J A N E L E T H B R I D G E

The Promotion of Investment Alliances by the World Bank Implications for National Health Policy

Keywords: global health policy, investment alliances, privatization, World Bank

This article will examine how World Bank policies that influence national healthcare systems have been facilitated through investment alliances between members of the World Bank Group, specifically the International Finance Corporation (IFC) and the Multilateral Investment Guarantee Agency (MIGA), regional development banks and multinational and national company interests. The data used in this article was gathered from the information and publications available through the websites of the World Bank Group, regional development banks, multinational companies and private equity investors. Some of the loan documents available through the websites of the World Bank Group and regional development banks were consulted. The financial complexity of many of the investments in new healthcare systems provides a challenge for future regulatory systems in healthcare. The involvement of a range of private sector interests in healthcare also poses problems for continued development of health knowledge within publicly funded systems.

Introduction

This article examines how World Bank (http://www.worldbank.org) policies that influence national healthcare systems have been facilitated through investment alliances between members of the World Bank Group, specifically the International Finance Corporation (IFC; http://www.ifc.org) and the Multilateral Investment Guarantee Agency (MIGA; http://www. miga.org), regional development banks and multinational and national company interests.

The data used in this article was gathered from the information and publications available through the websites of the World Bank Group, regional development banks, multinational companies and private equity investors. Some of the loan documents available through the websites of the World Bank Group, including the IFC and the MIGA, and regional development banks were consulted. Research that explored the impact of broader capital account changes linked to World Bank and International Monetary Fund (IMF) policies was considered initially as a way of providing a context for more specific healthcare investments. Research examining the impact of health sector reforms over the past decade was used to develop a perspective on the changes taking place within healthcare systems. [START_REF] Wade | Showdown at the World Bank[END_REF][START_REF] Wade | US Hegemony and the World Bank: The Fight Over People and Ideas[END_REF] characterizes two major agendas operating within the World Bank: the 'finance ministry' agenda that promotes privatization, eliminates deficits, opens the economy and promotes foreign direct investment; and, the 'civil society' agenda that stresses poverty reduction and empowerment of poor people. Although both agendas agree on the need for health, education, environment and institutional development policies, the 'finance ministry' agenda is determined to protects its core elements e.g. privatization.

These agendas can also be characterized as the results of a more fundamental conflict between neoliberalism and state-led developmentalism. The pursuit of neoliberalism, often described as the belief in free movement of markets with little or no regulation, has resulted in the setting up of markets in areas which until recently were considered public services and so not subject to market systems. Public sector reform has been promoted as part of the change necessary to create quasi-market structures in areas such as healthcare and education, so that the private sector can become providers of services. The private sector will be either paid by government on behalf of health services users or directly by users themselves. These policies have come into conflict with welfare state systems and with national governments that are attempting to build some form of social protection for the majority of the population. [START_REF] Strange | States and Markets[END_REF] and [START_REF] Leys | Market-Driven Politics, Neoliberal Democracy and the Public Interest[END_REF] both emphasize the role of multinational companies in national economies. [START_REF] Schneider | Business and the State: Mapping the Theoretical Landscape[END_REF] point out that companies often get access to the policy-making process in exchange for cooperation in the implementation phase. In the field of healthcare, the role of private companies is only beginning to be understood. As many healthcare systems are still evolving towards a mix of public and private provision, there is still much to understand about how healthcare companies develop long-term relationships with governments.

However, if the 'finance ministry' and 'civil society' agendas are seen as proxy indicators for the fundamental struggle between neoliberalism and welfare state development policies, they provide a useful framework for examining the process of transformation that is taking place in the healthcare systems of many developing countries and countries in transition. Some of the tensions that operate within the World Bank in relation to these two agendas can be illustrated by the case of healthcare investments and the World Bank Private Sector Development (PSD) Strategy. The process of developing the PSD Strategy provides further evidence of how World Bank policy is subject to pressure from both the 'finance ministry' agenda and the 'civil society' agenda although the extent to which 'civil society' can influence overall policy goals is probably limited.

World Bank Policies

The influence of the World Bank on national healthcare policies can be seen through World Development Reports (WDRs) relating to both healthcare and private sector development, and more specific healthcare strategies for parts of the World Bank Group. The annual WDR can be seen as a strong indication of World Bank policy. One of the most influential WDRs in relation to healthcare was 'Investing in Health' (World Bank, 1993), which presented strategies for providing cost-effective basic packages of public health and healthcare services. It argued that in order to deliver basic healthcare packages, the rest of the healthcare system would have to become self-financing. Extensive reforms and reallocation of public spending were needed to achieve this.

Governments were recommended to adopt user fees and self-financed insurance as well as investing in local level health centres and community care rather than more specialized care. Privatization of drug distribution, decentralization of healthcare management and more involvement of the private sector were also highlighted. Government regulation of insurance and the private sector were presented as an integral part of these reforms (World Bank, 1993). This report has influenced many government healthcare policies, which have often led to deterioration in the quality of services and level of accessibility rather than improvements in care [START_REF] Afford | Failing Health Systems in Eastern Europe[END_REF][START_REF] Bloom | Health and Poverty in Sub-Saharan Africa[END_REF][START_REF] Bloom | Pluralism and Marketisation in the Health Sector: Meeting Health Needs in Contexts of Social Change in Low and Middle Income Countries[END_REF].

Although essential elements of public sector reform involve the promotion and development of the private sector to deliver public services, the process of outsourcing and contracting out of services has been slow in many developing countries [START_REF] Polidano | The New Public Management in Developing Countries[END_REF][START_REF] Schacter | Public Sector Reform in Developing Countries[END_REF][START_REF] Schick | Principles of Public Expenditure Management[END_REF]. The introduction of specific private sector development strategies in the late 1990s by multilateral financial institutions may be interpreted as an indicator of the lack of response of the existing private sector to the process of economic and public sector reform. It can also be seen as a response to the pressure to adopt strategies that reduce poverty and provide services for poor people.

