Health Services and Access to Medicines and Other Health Technologies

Part of the Palgrave Studies in Public Health Policy Research book series (PSPHPR)


This chapter explores the implications of trade agreements for the provision of health services and access to medicines and other health technologies. It first examines the potential effects of the General Agreement on Trade in Services and subsequent bilateral and regional trade agreements on the provision of universal health care and the ‘brain drain’ of health workers from low-income countries. Next, the intellectual property rights (IPRs) provided for pharmaceuticals by the Agreement on Trade-Related Aspects of Intellectual Property Rights are described, and the way in which these IPRs have been expanded and extended through subsequent bilateral and regional trade agreements elaborated. This chapter also considers other mechanisms through which trade agreements can affect access to health technologies including rules applying to marketing approval processes, pricing and reimbursement and pharmaceutical advertising.


GATS Health services Health workforce TRIPS Access to medicines Pharmaceutical policy 


  1. 1.
    Ghebreyesus TA. All roads lead to universal health coverage. Lancet Glob Health. 2017;5(9):e839–40. Scholar
  2. 2.
    World Health Organization and International Bank for Reconstruction and Development. Tracking universal health coverage: 2017 Global Monitoring Report. Geneva; 2017.Google Scholar
  3. 3.
    United Nations. Sustainable development goals [Internet]. n.d. [cited 2018 Sep 21].
  4. 4.
    World Health Organization. WHO medicines strategy: countries at the core 2004–2007. Geneva: WHO; 2004.Google Scholar
  5. 5.
    World Health Organization. World Bank. Tracking universal health coverage: First Global Monitoring Report. Geneva: WHO and the World Bank; 2015.Google Scholar
  6. 6.
    Missoni E. Understanding the impact of global trade liberalization on health systems pursuing universal health coverage. Value Health. 2013;16:S14–8. Scholar
  7. 7.
    World Bank. Trade in services (% of GDP) [Internet]. World Bank; n.d. [cited 2018 Sep 21].
  8. 8.
    Mashayekhi M, Tuerk E. Regional trade agreements and health services. In: Smith R, Blouin C, Mirza Z, Beyer P, Drager N, editors. Trade and health: towards building a national strategy. Geneva: World Health Organization; 2015. p. 56–75.Google Scholar
  9. 9.
    World Trade Organization. Understanding the WTO: services: rules for growth and investment [Internet]. n.d. [cited 2018 Sep 21].
  10. 10.
    Sauve P, Blouin C, Bhushan A, Cattaneo O. Trade in health services. In: Smith R, Blouin C, Mirza Z, Beyer P, Drager N, editors. Trade and health: towards building a national strategy. Geneva: World Health Organization; 2015. p. 76–91.Google Scholar
  11. 11.
    Adlung R, Carzaniga A. Health services under the General Agreement on Trade in Services. Bull World Health Organ. 2001;79(4):352–64.PubMedPubMedCentralGoogle Scholar
  12. 12.
    Chanda R. Trade in health services. Bull World Health Organ. 2002;80(2):158–63.PubMedPubMedCentralGoogle Scholar
  13. 13.
    Smith RD. Foreign direct investment and trade in health services: a review of the literature. Soc Sci Med. 2004;59(11):2313–23. Scholar
  14. 14.
    Beladi H, Chao C-C, Ee MS, Hollas D. Medical tourism and health worker migration in developing countries. Econ Model. 2015;46:391–6. Scholar
  15. 15.
    Hopkins L, Labonté R, Runnels V, Packer C. Medical tourism today: what is the state of existing knowledge? J Public Health Policy. 2010;31(2):185–98. Scholar
  16. 16.
    Smith R, Martínez Álvarez M, Chanda R. Medical tourism: a review of the literature and analysis of a role for bi-lateral trade. Health Policy. 2011;103(2):276–82. Scholar
  17. 17.
    Castro-Palaganas E, Spitzer D, Kabamalan MM, Sanchez M, Carcativo R, Runnels V, et al. An examination of the causes, consequences, and policy responses to the migration of highly trained health personnel from the Philippines: the high cost of living/leaving—a mixed method study. Hum Resour Health. 2017;15(25):1–14. Scholar
  18. 18.
    Walton-Roberts M, Runnels V, Rajan I, Sood A, Nair S, Thomas P, et al. Causes, consequences and policy responses to the migration of health workers: key findings from India. Hum Resour Health [Internet]. 2017 [cited 2017 Apr 5];15(28):6.
  19. 19.
