Public Services International Research Unit (PSIRU)
2001-01-H-Over
Globalisation, privatisation and healthcare
– a preliminary report
by
David Hall, Senior Research Fellow, PSIRU, University of Greenwich
January 2001
This report was commissioned by Public Services International
Comments on this paper, especially from PSI affiliates, are welcomed at psiru@psiru.org .
Public Services International Research Unit (PSIRU)
School of Computing and Mathematical Sciences, University of Greenwich
30 Park Row, London SE10 9LS, U.K.
Email: psiru@psiru.org Tel: +44-(0)208-331-9933 Fax: +44 (0)208-331-7781 www.psiru.org
Director: David Hall Researchers: Kate Bayliss, Steve Davies, Emanuele Lobina, Sam Weinstein
The PSIRU was set up in 1998 to carry out empirical research into privatisation, public services,
and globalisation. It is part of the School of Computing and Mathematics in the University of
Greenwich, London. PSIRU’s research is centred around the maintenance of an extensive and
regularly updated database of information on the economic, political, financial, social and
technical experience with privatisation and restructuring of public services worldwide.
This core database is financed by Public Services International (PSI), the worldwide confederation
of public service trade unions. www.world-psi.org
© Unless otherwise stated, this report is the copyright of the PSIRU and the organisations which
commissioned and/or financed it
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Executive summary
Abbreviations
3
4
1. Globalisation, privatisation and public services
1.1 Globalisation and public services

Privatisation and internationalisation (see also Annexe A)
1.2 The channels of globalisation
5
5
5
6
2. The WTO threat to public services
2.1 WTO – the potential impact of GATS
2.2 GATS exemptions – government services and procurement
2.3 TRIPS
6
6
7
7
3. The influence of other international institutions
3.1 IMF and World Bank: general conditionality
3.2 World Bank –IBRD projects

Tanzania

Indonesia

Bulgaria
3.3 World Bank: International Finance Corporation (IFC)

Russia

Dominican republic

Brazil

Nigeria

India
3.4 World Bank: Multilateral Investment Guarantee Agency (MIGA)
3.5 Other international organisations and treaties

WHO

OECD

Energy charter treaty

Regional trade zones: NAFTA, Mercosur, Asean, EU
3.6 Public procurement
7
7
7
8
8
8
8
9
9
9
9
9
9
10
10
10
10
10
11
4. Governments and multinationals
4.1 Government decisions
4.2 Managed care schemes
4.3 The problem of trade unions
4.4 MNCs’ marketing - the annual global conference
11
11
12
12
12
5. The multinational companies
5.1 Insurance multinationals
5.2 Hospital multinationals
5.3 Clinical, laboratory and other services
5.4 Support services multinationals
13
13
14
14
15
6. Observations
6.1 Globalisation
6.2 Multinationals
15
15
16
Annexe A: Comments on privatisation/internationalisation chart
17
Annexe B: Current World Bank projects involving healthcare
18
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 Executive summary
The paper distinguishes between globalisation, which may have a negative development impact in any
sector, and privatisation, which specifically damages public services. Various channels are identified of
globalisation influencing the privatisation of healthcare, including international institutions, government
policies, and the activities of multinationals themselves.

The WTO provides two kinds of threat to health services. The first is the potential threat of GATS,
which could force more privatisation in future. The second is the effect of TRIPS in supporting
pharmaceutical profits at the expense of health needs.

The World Bank has a major impact on privatisation of healthcare services through its projects,
which often have greater privatisation as a stated objective. Other parts of the World Bank also
support privatisation: the direct investment activities of the IFC, and the investment guarantees of
MIGA. Other international organizations such as the WHO and OECD also influence privatisation.

The various regional trade zones of the world have rules which may facilitate privatisation:
healthcare policy changes in Alberta Canada, for example, could become a ‘one-way street towards
privatisation of the health sector’ because of NAFTA. Procurement rules can also affect the
introduction of private capital into public services.

Government decisions to introduce healthcare privatisation have been and are being made in a
number of developed and developing countries. These include service provision and also privatised
insurance schemes like HMOs.

The marketing activities of MNCs themselves are central to the processes of privatisation and
globalisation. This marketing may involve international agencies and governments, as at the annual
AIHS conference.
The main multinationals active in health so far are listed in four categories: insurance, hospitals, clinical/labs
etc, support services.
Some general comments can be made from this preliminary review:
 The World Bank is a very significant force driving privatisation in healthcare, both through projects,
investments, and institutional support for the multinationals.
 WTO and GATS provide a threatening background against which privatisation in one form or
another is already happening in a wide range of countries .
 Trading and procurement rules of organisations like NAFTA and the EU may impact on
privatisation of public services.
The picture of multinational behaviour by private healthcare companies is not as coherent or as expansionist
as in other sectors.