The process of developing the World Bank PSD Strategy involved consultation with a range of stakeholders, including private sector, nongovernmental organizations (NGOs), trade unions, governments and regional development banks. An 'Issues and Options' (World Bank, 2001) paper was made available in June 2001 and this led to some form of dialogue with stakeholders worldwide. A draft version was made available in December 2001, with a final version approved by the Executive Directors in February 2002. [START_REF] Bayliss | Glimpses of an Alternative: The Possibilities of Public Ownership in the World Bank's Latest Private Sector Development Strategy[END_REF] analysed how the final version that was approved by the Executive Directors differed from the initial 'Issues and Options' paper. They found that there had been some changes made as a result of the consultation particularly in relation to the possibility of public provision of public services. One change in position was in relation to the failure of the private sector to take on the financial risks involved in delivering services, which had been the subject of criticism by a range of civil society organizations. Other issues that had been modified or at least showed some indication that other experiences had been considered covered competition and regulation. In relation to regulation, the new paper emphasized the need to regulate public and private sector providers which, while acknowledging the public sector, can still be interpreted as a subtle pro-privatization policy. Although the main aim of the strategy -to promote the development of the private sector -remained unchanged, it pointed out that 'Public provision of basic services is also a key component of developing a national-wide health or education system'.

The revised PSD strategy, launched by the World Bank in 2002, anticipates a wider role for the private sector in providing health and education services. The World Bank Group's Implementation Progress Report on PSD Strategy highlights its work so far in building up a private sector to deliver social services (World Bank, 2003a). There are signs that there has been extensive debate within the World Bank about how to promotion private provision in health and education.

However, the specific role of supporting private sector development in the healthcare sector is taken increasingly by the IFC, part of the World Bank Group, which describes itself as 'the largest multilateral source of loan and equity financing for private sector projects in the developing world' (accessed 1 February 2005, http://www.ifc.org). The IFC was set up to promote the flow of private capital from world money markets to developing countries, which helps to promote the development of a private sector in a specific industry [START_REF] Lavelle | International Finance Institutions and Emerging Capital Markets in Africa[END_REF]. The IFC requires the support of state and non-state social coalitions in order operate effectively.

Although providing support for the development of a private sector, the IFC tries to complement private investors rather than supplant them, it also draws in additional funds from other sources and has to persuade investors to pursue the full commercial market risk in making investments. Unlike many international organizations, the IFC has a profit goal as well as a development goal. The work of the IFC complements the work of the World Bank in public sector reform, by focusing on the development of the private sector. The IFC is expected to increase its lending to private companies working in health in support of the World Bank PSD [START_REF] Bijlmakers | The World Bank's Private Sector Development Strategy: Key Issues and Risks Executive Summary[END_REF]. [START_REF] Lavelle | International Finance Institutions and Emerging Capital Markets in Africa[END_REF] argues that over time, the IFC has changed from being the banker for developing countries to promoting funds where international investor interest is limited. In reality this means more IFC investments in poorer, riskier countries. In this sense, the IFC can be seen to be guided more by the 'finance ministry' than the 'civil society' agendas although the trend towards making IFC investments in poorer, more high risk countries, suggests that it too is also influenced by 'civil society' agendas.

Regional development banks were consulted as part of the PSD Strategy. Officially regional development banks describe their relationship with the World Bank Group as one of cooperation but there are also elements of competition between these regional players and multilateral financial institutions [START_REF] Bull | Multilateral Development Banks as Regionalising Actors: The Asian Development Bank and the Inter-American Development Bank[END_REF]. Although the World Bank ( 2002) PSD Strategy has the highest profile, some of the regional development banks have developed their own private sector development strategies, often as a part of a poverty reduction strategy in the last few years (Asian Development Bank [ADB], 2000; Inter-American Development Bank [IADB], 2004).

Policy Implementation

An analysis of the healthcare investments that contribute to the development of financial infrastructure of the private healthcare sector, made by the IFC and the MIGA, both part of the World Bank Group, and regional development banks illustrates how healthcare reform programmes, privatization and private sector development strategies are beginning to intersect at international, regional and national levels. This article seeks to explore the hypothesis that multilateral agencies and regional development banks invest in the development of financial infrastructure for different forms of social protection, including healthcare, as part of a long-term strategy for the promotion of US-style social policies. The long-term implementation of USstyle social policies would be less effective without this specific financial infrastructure. Its development has a significant impact on the power of national governments to plan and control national healthcare systems.

Healthcare investments are often supported through several different types of investment alliances. The alliances developed by the IFC show how multinational companies and local companies are investing together in financial healthcare infrastructure projects. The relationships between the investment partners and the new companies being built up are focused on a shared set of financial interests that could lead to expanded business opportunities in future. For both multinational and local companies, shared investments in these new companies help to minimize the investment risk in a new enterprise.

Investment companies and financial institutions are also involved in IFC investments. The IFC remains a strong promoter of venture capital. Private equity and venture capital are playing an increasing role in providing investment for the global healthcare sector. Several US multinational healthcare companies have set up their own venture capital funds, for example, Humana Inc. (Summa Foundation, 2002; http://www.humana.com). These developments can be seen as another means of exporting US approaches to healthcare provision.

Several of the IFC investments are made in partnership with venture capital funds from global financial companies and independent venture capital trusts. Their relationship may be considered an investment alliance, which will help to yield a high rate of return rather than leading to future business opportunities in healthcare. In only one case has the private equity investor actually changed all its business interests into healthcare activities (http://www. oresaventures.com).

Several bilateral investment funds are partners in IFC projects. These alliances show how bilateral agencies are pursuing their own private sector development strategies. These strategies are not necessarily focused specifically on the development of private healthcare providers but on a wider private sector expansion.

The expansion of venture capital and private equity investments in the last decade can be seen as part of the expansion of the private sector worldwide. It can also be interpreted as the result of the over-accumulation of capital, which has led finance capital to search for new investment opportunities [START_REF] Harvey | The New Imperialism[END_REF]. There is also a relationship between the creation of a new private healthcare sector and limiting funding for the public healthcare sector. The types of healthcare company receiving this financing are an indication of how the private healthcare sector will develop in future. There appears to be little interest in investing in the development of integrated primary health care or in developing preventive strategies.

