likely
that the volume of trade under mode 1 is negligible.
N relation to mode 2, no data exists on financial resources spent
on health education abroad and treatment abroad is likely to be
limited due to affordability. There are no figures on the number of
Syrians studying medicine abroad, although popular destinations
include neighbouring Jordan and Lebanon, in addition to the
European Union and, to a lesser extent, the USA.
For mode 3, no data is available on the breakdown of inward
FDI flows, but the majority is assumed to be in the oil and gas sector.
There is no specific legislation regulating FDI in the health sector.
In terms of mode 4, no statistics are available on the number of
health care professionals working abroad, although the vast majority
who do are there on a permanent or long-term basis. Popular work
destinations for expatriate Syrians are the countries of the Arabian
peninsular.
As for foreign health care professionals in the Syrian Arab
Republic, labour regulations make it very difficult for foreigners to
obtain work permits, but exceptions are made for specializations that
are not available in the country, although this is hard to prove. There
are no published figures on the number of foreign nationals working
in the Syrian health care system.
Lack of data makes it difficult to assess the status of trade in
health services in the Syrian Arab Republic, making it impossible to

44 Trade in health services in the Eastern Mediterranean Region
formulate an evidence-based negotiation strategy for their
liberalization. The Ministry of Health has made improvements in
administration of the health care system a priority. This includes
implementing more efficient IT systems, introducing telemedicine
and creating electronic health records.
3.11 Tunisia
Dr Noureddine Achour
In 2004, life expectancy at birth was 73.4 in Tunisia, with a birth
rate of 16.8/1000. Total expenditure on health was 6.2% of GDP in
2004, at US$ 174 per capita, with 52.2% being government
expenditure and 47.8% being private expenditure. The Tunisian
health system is a mix of public and private provision.
The health system is currently having to respond to the
changing demographic, epidemiological and risk profile of the
population, as well as to rising expectations, changes in medical
technology, a fast growing private sector and the desire of
government to expand services and achieve universal health
coverage. This has produced new responsibilities related to public
health, health system reform and regulation. Tunisia has no specific
commitments in health services under GATS.
With regards to trade in health services under mode 1, there is
limited usage of cross-boarder supply of medical services in Tunisia,
mainly due to the high cost of installing and the limited capacity to
use such services.
In terms of mode 2, a total of 132 foreign patients were treated
at a cost of US$ 3.2 million in Tunisia in 2003.
Under mode 3, Tunisia has not yet achieved any significant
progress with regards to foreign commercial presence in the health
care sector. There is only one off-shore clinic in Djerba financed by
local and French (majority) capital.
With regards to mode 4, Tunisia exports health professionals to
many countries (GCC and European countries). Foreign physicians
recruited by the Ministry of Public Health are mainly from eastern
Europe and China. There are also a small number of private
physicians who are married to Tunisians.

3.12 Yemen
Dr Zeinab El Bakri
An application was made to join WTO in 1999, and Yemen has
so far been granted observer status. The National Committee under
the Ministry of Trade oversees preparation for Yemen’s accession. As
Yemen is a least developed country, GATS articles requiring
commitments on market access and national treatment do not apply
immediately.
The public health sector infrastructure has expanded
tremendously since 1990. However, there is lack of operating funds,
medical staff and a problem regarding the geographical disparity in
facilities. Also, there is an inability to provide efficient and quality
services or accessibility to the poor. As a result, a health sector reform
strategy was initiated in 1998, although no major improvement in
health situation is evident as yet.
Yemen is a net importer in trade in health services. Existing
health institutions, public or private, are not equipped or staffed to
provide quality health care. The government promotes provision of
health services through private sector and foreign investors, granting
easy entry to foreign professionals. Mode 2 is of particular
importance to Yemen, since a large number of patients travel to seek
medical services abroad. The government facilitates and partially
funds the movement of Yemeni patients to seek medical treatment
abroad for complicated diseases.
In relation to mode 3, Yemen has so far attracted the
establishment of only small-sized Arab investment in the health
sector despite the liberal and generous provisions of its recently
amended investment law. Mode 4 mainly involves the movement
into Yemen of foreign health personnel to either work in national
health facilities, public and private, or in medical colleges of
government universities. Yemen enjoys no comparative advantage or
potential for exporting professional health services to other countries.
The three main issues that concern this area are the absence of a
well-established system of data collection on trade in health services,
deficiency in the regulatory regime governing the external trade in