Many of the USA groups are weak internationally
The private hospital companies have not been very successful so far at expanding internationally.
Cleaning and catering support services exhibit the ‘classic’ pattern of multinational dominance
worldwide, at least in developed countries.
The insurance companies, as insurers or with HMO schemes, are also expanding.
There is multinational expansion in clinical diagnostic or therapy services, such as dialysis, blood
products, MRI scans, in a number of countries
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There is little sign of vertical integration of private healthcare companies, or of any consistent
synergies with other services.
Privatisation of services may be established first before globalisation
 Abbreviations
EU
GATS
HMO
IBRD
IFC
IMF
MIGA
MNC
MRI
NAFTA
OECD
PFI
PPP
TRIPS
WHO
WTO
European Union
General Agreement on Trade in Services
Health management organisation (managed care)
International Bank for Reconstruction and Development (‘core’ part of World Bank)
International Finance Corporation (part of World Bank)
International Monetary Fund
Multilateral Investment Guarantee Agency (part of World Bank)
Multinational company
magnetic resonance imaging
North American Free Trade Agreement
Organisation for Economic Cooperation and Development
Private Finance Initiative (UK)
Public private partnership
Trade-Related Aspects of Intellectual Property Rights
World Health Organisation
World Trade Organisation
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1. Globalisation, privatisation and public services
1.1 Globalisation and public services
There are many issues connected with globalisation and its impact especially on developing countries. These
include economic development in general, development of national industries, exporting of profits, labour
conditions, environmental impacts, and erosion of power of democratic institutions. This paper is concerned
with the impact on public services in general, and health services in particular.
In most sectors - e.g. agriculture, extraction, production and service industries - the problem of globalisation,
in the sense of opening up these sectors to foreign capital, is its threat to national development. This problem
is significant whether the industry is in local private or public hands, whether privatisation is an issue or not.
The worst effects of globalisation on public services - e.g. health, education, water, energy – on the other
hand are specifically connected with privatisation: either through limiting social and economic solidarity in
the financing of services, so undermining the basic principle of public services; or privatisation of service
provision - once services such as health, education, transport, water, energy, waste management have been
privatised, the provision is dictated by the requirements of profits.
Whether the private companies involved are national or foreign is arguably a less important issue for public
services than the impact of privatisation on financing or service provision. For example, UK rail
privatisation is just as much of a problem in the hands of a UK-owned company like Railtrack or Virgin as
in the hands of a foreign-owned multinational like Vivendi. The same can be said in developing countries the privatisation of support services in Malaysian hospitals to a Malaysian-owned company does as much
damage to the public service as if it had been privatised to a multinational. There may still be negative
development consequences of globalisation in these services, from the entry of foreign capital, but the
distinctive damage to public services happens through privatisation.
The chart attempts to illustrate these distinctions. It presents a categorization of providers according to the
corporate form, the sector in which they are owned, and whether they are nationally or internationally based.
It can be used to identify various structural changes. For comments on the different elements in this chart,
see Annexe A.
 Privatisation and internationalisation (see also Annexe A)
Public
WHO, World
Bank
2. International
D
Munic
-ipal
Corporatised
Trusts,
municipal
enterprises
Not-forprofit
NGOs,
churches,
Foreign
public
enterprises
International
NGOs
Private
E
PPPs
Privatisation boundary 2
National
health,
universities
C
Privatisation boundary 1
State
1. National
B
Corporatisation boundary
A
Joint
ventur
es
Global
PPPs
F
Companies,
PPPs
National
companies,
partnerships
Globalisatio
n boundary
Multinationals
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1.2 The channels of globalisation
There are a number of different channels through which the process of globalisation is driving the
privatisation of public services. The most prominent at present is the role of the World Trade Organisation
(WTO) and the liberalising drive of its agreement on trade in services. But the agents of change also include
other international institutions – notably the international financial institutions (IFIs), the IMF and World
Bank, and also bodies such as the WHO and OECD. They also include the rules of the regional trading
zones, like NAFTA, or the EU, or Mercosur – these regions may already have in place trading rules and
procurement rules that impact on privatisation of public services. And they include bilateral relations
between countries, either through formal trade deals or through other international political relations, in
which countries such as the USA may place conditions on other countries which concern privatisation or
liberalisation of services.
Most of all, there are the constant activities of the corporations themselves, engaging in individual and
collective marketing of themselves, forming national and international political relations through a range of
mechanisms including corruption and promoting both privatisation and trade liberalisation as inevitable
historical trends.
The various elements are not necessarily co-ordinated, and there may be contradictions between these
elements. In November 2000 Suez-Lyonnaise is reported to have sounded a cautionary note about GATS at
a meeting discussing the position of EU and France in pushing for further liberalisation through GATS. The
company is said to have commented, “We are very careful with the terminology "liberalism". Therefore, we
want to preserve the public service in the framework of the liberalisation, in the long term it is the only way
we can ensure the profitability of our investment, by doing so we keep the confidence of the population in
our investment and in general we know if we liberalised one sector it does not work. That is why we are
developing public/private contracts." 1 Water privatisations are happening already, profitably, through
agreements reached between the company and governments. An aggressive push for liberalisation of trade
rules, which are not at present an obstacle in most countries, could just succeed in creating greater political
opposition to the process.
Finally, at the end of the chain are the decisions taken by governments to privatise or liberalise particular
services. Such decisions have already been made in many countries, in healthcare as well as other services
such as water, and are being discussed in others.
The rest of this paper looks at some of these factors, and ends with a brief survey of internationally active
healthcare companies.
2. The WTO threat to public services
2.1 WTO – the potential impact of GATS
The World Trade Organisation (WTO), through the General Agreement on Trade in Services (GATS), is
creating potential extra pressure for privatisation of public services, especially healthcare. There have been a
number of detailed analyses of the potential impact of GATS in general 2, on health services in particular, 3
from the perspective of international trade unionism, 4 and from a development perspective.5
The key element in GATS is for countries to make ‘commitments’ to open a sector to trade. Countries are
not obliged to open sectors, but can do so: a number of countries have already done so in some aspect of
health services. 6
So far the impact of GATS is potential rather than actual: “the GATS is a framework agreement that is not
yet in application”7. But the WTO is working to increase the sanctions for not offering to open sectors, by
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insisting that states must prove they are not using anti-competitive policies to protect a sector: “The legal
tests under consideration would outlaw the use of non-market mechanisms such as cross-subsidisation,
universal risk pooling, solidarity, and public accountability in the design, funding, and delivery of public
services as being anti-competitive and restrictive to trade”.8
2.2 GATS exemptions – government services and procurement
At present GATS rules contain two clauses which exempt much of the public services area. The first is the
direct supply of services by government, as long as the services are “supplied in the exercise of
governmental authority” and “supplied neither on a commercial basis, nor in competition with one or more
service suppliers”. . The second exemption – in article XIII - exempts government procurement, which
includes contracts issued by public authorities for services of all kinds e.g. hospital cleaning. Between them,
they mean that inhouse services and contracted-out work are so far not covered by GATS.
But these exemptions have been explicitly targeted for removal or amendment by business. For example, in
1999 the European Services Network (ESN) proposed 9 that the procurement exemption should be removed:
“The absence of multilateral rules for procurement is probably the most important non-tariff barrier
affecting the services sector. The GATS 2000 global talks provide the right tool to improve the situation
either by deleting Art. XIII of the GATS or by extending the Agreement on Government Procurement to all
GATS member states.”
The ESN also proposed a tightening of the exemption for direct services: “A major obstacle to the
international fair competition is that public authorities try to get around public procurement regulations by
using so-called "in-house services" and therefore feel that by this they are not required to follow public
procurement laws. Federal, regional and local governments must be strictly advised that any body governed
by public law is obliged to follow public procurement regulations. This includes …. any association
formed by one or more of such authorities or bodies governed by public law…”
These areas may also be subject to pressure under procurement rules of governments or trading zones, such
as the EU. See below for an example of how the EU procurement regulations and provisions on concessions
may threaten to extend the portion of public services which may be forced open to private sector bids.
2.3 TRIPS