    Labonté R, Sanders D, Mathole T, Crush J, Chikanda A, Dambisya Y, et al. Health worker migration from South Africa: causes, consequences and policy responses. Hum Resour Health [Internet]. 2015 [cited 2015 Dec 3];13(92):16.
  20. 20.
    World Health Organization. Global strategy on human resources for health: workforce 2030 [Internet]. Geneva: World Health Organization; 2016 [cited 2018 Sep 15].
  21. 21.
    OECD. International migration outlook 2015: changing patterns in the international migration of doctors and nurses to OECD countries [Internet]. 2015 [cited 2018 Sep 15].
  22. 22.
    Aluttis C, Bishaw T, Frank MW. The workforce for health in a globalized context—global shortages and international migration. Glob Health Action. 2014;7(1):23611. Scholar
  23. 23.
    Cambell B, Blouin C, Foster J. Putting health first: Canadian health care reform, trade treaties and foreign policy. Ottawa: Canadian Centre for Policy Alternatives Consortium on Globalization and Health; 2002.Google Scholar
  24. 24.
    Reynolds L, McKee M. Is the NHS really safe from international trade agreements? BMJ. 2015;350:h2179. Scholar
  25. 25.
    Ankersmit L. Achmea: the beginning of the end for ISDS in and with Europe? Investment Treaty News [Internet]. 2018 Apr 24 [cited 2019 Feb 20].
  26. 26.
    World Trade Organization. Briefing note: trade in services. [Internet]. Geneva: World Trade Organization; 2013 [cited 2018 Sep 15].
  27. 27.
    European Commission. Trade in Services Agreement (TiSA) Fact Sheet [Internet]. 2016 [cited 2018 Sep 15].
  28. 28.
    Neilson J. Ten steps to consider before making commitments in health services under the GATS. In: Blouin C, Drager N, Smith R, editors. International trade in health services and the GATS: current issues and debates. Washington, DC: The World Bank; 2006. p. 101–39.Google Scholar
  29. 29.
    Lipson DJ. The World Trade Organization’s health agenda: opening up the health services markets may worsen health equity for the poor. BMJ. 2001;323(7322):1139–40.CrossRefGoogle Scholar
  30. 30.
    Mashayekhi M, Julsaint M, Tuerk E. Strategic considerations for developing countries: the case of GATS and health services. In: Blouin C, Drager N, Smith R, editors. International trade in health services and the GATS: current issues and debates. Washington, DC: World Bank; 2006. p. 17–81.Google Scholar
  31. 31.
    Smith RD, Chanda R, Tangcharoensathien V. Trade in health-related services. Lancet. 2009;373(9663):593–601.CrossRefGoogle Scholar
  32. 32.
    Kyle M, McGahan A. Investments in pharmaceuticals before and after TRIPS. Rev Econ Stat. 2012;94:1157–72. Scholar
  33. 33.
    Morgan S, Grootendorst P, Lexchin J, Cunningham C, Greyson D. The cost of drug development: a systematic review. Health Policy. 2011;100(1):4–17. Scholar
  34. 34.
    Galkina Cleary E, Beierlein JM, Khanuja NS, McNamee LM, Ledley FD. Contribution of NIH funding to new drug approvals 2010–2016. Proc Natl Acad Sci. 2018;115(10):2329. Scholar
  35. 35.
    Tay-Teo K, Ilbawi A, Hill SR. Comparison of sales income and research and development costs for FDA-approved cancer drugs sold by originator drug companies. JAMA Netw Open. 2019;2(1):e186875. Scholar
  36. 36.
    World Trade Organization. Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) [Internet]. 1994 [cited 2017 May 22].
  37. 37.
    Sell SK. TRIPS-Plus free trade agreements and access to medicines. Liverpool Law Rev. 2007;28:41–75. Scholar
  38. 38.
    Shadlen KC. Intellectual property, trade, and development: can foes be friends? Glob Gov. 2007;13(2):171–7.CrossRefGoogle Scholar
  39. 39.
    Townsend B. International medicines governance 1940s to 1970s: lessons for public health. Crit Public Health. 2016;26(4):466–76. Scholar
  40. 40.
    ‘t Hoen E. Private patents and public health: changing intellectual property rules for access to medicines. Amsterdam: Health Action International; 2016. p. 181.Google Scholar
  41. 41.
    Lopert R, Gleeson D. The high price of “free” trade: US trade agreements and access to medicines. J Law Med Ethics. 2013;41(1):199–223. Scholar
  42. 42.
    Abbott FM. Trade in medicines. In: Smith R, Blouin C, Mirza Z, Beye P, Drager N, editors. Trade and health: towards building a national strategy. Geneva: World Health Organization; 2015. p. 117–40.Google Scholar
  43. 43.