At the moment there do not appear to be investment alliances set up between the IFC and any of the regional development banks in the field of healthcare. This may be related to different perspectives and understandings of health and social protection. However, one of the new IFC ( 2004) priorities is to develop stronger links with regional development banks so that this situation may change (http://www.ifc.org).

The investment alliances developed by regional development banks are more often focused on national partners. Government health ministries as well as private and non-governmental agencies have been drawn into invest- [START_REF] Wade | Showdown at the World Bank[END_REF][START_REF] Wade | US Hegemony and the World Bank: The Fight Over People and Ideas[END_REF], in a discussion of the hegemony of the World Bank, uses the term 'soft power' defined as 'the ability to make others want the same thing as yourself' (Wade, 2002: 217). This perspective is useful in trying to understand some of the investments made by the IFC and regional development banks in healthcare. Since 1997, the majority of IFC healthcare investments have been for the development of hospitals and clinics, which provide a specific physical infrastructure for the healthcare sector. There is also a second, smaller group of investments, concerned with the financing of healthcare and the use of information communications technologies, both contributing to a new form of healthcare development (Table 1). These investments are often characterized by the development of holding companies and other forms of financial infrastructure, which will be discussed. These are characteristics of a commercialized healthcare system illustrated most clearly by the USA. As some of these financial investments were made between 1997 and 2000, it is now possible to evaluate some of the short term 'successes' of these projects.

HOLDING COMPANIES

Although the majority of IFC healthcare projects in Latin America have been conventional investments in hospitals, there are several investments that have supported the setting up of companies which are contributing to new ways of organizing and financing healthcare systems, dominated by private sector providers. By investing in holding companies, these investments are effectively trying out new types of healthcare delivery and providing some of the management and information services that reformed health services require, which are all part of a commodified approach to healthcare delivery. The use of new information and communications technology is considered to have an important role to play in future healthcare services by making information about costing and payments easily available as well as providing health information for patients. The example of Innovative Health Services, a Brazilian holding company, which received a loan of US$6.25m loan from the IFC as part of a proposed capital budget of US$25m in 1999, shows how within five years, this investment has resulted in the establishment of three new companies which deliver home healthcare, medical auditing and hospital management services. 'Med-Lar', the home healthcare services company has become one of the leading companies in Brazilian home healthcare. 'Gestal' provides management services for hospitals, which are experiencing falling sales and increased demand for quality services, a reflection of the changing position of many hospitals as a result of recent reforms. These two companies can be described as meeting the initial aim of the holding company, which was 'to provide support to new ventures and early stage development companies to improve the effectiveness and efficiency of the health care industry' (accessed 1 February 2005, http://www.ifc.org).

The investment alliance involved in this project brings together the IFC, a multinational company and a local company. Jose de Mello Saude (JMS; http://www.josedemello.pt), the healthcare division of the Portuguese Jose de Mello Group, which is active in several public-private healthcare projects in Portugal, owns 30% of 'Innovative Health Services' (http://www.ihs.com.br). The Brazilian controlled ICATU group (http://www.icatu.com), one of the largest conglomerates in Brazil, also owns 30%. This shows how both national and multinational healthcare companies are involved in investments that are expanding the private sector role in healthcare.

The significance of these types of private sector development in Brazil is threefold. The development of a homecare company shows that the delivery of care to people at home who are prepared to pay is considered to be profitable. Setting up companies that assess risk for life and health insurance companies puts an important part of the health insurance in place. The provision of management services for hospitals experiencing falling sales is an indication that the new markets in healthcare lead to both financial successes and failures. This is how market operating affects the provision of hospitals and healthcare. It is not determined by needs of local communities.

A more controversial holding company investment, started by the IFC but completed by the MIGA, illustrates how some hospital companies are changing the nature of their business interests from direct hospital management to the provision of finance for hospitals to lease equipment. National government investment companies and private investment companies are also becoming involved in this type of investment.

In 1999, MIGA issued a US$90m guarantee for financing of a capital markets issue, providing international finance at lower interest rates to set up a holding company, MSF Funding LLC (MSF), for financing of medical equipment. MSF Holding was initially set up by IFC, forming a joint venture with DVI Inc. (a company financing leasing of medical equipment but previously owning hospitals) to form MSF Cayman, based in the Cayman Islands. DVI Inc. is a majority shareholder of MSF Holdings. The Netherlands Development Finance Company and Philadelphia International Equities are also shareholders, showing that both bilateral investment agencies and finance companies are involved in healthcare investment alliances.

INFORMATION COMMUNICATIONS TECHNOLOGY

Information communications technology (ICT) also plays an important role in the new financial infrastructure of healthcare. The demand for this type of investment in healthcare seems not to have been affected by the collapse of Internet investments. The use of ICT in healthcare should be seen as part of an information infrastructure which private healthcare depends on to cost, price and collect payments for healthcare services. Information systems to support contract payments and check patient eligibility for care are also becoming important for public healthcare systems that operate as an internal market.

Some of these elements can be seen in an e-health company called Salutia that aims to apply new information communications technologies to healthcare. Set up in 1999, Salutia quickly attracted equity investors, such as Merrill Lynch, Newbridge and UBS Capital as well as the IFC to invest in technology, infrastructure and human resources. After surviving the economic crisis in Argentina, the company is now well established in Brazil. It describes itself as a company that 'provides solutions using technologies that improve efficiency and reduces management costs'. It works with many large healthcare companies as well as with over 500 smaller members in Argentina and Brazil. There has been a change in the image that it has presented on its website during the past three years. Starting as an Argentine company, which used the Internet to provide information for healthcare, it initially provided information for patients as well as developing services for healthcare companies. Three years later, it has developed a stronger Brazilian base and is now primarily working with companies.