The Trade-Related Aspects of Intellectual Property Rights (TRIPS) agreement, which concerns international
patents, is administered by the WTO, but is separate from the GATS. TRIPS can also exacerbate the
problems of public services, especially in healthcare, because it reinforces the rights of patent-holders such
as the pharmaceutical companies. This makes the provision of drugs more expensive than it would otherwise
be – and so boosts the revenues of the pharmaceutical companies, at the expense of other healthcare
expenditure, as well as making some needed medicines - notably anti-AIDS drugs, for example –
prohibitively expensive.10 When South Africa and Thailand recently announced that they would grant
compulsory licences to make anti-AIDS drugs at low cost, the US threatened them with trade sanctions.11
3. The influence of other international institutions
3.1 IMF and World Bank: general conditionality
Structural adjustment programmes (SAPs) introduced under the IMF carry a large number of conditions. In
some cases these conditions explicitly refer to the privatisation, or commercialisation of public services. In
Tanzania, for example, increases in charges for healthcare and education were required as a condition of the
SAPs; in Ecuador the conditions included increases in energy prices12, in Ghana water privatisation was a
condition both for an IMF restructuring package and as a general condition of World Bank assistance.13
3.2 World Bank –IBRD projects
Specific loans from the World Bank may involve, and be conditional upon, privatisation of the provision of
the relevant services. This is now a commonplace in energy (recent examples include Uttar Pradesh in India,
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and Kenya) and water, where loans to Palestine, Ghana, and others have required privatisation of the water
service.14 The imposition of these conditions makes privatisation almost unavoidable, assuming that the
country needs the World Bank loan to develop the service further.
The World Bank is currently operating over 200 projects which concern healthcare: a list is attached at
Annexe B 15. Many of these projects are concerned, directly or indirectly, with restructuring of the public
health system, and effectively require further privatisation. Three examples illustrate the ways in which
private sector involvement, or private payment principles, form part of the agenda of these projects.
 Tanzania
The Bank has a $22m “Health Sector Development Program” Project in Tanzania which is concerned with
reforming the whole health sector. It’s first stated goal, “Strengthening Service Delivery” includes
improving quality and financial viability of services and will explicitly “promote private sector involvement
in delivery of health services”.16
 Indonesia
The Provincial Health Project for Indonesia starts with the stated aim of establishing ”effective health sector
decentralization” in two provinces, and includes later elements of a market-based approach including
“reviewing and piloting alternative insurance approaches” and “examining tax-based and other means of
generating resources for health”.17
 Bulgaria
The project in Bulgaria is summarised as assisting the government to restructure and improve access,
quality, and financial and operational sustainability – with no overt mention of private sector involvement. 18
However, the detailed project appraisal document 19 states that in the context of the Bank’s overall
programme for Bulgaria, the key areas with respect to the health sector include “putting into place an
efficient and sustainable health financing regime through an effective health insurance system and an
increased role for the private sector; reducing structural inefficiencies by reducing excess capacity,
strengthening sector management at the central and local levels, and promoting competition among
providers”.
Hospitals will be corporatised not for greater efficiency, but for ultimate handover to the private sector, so
the project aims: “to complete the re-registration of the health care establishments as trade companies in
the light of creating opportunities for subsequent privatisation, with guaranteed preferential participation of
doctors and dentists working within the health care system.”
3.3 World Bank: International Finance Corporation (IFC)
The IFC is a division of the World Bank, which invests solely in the private sector. As such, IFC loans in
public services are bound to be restricted to privatised ventures.
The IFC has a declared policy of being simply in favour of extending the role of the private sector in public
services, including healthcare. Its chief executive, Peter Woicke, declared in September 1999:
“….IFC is also moving aggressively to invest in sectors where we believe there is substantial scope for more
private sector involvement. This ranges from water and transportation investments to healthcare, education,
and the environment. Not that we believe the private sector should replace the public sector, but private
education and healthcare can and must compliment the public providers of these services. And a little bit of
competition will create innovation in these areas, often desperately needed, and hopefully this will have a
positive spill-over effect on badly run public service providers.” 20.
IFC has a special director for health and education projects, Karl Voltaire.
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The IFC’s investments are quite simple financial investments in private facilities, usually clinics providing
various diagnostic and therapeutic services, or hospitals, to private patients. The IFC investments so far have
been with partly local and partly multinational partners (based in Finland, Portugal, Spain, and Singapore).
 Russia
Most recently (January 2001), it has invested $2.1m in a new private clinic in St Petersburg, the New
Medical Center (NMC). This is described as an “a one-stop facility for most preventive, diagnostic, and
treatment services”, and is a venture of the private Finnish medical company Scanfert Oy, (see previous
section). IFC’s press release is somewhat misleadingly titled “IFC invests to boost Russian healthcare
system”: more accurately it states “IFC and its partners will be tapping into a potentially large market for
high quality private facilities in Russia”. 21
 Dominican republic
IFC has made similar investment in Dominican Republic (April 2000), where it invested US$22 million in
four private hospitals, to be run by Spanish hospital company Hospiten, in tourist destinations of the
Dominican Republic. The hospitals are said to ‘serve local residents’, but are basically an investment in the
tourist industry: “the lack of quality healthcare services has been identified as one of the major barriers to
the development of tourism in the Dominican Republic”. 22
 Brazil
In Brazil, IFC has invested $6.5m, in Innovative Health Services (IHS), a $25m joint venture with a
Brazilian financial company, ICATU, and a Portuguese company, Jose de Melo Group. I.H.S. is a holding
company which will invest in companies operating “in areas such as home care, occupational and
preventive medicine, information technology, prescription benefit management and hospital services and
management”.
This has been done explicitly to cater for the growth in private health insurance in Brazil, because the
insurance companies want more providers. IFC expects that the project will “create new options in
healthcare, which may change the way such services are delivered in Brazil”. 23
 Nigeria
In Nigeria, IFC has invested twice in private clinics serving the private healthcare market. In 1999 it
invested US$581,000 in Hygeia Nigeria Limited, a company headed by two local doctors, building five
clinics and upgrading facilities at Lagoon Hospital in Lagos, to “extend the managed care coverage for the
company's existing and potential clientele” 24. In 1997 it invested $290,000 in the Radmed Diagnostic
Center. 25
 India
The IFC’s largest investment in health remains the $8 invested in a new private 270-bed hospital in Calcutta,
India in 1997. The hospital is part of the Gleneagles chain, owned by the Singapore-based Parkway
Holdings. 26
3.4 World Bank: Multilateral Investment Guarantee Agency (MIGA)
Another section of the World Bank, MIGA, provides investment guarantees to protect mainly against
political risk.
Together with the IFC, MIGA has provided two remarkable forms of support for the private leasing of
medical equipment by a USA firm – DVI – into Brazil. DVI Inc is a company which finances the leasing of
medical equipment, mostly MRI scanners, but increasingly treatment equipment such as lasers. Until 1993 it
also owned hospitals, but now focuses exclusively on leasing it. DVI “provides equipment financing and
related services for users of diagnostic imaging, radiation therapy, and other medical technologies”. DVI
has expanded internationally and now does business in Europe, Asia-Pacific, and Latin America. 27 For such
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a company, the growing Brazilian market for health care – whether private or public – provides major
opportunities for growth business, but there remain currency risks and political uncertainty.
DVI has found the IFC and MIGA perfect business partners. First, the IFC formed a joint venture with DVI,
called MSF Cayman, in the offshore tax haven favoured by money-launderers, the Cayman Islands. The role
of MSF Cayman is to provide “cross-border loans and lease financing to private hospitals, clinics and
physician groups throughout Latin America, for the purchase of state-of-the-art diagnostic imaging and
radiation therapy equipment. The equipment includes magnetic resonance imaging (MRI), CAT scanners
and other medical devices that are essential to the improvement of health care delivery worldwide … The
developmental impacts of this project are significant particularly for cancer patients. It offers high-quality,
cost-effective and more efficient alternatives to invasive surgery or travelling abroad to the United States or
Europe for diagnosis and treatment”. 28
Then MIGA’s role was to provide insurance worth $75m to protect the investments against political risks,
including the risk of restrictions being placed on the export of profits, and the risk of expropriation.
A year later, in 2000, MIGA provided a further boost to the venture. This time it provided $150m worth of
guarantees against political risks for notes issued by MSF secured on future revenues from dollardenominated contracts in Brazil. This insurance was worth a lot to MSF and DVI, because it raised the credit
rating of the notes higher than the credit rating of Brazil itself – so international finance could be obtained by
MSF at lower interest rates than they could have otherwise. Once again, MIGA claimed that this has
development benefits: “This is a project with high development impact, which will help improve the
