Cambodia’s anticipated entry into the World Trade Organization this September has critics worried that further opening the country’s health care system to foreign health care and drug companies will damage efforts to establish a viable health care system.
The WTO facilitates business between corporations and member states by encouraging nations to reduce or eliminate restrictions over how foreign companies can operate within their borders, a phenomenon called liberalization or deregulation. The WTO can impose sanctions on states in violation of agreements.
Cambodia would be the first nation categorized by the WTO as a least-developed country to join the organization since its founding in 1995. Cambodia is scheduled to complete procedures for membership at a meeting today in Geneva.
In an e-mail last week, a WTO official wrote that a least-developed country such as Cambodia will get more leeway than developed countries in terms of how many industries it must open to foreign companies. However, he wrote, “there may be some pressure in membership negotiations to allow some foreign competition in sectors that are already liberalized,” as health care is becoming.
According to Dr Jim Tulloch, representative of the World Health Organization, entering the WTO could affect two aspects of health care: It will likely increase the number of private clinics that would be too expensive for most Cambodians and create uncertainty about whether countries that manufacture generic versions of patented drugs will still be able to export them to Cambodia.
Sok Siphana, secretary of state for the Ministry of Commerce and a leader in Cambodia’s efforts to join the WTO, said a growing number of Cambodians can afford private health care and are going abroad to receive it.
“Money is going out and not benefiting our country,” he said.
In addition the foreign doctors staffing private clinics would provide their Cambodian counterparts with insights into more sophisticated techniques currently unavailable here, he said.
Sok Siphana was unconcerned that the best doctors would leave public clinics to join private ones in search of better pay since “that has already happened.”
An increase in private clinics would “make no difference” for those who cannot afford them, Sok Siphana said. “We’ve been liberalizing without even knowing it.”
But some critics say Liberalization has not necessarily improved the medical care in Cambodia.
According to a 2003 International Monetary Fund report, between 1997 and 2001 the number of hospital beds, health care workers and nurses declined as the population increased by 1.6 million. The number of doctors increased.
Tulloch said he was “skeptical” that foreign doctors in Cambodia would increase the expertise of their Cambodian counterparts. “It’s reasonable to assume that their primary interest is to profit,” he said Friday. “And there’s more money to be made out of bad medicine than out of good medicine.”
All nations in the WTO sign the Agreement on Trade-Related Aspects of International Property Rights, an intellectual property treaty. In the health care field it ensures that drug patent-holders receive payments for the use of their drugs. It ensures, the WTO official wrote, that pharmaceutical companies “have an incentive to produce more drugs.”
Concerned that this would prevent poor countries from obtaining necessary generic drugs, especially drugs to treat HIV/AIDS, a declaration produced at the WTO meeting in Doha, Qatar, in November 2001 states “the TRIPS agreement does not and should not prevent members from taking measures to protect public health.”
Victor van Spengler, a consultant to Medecins sans Frontieres assisting the Ministry of Health, said the US has led efforts to ensure the declaration is not legally binding. Despite this, he said Cambodia, as a least-developed country, will be able to import the generic drugs it cannot produce from countries such as Thailand until 2016. But it has not yet been determined whether under TRIPS regulations, Thailand will be able to export drugs to Cambodia.
“That’s the big question,” van Spengler said Sunday. “You can’t predict accurately what will happen.”
But he doubted that Thailand would stop exporting drugs to Cambodia unless under severe international pressure. Similarly, he said, pharmaceutical companies might be willing to cut their losses when it comes to Cambodian AIDS patients.
“From a public relations point of view, it’s not something to act very aggressively on,” he said.
The uncertainty about the international sale of drugs extends to NGOs that purchase drugs for distribution in Cambodia.
Richard Vermeer, head of mission in Cambodia for Medecins sans Frontieres Holland-Belgium-Switzerland, said putting drug-maker profits above the health of the poor could have devastating consequences. “Make your money in Europe,” he said, “and leave Cambodia out of it.”