This example shows that information communications technology investments play an important part in facilitating changes in the healthcare sector in order to accommodate private sector interests. These changes help to convert healthcare into a commodity that can be bought and sold. Companies can also adapt to changing economic and financial circumstances as seen in the way that Salutia changed its focus from the healthcare market in Argentina to the Brazilian market.

HEALTH INSURANCE

A further example of how the 'finance ministry' agenda has had to engage with the 'civil society' agenda can be seen in the World Bank model of public health systems providing basic services for low income groups, while promoting health insurance as a means for middle-class groups to pay for treatment from private health providers [START_REF] Gwatkin | Free Government Health Services: Are they the Best Way to Reach the Poor?[END_REF]World Bank, 2003b). The IFC, in a recent health policy document, acknowledged that attempts to move people away from tax-based to insurance-based systems had had limited success in many countries (IFC, 2002). However, there is continuing pressure for middle-class groups in countries in transition and many developing countries to take out private health insurance in order to access private healthcare [START_REF] Gwatkin | Free Government Health Services: Are they the Best Way to Reach the Poor?[END_REF]. This is also recognized by multinational healthcare companies developing their activities in Asia [START_REF] Lethbridge | Strategies of Multinational Healthcare Companies in Europe and South East Asia[END_REF]. One of the dangers of increased health insurance coverage is that companies prefer to insure healthy people who will use health services relatively infrequently. Eligibility criteria for people joining health insurance schemes will ensure that people with high health risks will either be excluded or pay larger premiums. This is known as 'cream skimming' and results in limited coverage of the population, often restricted to young adults. Older people may be excluded altogether from certain health insurance schemes.

The progress of health insurance companies in entering new markets has been an erratic one. One example of the limited success of US insurance companies can be seen in the case of Cigna which has entered and retreated from the Indian health insurance market because of the legal requirement for insurance companies to invest a minimum amount of capital. Even so, several IFC loans have been used to support the expansion of small health insurance companies. The process of developing a client base for new health insurance companies is a slow process. Some attempts have been made to link health insurance with healthcare providers by the same company, which is a form of managed care. Investment companies seem to be particularly interested in the expansion of health insurance.

Only one of the IFC investments in Africa over the past decade has been directly involved in the development of a health insurance company but the progress of this investment shows how finance capital is becoming involved in health insurance, albeit in a cautious way. AAR Health Services Limited, a managed care company operating in Kenya, received an IFC loan in 1998 to support its expansion into other East African countries. Six years later, in 2004, the company had gained a new shareholder: the Acacia Fund, one of the funds managed by CDC Capital (http://www.cdcgroup.com), the privatized investment arm of the UK government investment development company Commonwealth Development Corporation. This is another example of how national government investment companies are becoming involved in these type of healthcare investments. However, in May 2004, the company sold 35% of its shares to Project Ventures International, a company dealing with health and information technology in several counties in Africa. This has taken place at the same time as the Kenyan Government has proposed a new national health insurance scheme, which may affect private healthcare providers because companies will no longer have to provide healthcare insurance for their employees [START_REF] Wandera | Firm Acquires Shares in AAR[END_REF]. This is significant in that it demonstrates that government policies can have a significant impact on private companies.

AAR is now planning to expand throughout Africa, using a franchise model of preventive and curative services. The franchise package entitles suitably qualified institutions to have access to an e-commerce-based computer software package, together with diagnostic, treatment, referral, laboratory, drug, customer care and accounting protocols. This package enables non-health companies to develop and deliver services themselves. Five franchise health centres have been set up in Tanzania, Uganda and Kenya.

MEDICAL TECHNOLOGY

Another form of technical infrastructure, which is becoming more important to the healthcare sector, is medical technology research and treatment, including the development of medical devices. Although this affects public and private healthcare sectors, private capital plays a key role in the expansion of research and the provision of equipment for diagnosis and treatment. The medical devices industry is part of a competitive global industry and it is a field of investment, which is considered to have the potential for high returns [START_REF] Altenstetter | International Collaboration in Medical Device Regulation Issues, Problems and Stakeholders[END_REF]. The value of high technology diagnosis and treatment is being recognized in the treatment of many diseases particularly noncommunicable diseases. For developing countries with limited healthcare systems, the focus on high technology equipment can result in the move of capital resources away from basic healthcare to more specialized services, which are only accessible to a minority of the population [START_REF] Donaldson | Health Financing in Thailand[END_REF]. Even when services are provided in public healthcare systems, they often result in a distortion of resources and services. High-technology equipment also needs a financial infrastructure to enable hospitals to borrow capital to buy or lease equipment.

Recent IFC investments reflect this trend towards high-technology treatments. Two East European investments show how private companies are building and leasing high-technology facilities to the public sector. In some cases, the initiatives attracted a wide range of investors. In others, particularly projects in countries with a recent history of war, investors need loan guarantees from MIGA because of the perceived element of risk involved.

Euromedic Diagnostics BV and International Dialysis Centers BV are both wholly owned subsidiaries of Euromedic International (http://www. euromedicgroup.com) a Netherlands based company. Euromedic is developing diagnostic centres with high-technology equipment to diagnosis and treat non-communicable diseases, e.g. renal care. Although established in five countries in Eastern and Central Europe, the IFC loan of US$13m was to encourage further expansion of the national subsidiaries of Euromedic. A new loan was given by IFC for further expansion in 2003. Unlike many of the other IFC healthcare loans, this company works in partnership with the public sector. Euromedic invests in the diagnostic centres and the public healthcare system pays for the service based on contracts drawn up with National Insurance Institutes and supported by the Ministry of Health. It is now the largest investor in healthcare in Central and Eastern Europe.

In Bosnia, in a similar project, the MIGA, also part of the World Bank Group, is providing a guarantee of US$1.3m for one of the same companies, International Dialysis Centers BV, to set up and manage an International Dialysis Centre in Banja Luka, which is being set up and managed within an existing hospital. A MIGA loan guarantee, rather than an IFC loan, is provided because of the perceived element of risk. The terms of the guarantee are to cover the risks of expropriation, war and civil disturbance. The European Union Investment Guarantee Fund is a second guarantor. This is an example of how private sector risks are being underwritten by IFC and the European Union (EU).