provision of health care in Brazil.” 29
3.5 Other international organisations and treaties
The activities of other international bodies also have an influence on the privatisation process.
 WHO
The World Health Organisation (WHO) has an obviously influential role both as an advisor and actor in
world health policy.30
 OECD
The Organisation for Economic Cooperation and Development (OECD), which exercises a powerful role as
economic policy advisor, provider of comparative international economic information – including
information on health services, and a growing regulatory role - although it abandoned its attempt to
introduce a Multilateral Agreement on Investment (MAI). It is currently taking coordinated initiatives on
bribery, offshore tax havens, and a code of conduct for multinational companies.31
 Energy charter treaty
The Energy Charter Treaty, as its name suggests, applies specifically in the energy sectors. It protects
multinational investments in energy in various ways, including an absolute legally enforceable right for
companies to export profits wherever they wish, in whatever currency they wish.32
 Regional trade zones: NAFTA, Mercosur, Asean, EU
Additionally, the various regional trade zones of the world have rules which may already affect trade in
services between countries in each zone. These rules may make privatisation easier or more likely in various
ways, for example by giving rights to investors anywhere in the zone to enter a market elsewhere.
In Canada, for example, the modification of healthcare policies in Alberta province could lead to a ‘one-way
street towards privatisation of the health sector’ because any attempt to reverse it could be met by investors
demanding compensation under NAFTA. 33
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3.6 Public procurement
Procurement rules can also affect the introduction of private capital into public services. This is an area
which is currently exempt from GATS, but in the EU at least, is covered by European regulations.
The EU has a set of common procurement rules for public authorities in all member states. They have to be
adopted as part of accession to the EU, and therefore have a similar impact on accession countries in CEE.
The main common principle is that they require every public authority in Europe, local, regional, and
national, to invite tenders from any undertaking in any country in the EU for all contracts issued by that
authority.34
There are some conditions to these requirements: direct service provision is not covered, because the
directives do not require compulsory tendering of any work carried out by the public authorities themselves,
or their own undertakings, then there is no requirement to invite tenders from private companies. (The
directives are thus the precise opposite of the tendering legislation that operated in the UK under the
Thatcher government, which insisted on tendering if the public authorities planned to do work themselves,
but allowed contracts to be given to favoured private contractors without any competitive tendering).
Tenders can be submitted by any organisation in Europe, public or private. Authorities cannot discriminate
against public sector undertakings, so a municipal enterprise in Italy can tender for a contract in Spain, for
example.
The services directive has a list of the services covered, which have to be tendered. At present the list of
services that have to be tendered includes services such as cleaning, catering, computing; but not health and
social services themselves. In practice however there is a considerable amount of Europe-wide
advertisement of health service work. The effect is that this work is open to both public and private sector
bidders, nationally and internationally.
Two small issues could change the effect of procurement directives dramatically. One is the scope of the
definition of direct services which are exempt – for example, the private sector have already tried to exclude
from this services provided by a consortium of local authorities (a common feature in continental Europe).
The more ‘arms length’ or corporatised the public sector body, the more vulnerable it could be to this kind of
shift. The other would be an extension of the list of services to include health and social services.
4. Governments and multinationals
4.1 Government decisions
The introduction of privatisation is ultimately by government decisions, as a result of a mix of influences –
national politics, international pressures, financial and economic crises or opportunities.
As in other policy areas, the dictatorship of General Pinochet in Chile was a pioneer in restructuring and
privatisation of health services in ways which are now more familiar – decentralisation of authority,
‘targeting’ of services to the poor, introduction of private health insurance competing with public systems but only for the money of the relatively rich and relatively healthy.35
Privatisation of services has since been introduced into a number of countries (extensively in India, for
example). In Europe at present there are proposals for further privatisation of services in both UK and
Germany (under social democratic governments)36. In Malaysia, there has been systematic and deliberate
privatisation of both hospitals and support services in recent years. Both supplies and support services were
privatised in huge monopoly contracts, accounting between them for 22% of the health budget. Private
hospitals and clinics have been expanding, and privatised health insurance has been proposed. 37
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4.2 Managed care schemes
A number of developing countries, especially in Latin America - notably Brazil and Argentina - started
introducing ‘managed care’ schemes in the last 20 years. A key aspect of these schemes is that they exert
downward pressure on payments to hospitals, reducing risk and improving margins at the expense of health
workers. 38
In Brazil, these schemes have developed over a number of years, with over 700 existing today, served by a
large number of private hospitals. Multinationals started to invest into this system in the late 90s, including
Aetna (then USA-based, now part of ING) which set up a $375 million arrangement with Sul America;
American International Group, with a $460 million investment in Unibanco Seguros; Cigna, in a partnership
with Bank Excel and Golden Cross; and ITT Hartford Life in a joint venture with Icatu Seguros.
In July 2000 it was reported that the Baylor system in Texas established relations with Brazilian Groups
Care and APPH to form Hospitalium, a joint venture with a R$250 million budget (in Brazilian currency) to
buy Brazilian hospitals.39
There is a similar picture in the Philippines, where a number of HMOs developed. Again, three US-based
multinational insurers – United HealthCare, Aetna, and CIGNA – have invested in these managed care
ventures. 40
4.3 The problem of trade unions
Trade unions and organised health workers are often a specific target of health restructuring. In Mexico, for
example, supporters of privatisation claim that the three biggest issues about introducing more privatisation
were the effect on standards, of care, the risk-selection policies of insurers, and “the effect of shifting jobs
from the control of the unions to the private sector” 41. The point is thus about increasing the vulnerability of
health workers to exploitation, but also about reducing the political influence of the trade unions: the
education union and social security workers union are described as “the last bastion of support for
preserving the state's role as corporate provider of health care”
4.4 MNCs’ marketing - the annual global conference
The marketing activities of MNCs are central to the processes of privatisation and globalisation. From the
companies’ point of view, many of the international agencies are in effect supporting these efforts, to the
extent of forming global partnerships.42
There is an annual trade conference on the global potential for private healthcare, organised by a body called
the Academy for International Health Studies (AIHS), which is not an academic institution but a USA
private healthcare business association. The December 2000 conference shows how the multinationals are
working with each other, with governments, and with international bodies in this global marketing effort.43
The multinationals involved in the conference were principally the insurance companies: Aetna International
(Netherlands); Allianz Group (Germany); Aon Healthcare Alliance (USA); CIGNA International Healthcare
(USA); UnitedHealthcare International (USA). Astra/Zeneca Pharmaceuticals (UK) was also involved.
The conference treats healthcare, worldwide, as simply a marketing opportunity. There were workshops on
“private health sector investment - opportunities and obstacles” in Argentina, Australia, Brazil, Chile,
Egypt, Germany, Indonesia, Israel, Mexico, Nigeria, Philippines, Poland and South Africa. Seminar themes
included: “Globalization of American Managed Care: Trends, Opportunities and Challenges”; “Employee
Benefits for the Multinational Corporation: Health Plan Challenges”; “Global Demographic Trends:
Implications for Payers, Providers and Pharmaceuticals”.
The conference was attended by the World Bank and the WHO, who made a joint presentation to a plenary
session of a “"State of the World's Healthcare Report”. The conference had been started with a keynote
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address from Jeffrey Sachs, Chair of the WHO Commission on Macroeconomics and Health, on "Health
Care Globalization in the 21st Century: Issues and Challenges”.
The conference was attended by high-ranking ministers and officials from many countries, and finished with
a “Ministries of Health” forum on "Perspectives on Public-Private Partnerships" (the conference had hoped
to host a formal inter-ministerial conference).
5. The multinational companies
This section gives a preliminary list by category of the main companies which have business in health
services in more than one country. It thus does not list private companies which are very important in their
own country but do not operate beyond there (for example, Clininvest, the healthcare chain of SuezLyonnaise des Eaux, which does not operate outside France; or a number of USA health insurance and
HMO companies, which do not operate outside the USA).
It represents the result of initial paper-and-web research by PSIRU into multinational company activities in
healthcare. (January 2000)
The data on these companies’ activities is now being collected into PSIRU’s database, and will be available
through the PSIRU website (www.psiru.org).
5.1 Insurance multinationals
Company
Aetna International
AIG
Allianz
Cigna
United Health
Adeslas (Aguas de
Barcelona)
BUPA