46 Trade in health services in the Eastern Mediterranean Region
health services and lack of rigorous study on the impact of each mode
of trade in health services.
3.13 Discussion on the country studies
It was asked whether the studies met Ministry of Trade needs
for information that would support GATS negotiations. It was felt
that countries need to establish a database on the health sector first,
before liberalizing. The current schedule of negotiation deadlines
requires that this is done soon. There is therefore need for the quick
dissemination of the research results of the ten country case.
However, it was questioned whether the recommendations of the
studies were based on strong enough data and provided a good
enough basis for policy-making.
Some felt that the studies seemed to describe trade in health
services rather than the impact of trade in health services and GATS
on health. There was a need to look beyond trade to questions about
the access to, quality and price of health services. It was, however,
noted that a dual system (public/private) already existed in countries,
and that the question should rather be whether foreign suppliers will
create or accentuate inequality. It was also noted that GATS will
affect the future of trade in health services and not the situation that
is described in the case-studies.
It was felt that there was no evidence as yet on the impact of
GATS on national public health objectives. The GATS system is
currently taking shape and it would be important to see how to
ensure that it was better geared to the objectives of the health sector,
taking into account that the health sector is different from the
commercial sector, with prominence given to issues of accessibility,
affordability, equality and equity. In this regard, liberalization is not
an end in itself, but rather health is the goal. Liberalization is a means
that can have both negative and positive impact; it is therefore
important to protect health if there is liberalization.
Some felt that the data seemed to indicate that it is best not to
rush into liberalizing until there is the evidence that countries are
ready for it. However, it was pointed out that the study of trade in

health services and of liberalization needs to be differentiated. The
evidence does not seem to be enough to support liberalization in this
regard. The next step should be to assess the impact of trade in health
services in the four Modes on health services.
It was felt that despite the pressure on countries to liberalize
their health sectors, they have the right to “wait and see” before
committing. Countries can start by making commitments in the least
controversial areas and take their time before committing on the
other areas. Countries should ask why they need to commit in an
area, how strong they are in it and what the impact will be. It was
noted that newer countries are paying a higher “price” in
commitments. There were questions around why those countries that
have made commitments have made them and on their
competitiveness in the various Modes.
It was pointed out that it would not be the decision of the
health sector whether to liberalize or not. However, the sector can
assess the situation, identify opportunities and threats, and put
policies in place to protect and improve health outcomes. The
instruments to do these things need to be developed. The issue is one
of how to make trade work to improve health outcomes, such as
access.
There was discussion on the potential opportunities and threats
of trade in health services, including the possibility of recycling funds
generated by health tourism into the public health system. It was
noted that health tourism in Jordan earns money that goes towards
the upgrading of the overall health system (both public and private),
as well as into the economy, and also leads to improved technology
and international standards in health services. However, it was
pointed out that it could lead to a focus on tertiary care at the expense
of secondary and primary care, sectors that are often weak in the
Region but which provide the vast majority of health care in
countries (and that could prevent cases that require more expensive
tertiary care). The increasingly expensive cost of health technology
and the issue of medical litigation as consumers go abroad for
services were also noted.

48 Trade in health services in the Eastern Mediterranean Region
The need to take a regional approach was discussed, to ensure
that different countries’ health services are coordinated so that they
compliment rather than compete with each other. Money spent
abroad on health services could be saved and spent on improving
services within countries, or at least kept within the Region. In some
cases, it was noted that there may be a “win—win” situation, such as
the treatment of patients from GCC countries in Jordan. It was
suggested that the country studies publication could incorporate an
index of competitiveness of countries of the Region in the different
Modes. This would be a useful platform for a regional approach.
The issue of the comparability of the country case-studies was
discussed. It was suggested that a balance needs to be struck between
achieving uniformity for comparability and reflecting the diversity of
the Region. It was noted that the data included in the studies covered
only formal rather than the informal flows in trade in health services
that would be needed to obtain a more complete picture. It was felt
that there was a need for more data, especially quantitative data, and
a greater analysis of trends. Comparative analysis and categorization
is required as countries are in different situations.
It was pointed out that information has a cost and needs to be
invested in. The case studies are just a beginning and the research is
exploratory at this stage, seeking to raise awareness of the issues
rather than providing hard evidence as yet. It was also observed that
the availability of data varies. However, it was noted that the
methodology guide would be very useful for other sectors.
4. Working groups
Participants were distributed in three groups based on
language preference (Arabic, English or French) to permit greater
interaction. Based on what they had discussed over the last three
days, the groups were asked to identify priority areas and propose
recommendations for Member States and WHO. The main
recommendations proposed by the three groups were as follows:

• Trade in health services-related activities need to be
institutionalized within the work of ministries of health and of
trade through the establishment of trade and health units.
• Resources are needed to move forward a trade and health
services agenda within countries. This would require writing
project proposals for submission and approaching funding
agencies, for which technical assistance from WHO will be
required.
• Improved coordination within and between countries in the
area of trade in health services can be achieved through the
establishment of a network for sharing experiences and
exchange of information.
• In-depth studies on specific modes of trade in health services
relevant to countries should be undertaken. This will require
further work on the development of assessment methodology
for each mode of supply.
• All stakeholders, including the professional orders, civil society
and consumers should be mobilized to build consensus and
greater policy coherence in the area of trade in health services.
• There is a need for more research, including econometric
studies, beyond the descriptive studies that have so far been
undertaken.
• A trade and health unit should be established in the Regional
Office that provides support to countries on all aspects of the
area, including trade in health services.
• WHO should continue dialogue with WTO to develop a
common understanding and perspective on trade and health
issues.
• WHO should allocate additional recourses to support capacity
building, country studies and regional meetings on trade and
health issues.
• WHO should allocate resources to a special programme on
trade and health in its biennial plan

50 Trade in health services in the Eastern Mediterranean Region
• WHO should produce a regional publication on current work in
the area, especially the country studies undertaken on trade in
health services.
• WHO should plan studies in future that measure the impact of
WTO membership on health outcomes and objectives.
Discussion
It was suggested that trade in health services could be
discussed at Regional Committee, possibly as a standing agenda item,
to support regional coordination on the issue.
A reservation was expressed that the language of the meeting
had been in English, restricting the full participation of some
attendees, particularly those from Francophone countries. It was
requested that the issue of interpretation into French and/or Arabic be
addressed in future gatherings.
The next steps in the process were outlined as being: a
workshop report; publication of the country case-studies; a policy
briefing on trade in health services; and an article in a peer-reviewed
journal. The need for a forum at country level to take the issues
forward was raised. It was noted that the case-studies publication
would be translated into Arabic and French. Attention was drawn to
the availability of relevant WHO headquarters publications in French.
Information on the case-studies and trade in health services would
also be made available on the Regional Office’s Health System
Observatory website (www.emro.who.int/healthobservatory) on
health services in the Region, which could become a forum for
networking.
It was noted that the same approach was required at countrylevel,
possibly within the broad framework of trade and health. It was
essential that countries build capacity in the area, strengthen
governance and develop their health system to meet the challenges
and opportunities posed by trade and health, and more broadly by
globalization. WHO country offices have a key role in supporting this

work, including facilitating coordination, capacity building, training
and bringing together stakeholders.
It was suggested that WHO Representatives could usefully
provide the case-studies to Ministries of Health and discuss with
Ministries of Trade. However, it was noted that focal points or
taskforces within ministries and mechanisms of coordination would
be more sustainable in many countries than the creation of new units,
given existing capacity. The issues would affect all departments in
Ministries of Health. The stewardship role of Ministries of Health
needs to be strengthened. Bringing together studies on governance,
public/private partnership, contracting and trade in health services
could help in this respect.
The utility of regional and country training seminars and
modules on the issue was expressed. Pre-conference training was
noted as a cost-effective approach to be considered. The existence of
WHO headquarters’ training modules, both web-based and face-toface,
on globalization, trade and health was noted. The development
of a critical mass of trained and experienced human resources
(including trade negotiators) within the Region would be useful, as
would be links to academic institutions. The experience that already
exists within the Region was pointed out, for instance Egypt and
Pakistan’s experience in GATS negotiations and Jordan’s experience
in coordination between ministries of health and trade. The useful
role of WHO headquarters in sharing existing experience and best
practice on the issue was noted, in helping countries to update
legislation for instance. It was suggested that WHO could host a joint
WHO/WTO meeting in the Region of representatives from Ministries
of Health and Trade.
It was observed that the opportunities provided by
globalization had not been explored enough and that countries
needed to address the challenges, given that the process was already
occurring, by strengthening their health systems and making them
more competitive, and in seeking to benefit from any comparative
advantages.

