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Analysis Trade and Health

The upside of trade in health services

BMJ 2019; 365 doi: (Published 28 May 2019) Cite this as: BMJ 2019;365:l2208

Linked analysis

Threat of compulsory licences could increase access to essential medicines

  1. Johanna Hanefeld, associate professor of health policy and systems1,
  2. Richard Smith, professor of health economics2
  1. 1Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
  2. 2College of Medicine and Health, University of Exeter, Exeter, UK
  1. Correspondence to: J Hanefeld Johanna.hanefeld{at}

Cross border movement of patients and health workers is often portrayed negatively but Johanna Hanefeld and Richard Smith discuss how it can benefit both source and recipient countries as long as the risks are properly managed

Trade in health services is the least researched aspect of trade and health.1 This is despite the fact that it includes the contentious issues of medical tourism and movement of health workers—both important concerns for health systems, especially in low and middle income countries. Estimates of the global value of medical tourism range from $60bn to $100bn annually,2 which is more than double the estimated $37bn available for health development assistance.3

Trade in health services, like all trade in services, is regulated by the World Trade Organization as part of the General Agreement on Trade in Services (GATS) (box 1).5 But data are extremely limited. Most of the trade in health services occurs within the private sector, and much of it is unregulated and subject to confidentiality and commercial sensitivity restrictions. Nonetheless, available data—for example, on the movement of patients26 or health workers7—suggest that trade in health services is growing. In addition, a small but growing number of countries import services to deal with capacity shortfalls in their health systems. These countries are tackling shortages of health workers and access to specialist services through schemes that facilitate medical travel.8

Box 1

Rules of trade in health services4

  • The World Trade Organization (WTO) is a global international organisation dealing with the rules of trade between nations. At its heart are the WTO agreements, negotiated and signed by the bulk of the world’s trading nations and ratified in their parliaments.

  • One of these agreements is the General Agreement on Trade in Services (GATS), which regulates all trade in services, including health services. The GATS …

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