Base
Netherlands
USA
Germany
USA
USA
Spain
Other countries
Many (excluding USA)
Many
UK
Spain, Ireland, Thailand,
Hong Kong
Many
Philippines, Hong Kong
Argentina
Activity
Insurance
Insurance
Insurance
Insurance
Insurance
Hospitals, insurance
Hospitals, insurance,
Aetna International was sold by its USA group to ING, the Netherlands insurance and finance
company, in December 2000. It no longer has any connection with the USA insurance group
Aetna.
AIG and Allianz are both very large insurance companies for whom health insurance is a small
part of their business. Allianz specialises in offering healthcare for multinationals’ employees.
Cigna has a substantial health insurance business, and has expanded into a number of countries
including Mexico.
United Health, a large HMO operator in the USA, now has health schemes in Philippines and
Hong Kong.
Adeslas is the largest healthcare company in Spain, as an insurer and as an owner of private
hospitals and clinics. It also operates in Argentina where it owns and runs private hospitals.
BUPA has expanded its insurance services to a number of countries, both in Europe and
elsewhere. It has hospitals in Spain, but as a consequence of their ownership of the 3rd largest
private insurance company, Sanitas, which owns 2 hospitals – not as an expansion of the UK
hospital business.44
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5.2 Hospital multinationals
Company
HCA
Sun Healthcare
Tenet
Paracelsus
Capio
Base
USA
USA
USA
Germany
Sweden
Parkway Holdings
Singapore
Afrox
South Africa