52 Trade in health services in the Eastern Mediterranean Region
5. Recommendations
To Member States
1. The knowledge base about trade in health services should be
further improved through additional research for each mode of
supply.
2. Trade in health services-related activities should be
institutionalized within the work of ministries of health and
collaboration improved with ministries of trade and commerce
so that public health priorities are protected during trade
negotiations.
3. National policy forums should be initiated bringing together all
concerned stakeholders, including civil society and academia,
to share information on trade in health services and to engage
in policy dialogue.
4. Resources should be mobilized in order to build capacity in the
assessment of national needs, in negotiations skills and in
policy dialogue and the updating legislation in relation to trade
in health services.
5. Methodological approaches should be developed and
implemented in order to assess the implications of trade in
health services on access to health, equity, safety and public
health, and to build national scenarios for trade in health
services.
To WHO
6. Technical support should be mobilized in countries seeking
help in various steps of accession negotiation and
implementation of GATS Agreement.
7. Support should be provided to development of a database on
trade in health services as part of the regional Health System
Observatory and to facilitate the sharing of the knowledge
among researchers and policy-makers in the Region.

8. A regional heath policy forum on trade in health services
should be initiated to help promote strategic thinking among
concerned parties in the Region.
9. The research methodology for each mode of supply in health
should be refined and national and regional tool kits developed
to support a comprehensive assessment of overall situation in
trade and health in the Region and to improve policy coherence
on trade in health services.
10. Capacity building should be supported in areas related to trade
in health services using existing links with academic, research
and public health institutions.

54 Trade in health services in the Eastern Mediterranean Region
Tuesday, 30 May 2006
Annex 1
Programme
08:30–09:00 Registration
09:00–10:30 Inaugural Session
Message of Dr Hussein A. Gezairy,
WHO Regional Director for the
Eastern Mediterranean
Speech by H.E Minister of Health,
Morocco
Comments on behalf of IDRC and
UNFPA
Objectives of the meeting
Introduction of participants and
nomination of Chairpersons and
Rapporteurs
1030–11:00 Globalization, trade and health:
WHO perspective/Nick Drager
11:00–11:30 Conceptual issues in trade in Health
services/Sameen Siddiqi
11:30–12:00 Methodological framework for
assessing trade in health
services/Azza El Shinnawy
12:00–14:00 Discussion
14:00–17:00 Country studies: Jordan, Lebanon,
Morocco, Pakistan, Syrian Arab
Republic
Discussion
Wednesday, 31 May 2006
08:30–09:00 GATS and trade in health services:
WTO perspective/Rudolf Adlung
09:00–10:30 Panel discussion on trade

liberalization in health services and
on-going GATS negotiations
10:30–14:00 Country studies: Egypt; Oman;
Sudan; Tunisia; Yemen.
Discussion
14:00–14:30 The challenge of assessing trade in
health services: An Eastern
Mediterranean Region
perspective/Sameen Siddiqi
14:30–15:10 Trade and health: A tool kit for
analysis and assessment of
countries/Nick Drager
15:10–15:30 How can health and trade objectives
converge at the policy level/Azza El
Shinnawy
15:30–17:00 Group work
Thursday, 1 June 2006
08:00–10:30 Group work
10:30–12:00 Group presentation and discussion
12:30–13:00 Closing session

56 Trade in health services in the Eastern Mediterranean Region
EGYPT
Walid El Nozhai
Head, Central Department
World Trade Organization
Cairo
Mr Gamal Abdul Rasheed
First Secretary
Trade Office
Geneva
Annex 2
List of participants
Azza El Shinnawy
Development Studies Institute (DESTIN)
London School of Economics
London
Dr Mohammed Tag El Din
Director
Arab Company for Trade and Medical Appliances
Cairo
JORDAN
Dr Ratib Hanawi
Ministry of Health
Amman
Dr Riyad Amin Okour
Directorate of Health Economics
Ministry of Health
Amman