    Reid Smith S. Introduction to intellectual property, trade and access to medicines. In: Asia Pacific Network of People Living with HIV/AIDS, editor. Our health, our right: the roles and experiences of PLHIV networks in securing access to generic ARV medicines in Asia. Thailand: APN+; 2010. p. 9–22.Google Scholar
  44. 44.
    Abbott FM. The TRIPS Agreement, access to medicines, and the WTO Doha Ministerial Conference. J World Intellect Prop. 2002;5(1):15–52. Scholar
  45. 45.
    World Trade Organization. Declaration on the TRIPS Agreement and Public Health [Internet]. 2001 [cited 2016 Nov 25].
  46. 46.
    Beall R, Kuhn R. Trends in compulsory licensing of pharmaceuticals since the Doha Declaration: a database analysis. PLoS Med. 2012;9(1):e1001154. Scholar
  47. 47.
    Son K-B, Lee T-J. Compulsory licensing of pharmaceuticals reconsidered: current situation and implications for access to medicines. Glob Public Health. 2018;13(10):1430–40. Scholar
  48. 48.
    ‘t Hoen E, Veraldi J, Toebes B, Hogerzeil H. Medicine procurement and the use of flexibilities in the Agreement on Trade-Related Aspects of Intellectual Property Rights, 2001–2016. Bull World Health Organ. 2018;96:185–93.CrossRefGoogle Scholar
  49. 49.
    Smith RD, Correa CM, Oh C. Trade, TRIPS, and pharmaceuticals. Lancet. 2009;373:684–91.CrossRefGoogle Scholar
  50. 50.
    Shadlen KC. Patents, trade and medicines: past, present and future. Rev Int Polit Econ [Internet]. 2019 [cited 2019 Jun 27].
  51. 51.
    Malpani R. All costs, no benefits: how the US-Jordan Free Trade Agreement affects access to medicines. J Generic Med. 2009;6(3):206–17. Scholar
  52. 52.
    Abbott RB, Bader R, Bajjali L, ElSamen TA, Obeidat T, Sboul H, et al. The price of medicines in Jordan: the cost of trade-based intellectual property. J Generic Med. 2012;9(2):75–85. Scholar
  53. 53.
    Shaffer ER, Brenner JE. A trade agreement’s impact on access to generic drugs. Health Aff. 2009;28(5):w957–w68.CrossRefGoogle Scholar
  54. 54.
    Akaleephan C, Wibulpolprasert S, Sakulbumrungsil R, Luangruangrong P, Jitraknathee A, Aeksaengsri A, et al. Extension of market exclusivity and its impact on the accessibility to essential medicines, and drug expense in Thailand: analysis of the effect of TRIPs-plus proposal. Health Policy. 2009;91(2):174–82.
  55. 55.
    Lexchin JR, Gagnon M-A. CETA and pharmaceuticals: impact of the trade agreement between Europe and Canada on the costs of prescription drugs. Glob Health [Internet]. 2014;10(30).
  56. 56.
    Bollyky TJ. A dose of TPP’s medicine: why U.S. trade deals have not exported U.S. drug prices. New York: Council on Foreign Relations; 2016.Google Scholar
  57. 57.
    Kapczynski A, Sampat BN, Shadlen K. Trade agreements, patents, and drug prices: continuing the debate. Research Paper No. 572. Yale Law & Economics; 2017.Google Scholar
  58. 58.
    Jung Y, Kwon S. The effects of intellectual property rights on access to medicines and catastrophic expenditure. Int J Health Serv. 2015;45(3):507–29. Scholar
  59. 59.
    Jung Y, Kwon S. How does stronger protection of intellectual property rights affect national pharmaceutical expenditure? an analysis of OECD countries. Int J Health Serv 2018:0020731418786095.
  60. 60.
    Flynn S, Baker B, Kaminski M, Koo J. The U.S. proposal for an intellectual property chapter in the Trans-Pacific Partnership Agreement. Am University Int Law Rev. 2012;28(1):105–202.Google Scholar
  61. 61.
    Médecins Sans Frontières. How the Trans-Pacific Partnership Agreement threatens access to medicines. TPP Issue Brief—September 2011 [Internet]. MSF; 2011 [cited 2011 Dec 28].
  62. 62.
    Megerlin F, Lopert R, Taymor K, Trouvin J-H. Biosimilars and the European experience: implications for the United States. Health Aff. 2013;32(10):1803–10.CrossRefGoogle Scholar
  63. 63.
    Gleeson D, Townsend B, Lopert R, Lexchin J, Moir H. Financial costs associated with monopolies on biologic medicines in Australia. Aust Health Rev. 2018;43(1):36–42. Scholar
  64. 64.
    Mulcahy AW, Hlavka JP, Case SR. Biosimilar cost savings in the United States: initial experience and future potential. Santa Monica, CA: RAND Corporation; 2017.Google Scholar
  65. 65.
    Gleeson D, Lexchin J, Lopert R, Kilic B. The Trans Pacific Partnership Agreement, intellectual property and medicines: differential outcomes for developed and developing countries. Glob Soc Policy. 2018;18(1):7–27. Scholar
  66. 66.
