title: Assessment of the association of health with the liberalisation of trade in services under the World Trade Organisation.
abstract: BACKGROUND
  The liberalisation of trade in services which began in 1995 under the General Agreement on Trade in Services (GATS) of the World Trade Organisation (WTO) has generated arguments for and against its potential health effects. Our goal was to explore the relationship between the liberalisation of services under the GATS and three health indicators--life expectancy (LE), under-5 mortality (U5M) and maternal mortality (MM)--since the WTO was established.
  
  
  RESULTS
  This was a cross-sectional ecological study that explored the association in 2010 and 1995 between liberalisation and health (LE, U5M and MM), and between liberalisation and progress in health in the period 1995-2010, considering variables related to economic and social policies such as per capita income (GDP pc), public expenditure on health (PEH), and income inequality (Gini index). The units of observation and analysis were WTO member countries with data available for 2010 (n = 116), 1995 (n = 114) and 1995-2010 (n = 114). We conducted bivariate and multivariate linear regression analyses adjusted for GDP pc, Gini and PEH. Increased global liberalisation in services under the WTO was associated with better health in 2010 (U5M: -0.358 p<0.001; MM: -0.338 p = 0.001; LE: 0.247 p = 0.008) and in 1995, after adjusting for economic and social policy variables. For the period 1995-2010, progress in health was associated with income equality, PEH and per capita income. No association was found with global liberalisation in services.
  
  
  CONCLUSIONS
  The favourable association in 2010 between health and liberalisation in services under the WTO seems to reflect a pre-WTO association observed in the 1995 data. However, this liberalisation did not appear as a factor associated with progress in health during 1995-2010. Income equality, health expenditure and per capita income were more powerful determinants of the health of populations.
authors: Observatory of Public Policies and Health, University of Alicante, Alicante, Spain.
authors: Román
authors: R
authors: Umaña-Peña
authors: National School of Public Health, University of Antioquia, Medellin, Colombia; Research Committee of the University of Antioquia (CODI): Research Group on public policy and health, Sustainability Strategy CODI 2013-2014, Medellin, Colombia.
authors: Álvaro
authors: Á
authors: Franco-Giraldo
authors: Carlos
authors: C
authors: Álvarez-Dardet
authors: Observatory of Public Policies and Health, University of Alicante, Alicante, Spain; Public Health Research Unit, University of Alicante, Alicante, Spain; CIBER Epidemiology and Public Health (CIBERESP), Madrid, Spain.
authors: Carlos Álvarez-Dardet
authors: CÁ
authors: Díaz
authors: Observatory of Public Policies and Health, University of Alicante, Alicante, Spain; Public Health Research Unit, University of Alicante, Alicante, Spain; CIBER Epidemiology and Public Health (CIBERESP), Madrid, Spain.
authors: María Teresa
authors: MT
authors: Ruíz-Cantero
authors: Observatory of Public Policies and Health, University of Alicante, Alicante, Spain; Public Health Research Unit, University of Alicante, Alicante, Spain; CIBER Epidemiology and Public Health (CIBERESP), Madrid, Spain.
authors: Diana
authors: D
authors: Gil-González
authors: Department of Public Health, History of Science and Gynaecology, Miguel Hernández University, San Juan de Alicante, Spain.
authors: Ildefonso
authors: I
authors: Hernández-Aguado
mesh_terms: D003132:Commerce; D003430:Cross-Sectional Studies; D006305:Health Status Indicators; D006801:Humans; D038622:Internationality