Other countries
UK, Switzerland
(UK)
Spain
Switzerland, USA
UK, Norway, Denmark,
Poland
Malaysia, Indonesia, Sri
Lanka, India, UK
Zimbabwe
Activity
Hospitals
Hospitals
Hospitals
Hospitals
Hospitals, clinical
services
Hospitals
Hospitals, occupational
health
The big USA hospital companies – HCA, Sun and Tenet – have all reduced their international
operations in recent years, but still have a presence in Europe.
Paracelsus operates outside Germany in Switzerland and the USA, where its indirectly owned
subsidiary has had financial problems.

Capio has grown rapidly in the last few years from its base in a privatised hospital in Stockholm.
However most of its other operations, including the overseas ones, are specialist clinics rather than
general hospitals. Capio was owned by Swedish venture capitalists Bure but was floated as an
independent company in September 2000.

Parkway Holdings has a significant number of hospitals in south and southeast Asia. It also owned a
hospital in London, but this has had financial problems and in 2000 it was seeking to sell it.

Afrox is a South African company which has operations in Zimbabwe and is hoping to expand
outside Africa.
5.3 Clinical, laboratory and other services
Company
Fresenius
Scanfert Oy
AstraZeneca
Healthsouth
Quest Diagnostics
Worldcare
Home
Germany
Finland
UK/Sweden
USA*
USA
USA
Other places
USA, others
Portugal, Russia
(USA)
UK, Australia
UK, Mexico
many
Sector
Dialysis, clinical services
Clinical services
Drugs, cancer care
Clinical services
Laboratories
Telemedicine

Fresenius is a German company, which started manufacturing kidney dialysis machines and has now
expanded into providing dialysis clinics in many countries. It now offers other clinical services too,
and hospital management.

Scanfert Oy is a Finnish company, which has recently expanded into St Petersburg (Russia) with the
backing of the World Bank’s IFC division.

AstraZeneca is an unusual case of a drugs multinational which also has a subsidiary in health
services – a cancer clinic chain in the USA.
Healthsouth is a major USA operator of outpatient surgery, which has expanded into diagnostic
centres, and occupational medicine centres in the US, Australia, Puerto Rico, and the UK

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
Quest Diagnostics is a major laboratory testing company which has expanded beyond the USA into
UK and Mexico.