    Lexchin JR, Gleeson D. The Trans Pacific Partnership Agreement and pharmaceutical regulation in Canada and Australia. Int J Health Serv. 2016;46(4):597–613. Scholar
  67. 67.
    Kilic B. NAFTA 2.0: Chapter 20: pharmaceutical related patent provisions. Washington, DC: Public Citizen; 2019.Google Scholar
  68. 68.
    Labonté R, Crosbie E, Gleeson D, McNamara C. USMCA (NAFTA 2.0): tightening the constraints on the right to regulate for public health. Glob Health [Internet]. 2019 [cited 2019 May 14];15(1):p. 35.
  69. 69.
    Lexchin J. Increase in drug spending in Canada due to extension of data protection for biologics: a descriptive study. Healthc Policy. 2019;14(3):10–8. Scholar
  70. 70.
    Office of the Parliamentary Budget Officer. The impact of the Canada-United States-Mexico Agreement on prescription drug expenditures in Canada. 2019.Google Scholar
  71. 71.
    Improving Access to Affordable Prescription Drugs Act. (H.R. 1776, 115th Congress), Section 303 (a), (3), (2017).Google Scholar
  72. 72.
    Wiseman P, Freking K. Trump administration, Democrats make progress on new NAFTA. AP News [Internet]. 2019, 31 July. [cited 2019 Aug 11].
  73. 73.
    Townsend B, Gleeson D, Lopert R. Japan’s emerging role in the global pharmaceutical intellectual property regime: a tale of two trade agreements. J World Intellect Prop. 2018;21(1–2):88–103. Scholar
  74. 74.
    Gleeson D, Neuwelt P, Monasterio E, Lopert R. How the transnational pharmaceutical industry pursues its interests through international trade and investment agreements: a case study of the Trans Pacific Partnership Agreement. In: de Jonge A, Tomasic R, editors. Research handbook on transnational corporations. Cheltenham, UK: Edward Elgar; 2017. p. 223–54.CrossRefGoogle Scholar
  75. 75.
    World Health Organization. Consultative Expert Working Group on Research and Development: financing and coordination. Sixty-Fifth World Health Assembly, Provisional Agenda Item 13.14.; 2012.Google Scholar
  76. 76.
    United Nations Secretary General’s High Level Panel on Access to Medicines. Report of the United Nations Secretary General’s High Level Panel on Access to Medicines: promoting innovation and access to health technologies. United Nations; 2016.Google Scholar
  77. 77.
    Saez C. WHO releases draft roadmap for access to medicines: comments show polarised views. Intellectual Property Watch [Internet]. 2018 Sep 20 [cited 2019 Feb 15].
  78. 78.
    Saez C. TRIPS debated as WHO Board reaches agreement on universal health coverage. Intellectual Property Watch [Internet]. 2019 Feb 5 [cited 2019 Feb 15].
  79. 79.
    Baker BK, Geddes K. The incredible shrinking victory: Eli Lilly v. Canada, success, judicial reversal, and continuing threats from pharmaceutical ISDS. Loyola Univ Chic Law J. 2017;49:479–513.Google Scholar
  80. 80.
    Ministry of Foreign Affairs and Trade. Trans Pacific Partnership: pharmaceutical and medical device purchasing (reimbursement)—Fact Sheet. New Zealand: Ministry of Foreign Affairs and Trade; 2015.Google Scholar
  81. 81.
    Pharmaceutical Management Agency. Annual Report for the year ended 30 June 2015. New Zealand: PHARMAC; 2015.Google Scholar
  82. 82.
    Gleeson D, Menkes DM. Trade agreements and direct-to-consumer advertising of pharmaceuticals. Int J Health Policy Manag. 2018;7(2):98–100. Scholar
  83. 83.
    Medécins Sans Frontières. A fair shot for vaccine affordability: understanding and addressing the effects of patents on access to newer vaccines [Internet]. MSF Access Campaign; 2017, September [cited 2019 Feb 15].
  84. 84.
    Crager SE. Improving global access to new vaccines: intellectual property, technology transfer, and regulatory pathways. Am J Public Health. 2014;104(11):e85–91. Scholar
  85. 85.
    Oguanobi HI. Broadening the conversation on the TRIPS Agreement: access to medicines includes addressing access to medical devices. J World Intellect Prop. 2018;21(1–2):70–87. Scholar
  86. 86.
    Beall RF, Kesselheim AS. Tertiary patenting on drug–device combination products in the United States. Nat Biotechnol. 2018;36:142. Scholar

Copyright information

© The Author(s) 2020

Authors and Affiliations

  1. 1.School of Psychology and Public HealthLa Trobe UniversityMelbourneAustralia
  2. 2.School of Epidemiology and Public HealthUniversity of OttawaOttawaCanada

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