All of these investments need to be considered in the light of a recent review of IFC projects, which resulted in a slight change in IFC priorities. The new IFC healthcare strategy has identified several new growth areas 'with higher investment probability and where the rationale for IFC investment is strongest'. Three of these new growth areas cover the themes that have been identified through the analysis of IFC investments as just discussed: an increase in non-hospital investments; a stronger focus on private health insurance; and increased investments in the pharmaceutical, medical devices and biotechnology sub-sectors. The only new growth area, which does not appear in existing IFC investments, are investments in health worker education and training (IFC, 2004).

There is a further interesting development shown in the recently published IFC healthcare strategy, which relates to the tasks needed to implement the strategy (http://www.ifc.org). One of the most important seems to be the 'development of instruments to support small projects', for example, 'standalone out patient clinics or networks of clinics' (World Bank, 2003a). This reflects the view of both the World Bank and IFC that small private initiatives play an increasingly important role in the provision of healthcare. This is in contrast to the building of large hospitals, which characterized many of IFC's earlier loans. It also suggests that a different approach is being taken to building up the private healthcare sector, starting with small healthcare practitioners probably influenced by the poverty reduction strategies. The IFC also wants to work more with the non-governmental sector to help maximize social impact and poverty alleviation. However, it frames this in terms of ensuring 'more people have better financial protection against ill health, which in turn can strengthen the middle class' ('IFC Health Care Strategy Executive Summary', accessed 1 February 2005, http://www.ifc.org).

Other operational objectives that underpin the new IFC healthcare strategy include the development of stronger collaboration with multilateral and bilateral agencies as well as the non-governmental sector. In the next section, the healthcare investments of the African Development Bank (http://www.afdb. org), ADB (http://www.adb.org) and the IADB will show to what extent they are also building up financial healthcare infrastructure and how actively they collaborate with the IFC.

Regional Development Banks

An examination of the policies and practice of regional development banks needs to start with the context of the specific regions within which they operate and the approach that regional development banks use in promoting social policy. [START_REF] Bull | Multilateral Development Banks as Regionalising Actors: The Asian Development Bank and the Inter-American Development Bank[END_REF] focused on the role of regional development banks and regionalism, and their work provides useful insights into how regional development banks differ. It also raises questions about how to define the relationships between multilateral financial institutions and regional development banks in relation to public sector reform and to what extent regional development banks are subject to the same pressures in terms of the 'finance ministry' and 'civil society' agendas.

Some indications of how regional banks respond to these pressures can be seen in the role that regional development banks play in regional integration. The ADB has supported a policy of sub-regional growth triangles, which can be seen as 'building blocks or foundations for a more all-embracing Southeast Asia regionalism' and the basis for a new security framework (Bull and Boas, 2003: 257). In contrast, the IADB has been able to play a role in some of the regional cooperation and integration processes that have taken place in Latin America through seeing them as technical issues and also 'filling regional projects with a specific content' (Bull and Boas, 2003: 257). [START_REF] Bull | Multilateral Development Banks as Regionalising Actors: The Asian Development Bank and the Inter-American Development Bank[END_REF] argue that the IADB has tried to present itself as an institution promoting a softer version of neoliberalism than the World Bank but it appears to be losing this struggle. It now appears as a strong promoter of neoliberal policies but it plays a specific role by providing technical expertise and support. Although there are broad similarities in health policies, a review of their health projects shows differences in implementation.

The ADB has provided loans for relatively few specific health projects and these are set within the framework of the ADB's social protection programme (Table 2). The amounts invested in either healthcare or social services are relatively small with most loans being less than US$20m. Only Indonesia, in 1998 during the Asian economic crisis, received two larger loans of US$300m for health, nutrition and social protection.

The loans of the ADB should also be seen in the context of East Asian development paths, which were shaped by the active role that the state played in national economic development [START_REF] Castells | Four Asian Tigers with a Dragon Head: A Comparative Analysis of the State, Economic, and Society in the Asian Pacific Rim[END_REF][START_REF] White | Developmental States and Markets in East Asia: An Introduction[END_REF]). This has often been considered in direct conflict with World Bank views that emphasize the importance of the market. However [START_REF] Berger | Lineages of Liberalism and Miracles of Modernisation: The World Bank, the East Asian Trajectory and the International Development Debate[END_REF] argue that the World Bank has actually been responsible for changing the perception of East Asian development from being state focused to a more moderate form of market development. East Asian governments that still play an active role in economic development may also influence ADB strategies, leading to some divergence with the investment strategies of the World Bank.

Health sector reform is the focus of one or two loans but rural health, Rural health -to provide primary and To improve access to health services by upgrading health 2000 US$68.3m UNFPA, preventive healthcare to the poor and dis-centres in rural areas. To enhance the skills of healthcare UNICEF advantaged, including ethnic minorities, service providers. To strengthen demand for health WHO women and children, in the rural areas of services through targeted information, education and co-financing 13 provinces of Viet Nam communication activities, improved community partners participation and more equitable health financing. To support the Government's scheme to provide free health cards to the poor. To support preventive healthcare through strengthening of food safety infrastructure and behaviour change communication Philippines

Early childhood development -to There are three components: (1) early childhood 1998 US$24.5 develop, provide and promote an development service delivery -programme support for integrated set of early childhood provinces and local government unit financing facilities development service delivery packages for municipal/city projects; (2) support for service to address the needs of children under six delivery; and (3) research and development Indonesia

Health and nutrition sector development -The policy reforms concentrate on four broad areas: 1999 US$300 to help alleviate the impact of the economic (1) maintaining access and equity (regional and sociocrisis on the most vulnerable groups and cultural), especially for the poor; (2) maintaining quality; building longer-term, sustainable reform (3) enhancing decentralized management; and in health services delivery (4) improving efficiency Central Asian Asian countries in transition for improved To test an umbrella regional programme for delivering nutrition and HIV/AIDS prevention projects have also been recipients of loans. However, within these broader health projects there are often some elements of health sector reform. The loan for the development of rural health in Vietnam includes strengthening 'the institutional capacity for public health care by coordinating and standardizing management systems, training programs and innovative financing approaches', which includes a pilot scheme to develop sustainable community health insurance (ADB, 2000).