Worldcare is a telemedicine company which has formed a consortium of leading USA hospitals, and
seeks to sell telemedicine services worldwide.
5.4 Support services multinationals
Company
ISS
Sodexho
Rentokil/Initial
Granada/Compass
EDS
Home
Denmark
France
UK
UK
USA
Elsewhere
many
Many
Many
Many
Many
Main service
Cleaning, care homes
catering
cleaning
catering
Computing
ISS is a cleaning and hotel services multinational, with hospital cleaning contracts in a number of countries.
It has diversified into residential care in Scandinavia, and is involved in 6 hospital concessions in the UK,
under the private finance initiative (PFI) which has encouraged consortiums with support services
companies.45
Sodexho is a French-based catering multinational, with hospital catering contracts in many countries. It has
withdrawn from its venture into residential care homes in Scandinavia. It also has a hospital PFI concession
in the UK.
Rentokil/Initial and Granada/Compass are the other two major cleaning and catering multinationals, each
with many contracts in hospitals in many countries.
6. Observations
This is a preliminary report, based on a first trawl through evidence on the behaviour of healthcare
multinationals and some of the global institutions. Some general comments seem possible, both on the forces
of globalisation and on the companies themselves.
6.1 Globalisation

The divisions of the World Bank appear to be very significant forces driving privatisation in
healthcare, both through projects, investments, and institutional support for the multinationals. The
WHO also seems to be associating itself with the policy collapse into ‘public-private-partnerships’
that is happening in other services too.

While the WTO and GATS is a clear background to these developments, privatisation in one form
or another is happening in a wide range of countries already. Campaigns against privatisation at the
country level require international support in addition to the global opposition to GATS.

Both trading rules and procurement rules of organisations like NAFTA and the EU may impact on
privatisation of health services. These effects are additional to the threats from the WTO, the World
Bank, etc.
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6.2 Multinationals
The picture of multinational behaviour by private healthcare companies is not as coherent or as expansionist
as in other sectors (including other public service sectors such as water, waste management, and energy).

Many of the USA groups, both the hospital companies and the HMO insurers, have experienced
financial and performance problems in recent years. The extreme illustration of the weakness of
these groups was the sale of Aetna’s entire international health division. (In this case, healthcare
does echo a similar international weakness of US companies in water and waste).

The private hospital companies have not been very successful so far at expanding internationally.
This is true not only for the USA groups but also the French companies. Vivendi withdrew from the
UK 4 years ago and Suez-Lyonnaise has never expanded Clininvest outside France, yet these two
groups are extremely internationally aggressive in all other public service sectors. Within Europe,
companies which are very large in their own country, - e.g. Paracelsus – show little sign of
expanding into neighbouring countries. Even Parkway Holdings, the most successful international
hospital group, is selling its UK hospital.

Cleaning and catering support services exhibit the ‘classic’ pattern of multinational dominance
worldwide, at least in developed countries. These companies may also establish themselves in more
general hospital concessions, but so far this has happened only with the UK’s PFI scheme.

The insurance companies, as insurers or with HMO schemes, are also expanding. Some of this
appears to be simply into ‘niche’ markets, for example, of multinationals’ employees, but there is
also some investment into developing countries HMOs. This expansion is obviously dependent on
countries adopting policies which create this market.

There is also evidence of international expansion in clinical diagnostic or therapy services, such as
dialysis, blood products, MRI scans. There is evidence of this kind of service being privatised in a
number of countries, including Brazil (see the IFC/MIGA financed schemes above), India (where
Delhi council hospitals are to franchise private companies to provide CT scan, cardiac doppler and
echo, respiratory lab, incinerator services and other high investment medical technologies 46),
Canada (where private MRI scans have opened up in a basically public healthcare system 47), and
this seems to be the market which companies like Fresenius, Capio and Scanfert are expanding into
(and which the World Bank/IFC seems keen to finance).

There is little sign of vertical integration of private healthcare companies, or of any consistent
synergies with other services. There are almost no signs of pharmaceutical companies buying
insurers or service providers and no consistent merger patterns. In fact demergers have been more
striking – Aetna selling its international business, Capio being sold off by its parent finance group,
Sodexho selling its venture into residential care.