LEBANON
Dr Walid Ammar
Director-General
Ministry of Public Health
Beirut
Dr Bahij Arbid
Planning Expert
Ministry of Public Health
Beirut
Dr Nabil Kronfol
President
Lebanese Health Care Management Association
Beirut
MOROCCO
Professor Lahcen Achy
Professor of Economics
INSEA, Rabat Institutes
Rabat
Mr Hamid Bekkar
Chef de la Division du Contentieux et Affaires Professionnelles
Rabat
Mr Abderrahim Chakour
Chef de la Division des Industries Chimiques et Parachimiques
Rabat
Mrs Khadija Meshak
Directeur de la Réglementation et du Contentieux
Rabat

58 Trade in health services in the Eastern Mediterranean Region
Mrs Samira Yamani
Chef du Service des Industries Chimiques
Rabat
Dr Abderrahmane Zahi
Secretary General
Fondation Hassan II pour les Marocains Residents a L’Etranger
Rabat
OMAN
Mr Salah Nasser Al Muzahmi
Director of Health Information and Statistics
Ministry of Health
Muscat
Dr Batool Jaffer Suleiman
Director of Regional Drug Use
Ministry of Health
Muscat
PAKISTAN
Mr Manzoor Ali Bozdar
Deputy Drugs Controller
Islamabad
Mr Ahmad Mokhtar
Section Office (WTO)
Ministry of Commerce
Islamabad

SUDAN
Dr Muneef Abdelbagi Babkir
Assistant Professor (Health Economics)
University of Khartoum
Khartoum
Dr Mustafa Salih Mustafa
Director
Planning Health Directorate
Khartoum
SYRIAN ARAB REPUBLIC
Dr Mahmoud Dachach
Director
Planning and International Cooperation
Damascus
TUNISIA
Dr Hichem Abdessalam
Director, Technical Cooperation Unit
Ministry of Public Health
Tunis
Dr Noureddine Achour
Director
National Institute of Public Health
Tunis
Mr Jamel Eddine Torki
Deputy-Director
General Directorate of Economic and Commercial Cooperation
Ministry of Commerce and Handcrafts
Tunis

60 Trade in health services in the Eastern Mediterranean Region
YEMEN
Dr Ebtihaj Al Kamel
Ministry of Public Health and Population
Sanaa
OTHER ORGANIZATIONS
AFRICAN DEVELOPMENT BANK
Dr Zeinab El Bakri
Director
Social Development Department
Central and West Region (OCSD)
Tunis
UNITED NATIONS POPULATION FUND (UNFPA)
Dr Faysal Abdel Gadir
Representative
Cairo
Dr Tarek Morsy
Project Officer
Unit for Monitoring Population Activities
Cairo
WORLD BANK
Dr Akiko Meada
Health Sector Manager, MENA Region
Washington
WORLD TRADE ORGANIZATION
Dr Rolf Adlung
Geneva

WHO Secretariat
Dr Abdel Aziz Saleh, Special Adviser (Medicine), WHO/EMRO
Dr Raouf Ben Ammar, WHO Representative, Morocco
Dr Belgacem Sabri, Director, Health Systems and Services
Development, WHO/EMRO
Dr Nick Drager, Senior Adviser, SDE, ETH, WHO/HQ
Dr Jaouad Mahjour, WHO Representative, Lebanon
Dr El Fatih El Samani, WHO Representative, Oman
Dr Ibrahim Abdel Rahim, WHO Representative, Tunisia
Dr Sameen Siddiqi, Regional Adviser, Health Policy and Planning,
WHO/EMRO
Dr Amr Mahgoub, Regional Adviser, Health Management Support,
WHO/EMRO
Dr Zafar Mirza, Regional Adviser, Essential Drugs and Biologicals,
WHO/EMRO
Dr Ong-arj Viputsiri, Acting Regional Adviser, Research Policy and
Cooperation, WHO/SEARO
Dr Benjamin Nganda, Focal Person for Trade and Health Issues,
Division of Health Environments and Sustainable Development,
WHO/AFRO
Dr Zein El Din Idrissi, Health Economics, WHO/EMRO
Mr Kevin Eisenstadt, Editor, WHO/EMRO
Mrs Hanaa Ghoneim, Senior Administrative Assistant, WHO/EMRO
Ms Lamia Torki, Secretary, WHO/EMRO