In Africa, many of the health projects funded by the African Development Bank are directed towards building up the infrastructure of the public sector, e.g. hospitals and health centres, developing programmes for the prevention and treatment of HIV/AIDS, and other communicable diseases. In some cases, especially through the Poverty Reduction Strategy Papers (PRSP) the objectives are to improve basic social services, which are considered to include health, education, transport services and rural outreach services. The African Development Bank has invested in relatively few projects targeted specifically at the development of the private sector. Of these, a project for Senegal is designed to facilitate the creation of an enabling environment for the private sector but not specifically for the healthcare sector.

Many of the projects funded by ADB and the African Development Bank reflect the overall aims of improving the health of the population so that it can play a role in development. The projects funded by the IADB in Latin America show a different profile to those of the African and ADBs. It is also a contrast to the 1997 IADB health policy. Of almost 50 projects funded up to 2004, over half were focused on health sector reform, supporting governments in programmes that cover regulation, management reform, strengthening the delivery system and the expansion of private or non-profit healthcare providers. There is also a sub-group of projects which are much more specifically targeted at the development of the private healthcare sector, funded by the Multilateral Investment Fund (MIF), a fund managed within the IADB.

The MIF, a part of the IADB Group, was created in 1993 'to encourage the development of the private sector and to improve the investment climate in the LAC region' (Grover and Lissfelt, 2000: 6). The current strategic priorities for MIF investments focus on four areas of activity: micro-enterprise, small business, financial sector and market functioning (IADB, 2004). The existence of MIF shows that IADB has a stronger policy focus on private sector development, specifically small-scale private sector development.

There are several approaches taken in the development of healthcare financial and organizational infrastructure by the MIF (Table 3). They illustrate the different elements of involving private healthcare providers in a wider public healthcare system and can be seen as part of national healthcare reform programmes. The promotion of new regulatory frameworks is considered a priority. This includes the development of new systems of regulation and helping local populations gain a better understanding of regulation. The development of contracting skills within reformed healthcare systems is also presented as helping to involve private providers in a public healthcare system. Other means of drawing the private sector into the public healthcare system include promoting the franchising of primary healthcare centres, developing public-private partnerships and encouraging private companies to manage healthcare under subsidized health plans. These investments all focus on the new systems and processes that are necessary for mixed economy healthcare systems to operate.

The MIF provides up to two thirds funding for each project. Other funding comes from the project partners, which are nationally based organizations. They are more varied than in many of the IFC projects because they come from government, private or non-governmental agencies. There is no apparent direct involvement of multinational capital or investment companies.

Regional development banks seem to focus more on direct support for national health sector reform programmes. The IADB is the most specific investor in projects that will contribute to a financial infrastructure for the healthcare sector. The differences between regional development bank investments may also be a reflection of the different regional health problems and their specific healthcare needs. However, the private sector is also becoming a focus for future regional development bank investments. These differences may be interpreted as a sign of the pressure of the 'finance ministry' agenda even though civil society influences seem to be stronger within regional development banks than within the IFC. However, these regional differences may also be the result of differences in role that the state has played in national development.

A number of investments made by IFC, MIGA and three regional development banks aim to create new private companies that will provide healthcare services. A healthcare system based on a US social policy model, needs a financial infrastructure that facilitates the costing, pricing and sale of healthcare. Specific investments are needed to build up this type of financial infrastructure before new private sector companies will enter the market.

The ways in which IFC, MIGA and regional development banks are approaching these types of developments give some indication of how the often conflicting agendas of economic growth and empowerment and poverty reduction agendas are being mediated at international and regional levels. There are some differences, with regional development banks showing a greater awareness of the need for poverty reduction and responsiveness, perhaps because of their proximity to national and local interests.

Implications for National Health Systems

With increasing healthcare investments being made by private equity investors and multinational and national companies supported by the IFC, an expanding private sector will be eager to sell products that contribute to healthcare delivery. One of the key issues facing national healthcare systems is how national governments can control and regulate the private healthcare sector.

The health sector is already highly regulated. Personnel are regulated through qualifications and systems of professional registration. Service providers are regulated through the inspection of facilities. Contract systems also provide a way of regulating providers of services through shared agreements about delivery of services and costs. Recent research has shown that multinational healthcare companies agree that there is a need for regulation of personnel. They welcome common inspection systems because they provide a 'level playing field' for providers. However, multinational healthcare companies felt that regulation of ownership restricted their expansion most actively [START_REF] Lethbridge | Strategies of Multinational Companies in Europe and Asia[END_REF]. This is significant in searching for a stronger regulatory role for governments. If governments are felt to have a significant influence over multinational healthcare companies when limiting their patterns of ownership, then this should be explored in more depth by national governments.

Some of the investment alliances discussed in this article, which draw on several investment partners, contribute to obscuring the ownership of a healthcare company. This will make it difficult for any government to limit the involvement of any company in these types of investments. The Brazilian holding companies are an example of a financial structure that blurs the actual ownership of each new company. Several companies and investors are involved in every company, both national and international. In order to avoid this situation, national governments need to development systems of regulation that have very detailed guidance on acceptable ownership structures for providers of government services. This may require extensive research on the part of governments and a willingness to challenge existing investment alliances.

As well as making it difficult for governments to control, the complexity of the financial structure will also make any standards of transparency or accountability difficult to impose. This is particularly important in relation to private sector companies that are delivering services directly to the public healthcare sector. This is an important issue because governments are becoming dependent on private companies for the delivery of public healthcare services. If a company develops financial problems, the government needs to be aware of them. However, with unclear ownership structures, this may be difficult. A future system of government regulation will have to introduce minimum standards of information that all private providers of health services will have to comply with.