Globalisation may not necessarily arrive at the first stage of privatisation. In Brazil and Philippines
with HMOs, the privatised systems were first established by local companies and then the
multinationals arrived, through joint ventures or acquisition.
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Annexe A: Comments on privatisation/internationalisation chart
The term “privatisation” is used to describe various boundaries in different situations. In transition countries
of central and eastern Europe and the former Soviet Union, the shift of responsibilities from the central state
into the hands of elected local authorities - across the boundary between A and B - is sometimes described as
‘privatisation’.
The corporatisation of public service organizations – crossing the boundary between B and C – usually
involves the introduction of business accounting if not plc/corporate status, and may be a change as
significant as that to private ownership itself.
The strict boundary of the private sector – between C and D – may not be of such great significance in
countries such as Germany where church and charitable organizations are incorporated into the public health
system: in this case the boundary between A, B, C and D on the one hand, and E or F on the other, may be of
greater relevance.
Finally, the difference between a joint venture where the public sector has some stake – E – and a 100%
privately owned undertaking – F – is often treated as very important for presentational reasons, whereas both
supporters and opponents of privatisation tend to agree that such PPPs bring nearly all the expected
consequences of full privatisation.
The horizontal division between national and international provides the distinction, in the final private
column, between services being privatised to locally owned businesses, and privatisation to foreign-owned
or multinational companies.
It is worth mentioning the other parts of the international section. The classification by sector of
international activities also helps raise the question of the differences between the activities of multinational
corporations, and international activities by public sector and NGO organisations.
The segments in the international band include activities of multilateral public sector bodies such as the
WHO or the World Bank; international NGOs, e.g. in many primary health care projects in developing
countries; global PPPs between the multilaterals and the private sector 48; and global charities like the Gates’
Foundation. All of these are now significant elements in healthcare systems of many countries.
There is even some international trading of healthcare by public sector organisations. For example, at least
one of the central European spas, Piestany, in Slovakia, was in the mid-1990s both providing free treatment
to Slovaks under the national health service, while at the same time treating foreign fee-paying patients,
mainly from Saudi Arabia.
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Annexe B: Current World Bank projects involving healthcare
Project Name
HIV/AIDS Rapid Response Project
Project
Id
Total
Amount
at Board*
(USD$M)
P060329
Health & Population(Supp).
P073278
Social Development Fund Project
Education Sector Investment Loan Project
P041566
P040650
Malaria/HIV/AIDS Project
P065713
HPSP HIV/AIDS Prevention Project
P069933
District AIDS and Reproductive Health (DARE)
Project
P066486
Rural and Small City Water Project
P049924
Health Sector Management Project
P064926
Multisectoral HIV / AIDS Project
P069886
15
Country
Gambia,
The
P065372
60 Tanzania
Health Investment Fund Project
P051174
10 Moldova
Integrated Early Childhood Development Project P068463
40 Eritrea
Health Sector Reform Project
P008797
40 Romania
Health Sector Reform Project
P055157
Water Supply and Sanitation for Low Income
Communities Project (02)
P059477
Health Sector Development Project
P058627
22 Tanzania
Provincial Health Project
P049545
38 Indonesia
Health Sector Reform Project
P053200
Policy Support Project
P064149
National Nutrition Project
P050751
92 Bangladesh
Tehran Sewerage Project Loan
P069946
145 Iran, Islamic R
Primary Health Care and Nutrition Project (02)
P069943
87 Iran, Islamic R
45 India
Health Sector Support Project
P055122
41.51 Chad
Immunization Strengthening Project
P067330
142.6 India
P050657
110 India
Project Name
P010505
P047319
P050483
Project
Id
100.48 India
50 Senegal
28.9 Yemen, Republic
Total
Amount
at Board*
(USD$M)
Country
Primary Health Care Project
P049894
5.4 Tajikistan
Health Sector Management Project
P051418
9.5 Slovenia
Hlth, Nutn &
Popultn
Water Supply
& Santn
Hlth, Nutn &
Popultn
Economic
Policy
Hlth, Nutn &
Popultn
Hlth, Nutn &
Popultn
Hlth, Nutn &
Popultn
Agriculture
Education
Education
Sector
Hlth, Nutn &
Popultn
Hlth, Nutn &
Popultn
Board
Approval
Date
Active 1/16/01
Active 12/21/00
Active 12/20/00
Active 12/20/00
Active 12/18/00
Active 12/12/00
Active 12/12/00
Active 10/17/00
Active 9/14/00
Active 9/12/00
Social
Protection
Hlth, Nutn &
Popultn
Hlth, Nutn &
Popultn
Hlth, Nutn &
Popultn
Hlth, Nutn &
Popultn
Hlth, Nutn &
Popultn
Hlth, Nutn &
Popultn
Hlth, Nutn &
Popultn
Hlth, Nutn &
Popultn
Economic Policy
63
Bulgaria
.3
77
Indonesia
.4
6.
Lesotho
5
8 Central African
Uttar Pradesh Health Systems Development
Project
District Poverty Initiatives Project - Rajasthan
Quality Education for All Project
Child Development Project
Multisector
Hlth, Nutn &
7 Rwanda
Popultn
30 Senegal Social Protection
44.99 Mali
Education
Hlth, Nutn &
40 Eritrea
Popultn
Banglade Hlth, Nutn &
40
sh
Popultn
Hlth, Nutn &
50 Kenya
Popultn
Water Supply &
32 Ecuador
Santn
Hlth, Nutn &
5 Samoa
Popultn
Hlth, Nutn &
59.7 Ethiopia
Popultn
Social Action Fund Project
Economic Reform Technical Assistance Project P059501
Sector
Proje
ct
Statu
s
Active
8/22/00
Active
8/22/00
Active
7/27/00
Active
6/27/00
Active
6/22/00
Active
6/15/00
Active
6/15/00
Active
6/15/00
Active
6/13/00
Active
5/30/00
Active
5/25/00
Active
5/18/00
Active
5/18/00
Active
5/12/00
Active
4/27/00
Active
4/25/00
Active
4/25/00
Active
Active
Active
4/25/00
4/11/00
3/21/00
Projec
Board
t
Approval
Status
Date
Active
3/7/00
Active
1/20/00
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P058358
Health Sector Reform Program Project
P062932
80 Peru
P050667
182.4 India
Uttar Pradesh District Primary Education Project
(03)
Mindanao Rural Development Project (APL)
P058842
4
Solomon
Islands
Health Sector Development Project
Hlth, Nutn &
Popultn
Hlth, Nutn &
Popultn
27.5 Philippines
Health Sector Support Project (02)
P051741
40 Madagascar
Health Project
P035780
21.24 Lithuania
Health Insurance for the Poor Project
P063388
4.9 Argentina
Active
1/6/00
Active
12/16/99
Education
Active
12/16/99
Agriculture
Hlth, Nutn &
Popultn
Hlth, Nutn &
Popultn
Hlth, Nutn &
Popultn
Active
12/2/99
Active
12/2/99
Active
11/30/99
Active
11/24/99
Marmara Earthquake Emergency Reconstruction
Project
Project
Id
Project Name
Total
Amount
at Board*
(USD$M)
Country
Health Surveillance System and Disease Control
Project
P055482
52.5 Argentina
EC SUPP SOC DEV II/HLTH & NUTRIT.
P068739
20.2 Ecuador
Social Action Project (02)
P064510
12 Burundi
Health System Project
P051273
29 Croatia
Fisheries Project (04)
P009468
Social Protection Initiatives Project
P066336
Structural Reform Support Project
Western Poverty Reduction Project
P052154
P046564
Health Sector Reform Project
P060392
25 Bolivia
Rural Water Supply and Sanitation Project (04)
P057352
46 China
Project Name
Project
Id
Sector
Hlth, Nutn &
Popultn
Hlth, Nutn &
Popultn
Social Protection
Hlth, Nutn &
Popultn
Agriculture
28 Bangladesh
Egypt, Arab
5
Rep
16.5 Georgia
160 China
Total
Amount
Country
at Board*
(USD$M)
44 Brazil
P055388
Integrated Drug Prevention Pilot Project
P058526
Basic Health Project
P044523
10
Health Project (09)
P036953
60 China
Health Project
P046499
42.5 Kazakhstan
Social Sector Support Project
P060943
60 Malaysia
Health Sector Reform Project
P039749
35 Jordan
P055003
4.9 Mauritania
P050732
P044840
22 Guinea
15 Moldova
Nutrition, Food Security and Social Mobilization
Project
Village Communities Support Project
Social Investment Fund Project
Project Name
Project
Id
4.75 Argentina
Total
Amount
at Board*
(USD$M)
BosniaHerzegov
Country
HN/NUTRI/HEALTH (SUPL)
P064866
10.4 Honduras
Public Works Project (02)
P060132
Municipal Development Project (02)
P055480
10.1 Chile
Health Sector Development Program
P040652
40 Mali
Health Financing and Management Project
P005525
66 Morocco
Maharashtra Health Systems Development
Project
P050651
50
Yemen,
Republic
134 India
Active
10/14/99
Active
10/7/99
Active
10/5/99
Active
10/5/99
Active
7/20/99
Social Protection
Active
6/29/99
Economic Policy
Agriculture
Hlth, Nutn &
Popultn
Water Supply &
Santn
Active
Active
6/29/99
6/24/99
Active
6/15/99
Active
6/3/99
Sector
Animal and Plant Health Protection Project
Projec
Board
t
Approval
Status
Date
Agriculture
Hlth, Nutn &
Popultn
Hlth, Nutn &
Popultn
Hlth, Nutn &
Popultn
Hlth, Nutn &
Popultn
Social Protection
Hlth, Nutn &
Popultn
Hlth, Nutn &
Popultn
Agriculture
Social Protection
Sector
Hlth, Nutn &
Popultn
Urban
Development
Public Sector
Mgmt.
Hlth, Nutn &
Popultn
Hlth, Nutn &
Popultn
Hlth, Nutn &
Popultn
Projec
Board
t
Approval
Status
Date
Active 5/27/99
Active 5/5/99
Active 5/4/99
Active 5/4/99
Active 4/8/99
Closed 3/30/99
Active 3/25/99
Active 3/15/99
Active 2/23/99
Active 2/16/99
Proje
ct
Statu
s
Board
Approval
Date
Active 1/28/99
Active 1/28/99
Active 12/22/98
Active 12/17/98
Active 12/17/98
Active 12/8/98
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Population and Reproductive Health Project
P041568
11.3 Guinea
HEALTH
P058520
12 Latvia
Health Sector Development Program Project
P000756
100 Ethiopia
Social Action Fund Project (02)
P049599
66 Malawi
Hlth, Nutn &
Popultn
Hlth, Nutn &
Popultn
Hlth, Nutn &
Popultn
Social Protection
Active 12/1/98
Active 11/12/98
Active 10/27/98
Active 10/15/98
1
French foreign trade Secretary Meeting minutes' on GATS meeting 17 November 2000 (translated)
Eg “How the World Trade Organization’s new “services” negotiations threaten democracy” by Scott Sinclair
Canadian Centre for Policy Alternatives; 2000
3
Rewriting the regulations: how the World Trade Organisation could accelerate privatisation in health-care systems
Allyson M Pollock, David Price Lancet 2000; 356: 1995-2000
4 “The WTO and the General Agreement on Trade in Services: What is at stake for public health“ Public Services
International and Education International (PSI & EI) July 2000
5 World Development Movement Report (WDM) “In whose service? The threat posed by the General Agreement on
Trade in Services to economic development in the South” by Ellen Gould and Clare Joy December 2000
http://www.wdm.org.uk/cambriefs/WTO/Inwhoseservice.htm
6
PSI & EI, p.14 and annexe
7
Sinclair, section 2
8
Pollock and Price, Lancet 2000; 356: 1995
9
European Services Network “ESN POSITION PAPER ON GATS 2000 AND PUBLIC PROCUREMENT Final Version
2
- April 23, 1999
10
PSI & EI, p.15
ICFTU, Brussels, 8/6/00
12
DR BANKENSTEIN'S MONSTERS: THE WORLD BANK, THE IMF AND THE ALIENS WHO ATE ECUADOR by
Gregory Palast The Observer, London Sunday, 8 October 2000
13
Source: Sarah Grutsky, Globalization Challenge Initiative
11
See PSIRU papers on “Independent Power Producers: A review of the issues” and “Privatisation of water
and energy in Africa”, both available at www.psiru.org/reports
14
The source of the material in Annexe B is the World Bank’s website www.worldbank.org. The various tables and
reports are generated in response to queries submitted by scripts.
16
World Bank Project ID P058627
17
World Bank Project ID P049545
18
World Bank Project ID P055157
19
Document of The World Bank Report No. 20339 BUL PROJECT APPRAISAL DOCUMENT ON A PROPOSED
LOAN IN THE AMOUNT OF US$63.3 MILLION TO THE REPUBLIC OF BULGARIA FOR A HEALTH SECTOR
REFORM PROJECT May 30, 2000
20
Peter Woicke Annual Luncheon Speech 25 September 1999 “A New Direction”
http://www.ifc.org/ifc/pressroom/speeches/amlunch/amlunch.html
21
“IFC INVESTS TO BOOST RUSSIAN HEALTH CARE SYSTEM“ IFC Press Release No. 01/36 Jan 2001
22
“IFC INVESTS IN HOSPITAL NETWORK IN THE DOMINICAN REPUBLIC” IFC Press Release 102, April 7 2000
23
“IFC MAKES FIRST HEALTHCARE INVESTMENT IN BRAZIL“ IFC Press release 99/124 March 19, 1999
24
IFC INVESTS IN HEALTHCARE AND MANUFACTURING IN NIGERIA” IFC Press release 00/25 Sept 9 1999
25
http://www.ifc.org/ifc/ABN/cic/nigeria/english/invest.htm#radmed
26
“IFC TO INVEST US$8 MILLION IN MODERN MULTI-SPECIALITY PRIVATE HOSPITAL IN CALCUTTA
INDIA” IFC Press Release No. 98/50 November 20, 1997
27
Hoovers profile of DVI Inc. www.hoovers.com
28
“MIGA Insures Ground-breaking Health Care Project in Brazil” MIGA Press release August 6, 1999
29 MIGA: “Latin Report: Public-Private Insurance” September 2000
30
www.who.org
31
See www.oecd.org, www.oecd.org/els/health
32
See www.encharter.org, www.encharter.org/English/Secretariat/index.html. The website is recent. Learning form the
lesson of the MAI, the Energy Charter Treaty was never available on the internet until it came into force in 1998.
33
Legal Opinion Appleton Associates 10/4/2000”NAFTA Investment Chapter Implications of Alberta Bill-11
34
The existing procurement directives are currently being consolidated. The proposed new directive provisions are
published in “Proposal for a DIRECTIVE OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL on the
coordination of procedures for the award of public supply contracts, public service contracts and public works
contracts”. Brussels, 30.8.2000 COM(2000) 275 final/2 2000/0115 (COD)
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35
Restructuring and privatization of health care services: Selected cases in the Americas by Sandra Polasyk. ILO
Action Programme on Privatization, Restructuring and Economic Democracy. November 1999
36
Restructuring and privatization of health care services: Selected cases in western Europe by Stephen Bach. ILO
Action Programme on Privatization, Restructuring and Economic Democracy. November 1999
37
“Privatisation, the State and Healthcare Reforms: Global Influences & Local Contingencies in Malaysia” by Chan
Chee Khoon, Citizens' Health Initiative. Paper presented to 9th International Congress of the World Federation of
Public Health Associations Beijing, People’s Republic of China September 2-6, 2000
http://prn.usm.my/chi.html
38
How the United States Exports Managed Care to Third-World Countries. By Howard Waitzkin and Celia Iriart,
Monthly Review May 1, 2000
39
“AIHS Country workshop report” Modern Healthcare International 17/7/2000
40
“AIHS Country workshop report” Modern Healthcare International 17/7/2000
41
“AIHS Country workshop report” Modern Healthcare International 17/7/2000 www.modernhealthcare.com
42
See Buse &.Walt Bulletin of the World Health Organization, 2000, 78 (4)
43
See www.aihs.com/summit/summitabout.html for information on speakers and agenda.
44
“A Spanish revolution; With surging economy, private sector plays vital role in healthcare system” FT 13/11/2000
45
ISS Half-yearly results August 2000
46
THE HINDU December 18, 2000: MCD move on hospitals to hit poor
47
Modern Healthcare International 13/11/2000 “Clash in Canada: Privatization legislation and NAFTA open
healthcare market to protests”
For a review of the extent of these Global PPPs see “Global public–private partnerships: parts I and II– a new
development in health?” K. Buse &G.Walt Bulletin of the World Health Organization, 2000, 78 (4)
48
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