Another implication for future healthcare developments is in the growing role of companies in the healthcare sector that have little understanding of healthcare delivery. The franchise model illustrates some of the dangers of these arrangements because it encourages business interests to take on the provision of a service, defined as a series of systems and protocols, which can be adapted to any region or country by any company. This makes healthcare a more attractive short-term investment for a wider range of companies which do not necessarily have any healthcare knowledge to support them. This also contributes to the depletion of health knowledge in the public health system if franchised companies are providing services.

In the future, the extent of private sector involvement in public healthcare systems will almost certainly have expanded. Many companies are more interested in becoming direct providers for the public sector, because profits are more easily guaranteed than through a system of private health insurance. The increasing number of joint public-private initiatives will further increase the role of the private sector in the public healthcare sector. This provides a challenge for governments to develop new systems of planning and control, which serve the interests of the population rather than private sector interests.

Dans cet article on examine comment les politiques de la Banque Mondiale qui influencent les systèmes nationaux de santé sont favorisées par des alliances d'investissement parmi les membres du Groupe de la Banque Mondiale, plus spécifiquement la Corporation financière internationale (IFC) et l'Agence Multilatérale de Garanties pour les Investissements (MIGA), les banques régionales de développement, et les intérêts des entreprises nationales et multinationales. Les données fournies dans cet article ont été obtenues des informations et publications disponibles sur les sites Internet du Groupe de la Banque Mondiale, les banques régionales de développement, des entreprises multinationales et des investisseurs privés. Nous avons aussi examiné quelques documents à propos de crédits disponibles sur les sites Internet du Groupe de la Banque Mondiale et des banques régionales de développement. La complexité financière de plusieurs investissements dans le domaine de nouveaux systèmes de soins de santé pose un défi pour les systèmes futurs de régulations de ces systèmes. La participation d'une vaste gamme d'intérêts privés dans les services de santé elle aussi pose des problèmes pour le developpement continu de connaissances sur la santé dans le cadre des systèmes avec financement publique. resumen La Promoción de Alianzas de Inversión por el Banco Mundial: Implicaciones para una Política Nacional de Salud Este artículo examina cómo las políticas del Banco Mundial que influyen en los sistemas nacionales de atención a la salud son facilitadas a través de alianzas de inversión entre integrantes del Grupo del Banco Mundial, específicamente la Corporación Financiera Internacional (IFC) y la Agencia Multilateral de Garantía de Inversiones (MIGA), los bancos regionales de desarrollo y los intereses de empresas multinacionales y nacionales. Los datos que se presentan en este artículo provienen de información y publicaciones disponibles en las páginas web del Grupo del Banco Mundial, los bancos regionales de desarrollo, empresas multinacionales e inversionistas privados. También se consultó algunos documentos sobre créditos disponibles en las páginas web del Grupo del Banco Mundial y los bancos regionales de desarrollo. La complejidad financiera de muchas de las inversiones en los nuevos sistemas de cuidado de la salud constituye un reto para los futuros sistemas regulatorios de la atención de la salud. La participación de una gama de intereses privados en la atención a la salud también presenta problemas para el desarrollo continuo de conocimientos sobre la salud en el marco de sistemas con financiamiento público.

  mothers and children micronutrient-fortified salt and wheat flour to the populations of participating Asian Countries in Transition (ACT), Azerbaijan, Kazakhstan, Kyrgyz Republic, Mongolia, Tajikistan and Uzbekistan. Greater Community action for preventing HIV/ Strengthen capacities of the national and local HIV 2001 US$7.0 Mekong Delta AIDS authorities and selected NGOs for the development of community-based prevention and care programmes Source: http://www.adb.org

  E L E T H B R I D G E has been Senior Research Fellow at the Public Services International Research Unit (PSIRU), University of Greenwich since 2001. She has worked in the public and NGO sectors on UK and international public health issues. Her research interests are the global commercialization of health and social care, social dialogue and trade union action. Please address correspondence to: Jane Lethbridge, Senior Research Fellow, Public Services International Research Unit (PSIRU), Business School, University of Greenwich, Old Royal Naval College, Park Row, London SE10 9LS. [email: j.lethbridge@gre.ac.uk]

table 1

 1 International Finance Corporation (IFC) loans to private sector initiatives in the healthcare sector For example, in Ecuador, the IADB (http://www.iadb.org) and Care Ecuador, a national branch of Care, a US non-governmental aid organization, are working together to test health franchising models through public-private partnerships in primary healthcare provision.

	Project	Details	IFC loan/total budget	Multinational company	National/ local investment
				(MNC) involvement
	Innovative Health	Holding company which	US $6.5m/US $25m Jose de Mello Saude,	ICATU, Brazilian family-
	Services (Brazil)	supports companies developing		Portugal	owned conglomerate
		new healthcare services
	MSF Funding LLC	Leasing medical equipment	MIGA guarantee	DVI Inc. Philadelphia	Netherlands Development
	(MSF)		US $90m	International Equities	Finance Company
	Salutia (Argentina	E-health to provide solutions using	US $2.5m/US $12.5m Merrill Lynch Global Emerging 30 local investors
	and Brazil)	information communications		Markets Partners, UBS Capital
		technologies to improve efficiency		and NAP Acquisition/
		and reduce management costs		Newbridge Latin America
	AAR Health Services	A managed healthcare	US$0.5/US$1.0m	Acacia Fund, a managed fund of Beckmann family
	Limited, Kenya -1998	organization which aims to broaden		Aureos Capital, one of two
		the shareholding and provide the		managed funds for CDC Capital
		Company with credibility and		Project Ventures Group (from
		enhance AAR's ability to enter the		June 2004)
		larger East African market
	Medicover (Central	Provision of health insurance, health US $7m/US $22m	ORESA Ventures, a venture	-
	and Eastern Europe)	services to companies and individ-		capital investor became Medicover
		uals in Central/Eastern Europe
	Ascent Technology	To provide funds for medical	US $10m/US $100m Ascent Private Equity II, a private	-
	Fund	technology research in developing		US medical technology and
		countries		devices fund
	Euromedic Diagnostics To expand the existing network of	US $13m/US $33m	GE Equity Dresdner Keinwort	HPM Partners -a privately
	BV and International	Euromedic diagnostic imaging	and US $11.4/	Benson Global Environment	held Dutch investment
	Dialysis Centres BV	centres in Hungary and other CEE US $23m	Fund Euromedic International	company
	(both subsidiaries of	countries; and establish a network of		NV
	Euromedic International) haemodialysis centres in the region
	International Dialysis	To set up an international dialysis	MIGA US $1.3m
	Centres BV	centre in Banja Luka, Bosnia	guarantee (2001) and
			€1.26m (2004)

Source: http://www.ifc.org ment alliances with regional development banks.

INTERNATIONAL FINANCE CORPORATION

table 2

 2 Asian Development Bank loans to private sector initiatives in the healthcare sector

	Country	Programme	Details	Date	Amount	Partners
	Mongolia	Health sector development -to help	Policy reforms, investments and technical assistance	1997	US$15.9	-
		Government implementation of health
		system reforms and investment to improve
		effectiveness, efficiency and sustainability
		of health services
	Vietnam

table 3

 3 Multilateral Investment Fund (MIF) projects in the healthcare sector

	Project name	Project description	Budget/date	Project partner(s)
	Brazil	To support a new regulatory framework for private health plans	MIF US$1,550,000	Secretary of State for
	Regulation of	to: enhance competition and efficiency in the private plan market;	Total US$3,100,000	Economic Development
	health plans	strengthen consumer protection organization; instil new under-	2000	in Minas Gerais
		standing and acceptance of new regulation in Brazilian society
	Belize	To create a policy, regulatory and purchasing environment for the	MIF US$771,650	Ministry of Health, Belize
	Support for health	expansion of domestic private sector in publicly and privately	Total US$1,228,790	Medical and Dental
	sector reform	funded health services	1999	Association
	Colombia	To encourage private enterprise to become involved in managing	MIF US$630,000	Corona Foundation
	Private enterprise	healthcare delivery under the subsidized health plans	Total US$1,040,000
	in subsidized		1999
	health programmes
	Ecuador	To test reform financing models through public-private partner-	MIF US$900,000	CARE Ecuador
	Development of	ships in the provision of healthcare and to improve the quality	Total US$1,550,000
	health franchises	and capacity of private sector provision of primary health services	2000
	Nicaragua	To support/promote private sector participation in the healthcare	MIF US$1,710,000	Ministry of Health
	Strengthening of	services market by improving and broadening existing regulations	Total US$2,840,000
	private healthcare	and creating an investment climate to support contracting.	2000
	services	This was cancelled in 2002
	Peru	To design and implement sharing health measurement information	MIF US$2,000,000	Superintendencia de
	Private sector health-	systems, implement consumer protections systems and launch public Total US$3,400,000	Entidades de Prestadoras
	care providers	information campaign	1998	de Salud -a public
				decentralized agency that
				regulates healthcare providers
	Source: http://www.iadb.org

Global Social Policy 5(2)

Global Social Policy 5(2)


Global Social Policy Forum Editor's Introduction and Signing Off

This is the last issue of Global Social Policy (GSP) that I will be responsible for as Editor of GSP. In fact this particular issue is guest edited by Gaby Ramia whose more detailed editorial appears below. I will have edited five volumes of the journal after founding it in 1999. I like to think that the journal is now making a useful contribution to the study of global social policy understood as the impact of global forces and processes on national level social policy and as supranational social policies operating at regional and global level. Whether the focus is social protection or education or health and social care or any other aspect of social provision, the analysis of current problems and policies is incomplete without an international dimension to the analysis or policy prescription.

The journal grew out of the Globalism and Social Policy Programme (GASPP, http://www.gaspp.org). GASPP is a Finnish funded programme based at STAKES in Helsinki. Without the support of STAKES finances and the collaboration of colleagues at STAKES this journal would not have come into existence. I would like to express my appreciation for the support of STAKES and in particular to its Director General Vappu Taipale for her faith in our project.

After a public call to tender for the editorship the Editorial Advisory Board of the journal, SAGE with my agreement have appointed to take over from me for an initial five-year period a team of three joint editors. They are Meri Koivusalo of STAKES Finland, Robert O'Brien of McMaster University, Canada and Nicola Yeates of the Open University, England. I am delighted to hand over the job to these excellent representatives of the next generation of international social policy scholars.

Please from now on send all materials for the journal to gsp@mcmaster.ca. In GSP 6.1 the new team will have an opportunity to set out their editorial policy.

My final comment is to reassert that the journal was created not only to further the understanding of the global dimension to social policy analysis but also to contribute to more effective and just global social policies. In this

Why Migration and Social Protection? Guest Editor's Introduction

In the scholarly analysis of social policy's global and supranational dimensions, the role of multilateral institutions in reshaping welfare and other forms of social amelioration has been prominent. Indeed Global Social Policy (GSP) springs from this very tradition (Deacon et al., 1997;Yeates, 2001). Within the GSP tradition a research agenda on the implications of civil society in its multiple life-forms has surfaced (Deacon, 2000;Ramia, 2003;Stubbs, 2003).

The under-theorized impact of privatization, corporations and other actors in the market sector have also made an entrance (GSP 5.2; see also Farnsworth, 2004;Holden, 2003). All of these lenses on global social policy assume, and have as a backdrop, ongoing globalization processes; infused and informed as these are by foreign direct investment and cross-border and multilateral trade in goods and services. But what of the movement of people? Despite some focus on the (generalized) human rights dimensions of migration (e.g. Graham and Poku, 2000;Weiner, 1995) the phenomenon of people-movement has received little systematic attention from global social policy specialists. The domain of migration studies has now had a long presence outside the field, but the implications and consequences of migration for global social policy are in need of greater scholarly consideration; not least because of the increasing numbers of refugees and asylum-seekers, who are stateless non-citizens (Castles and Miller, 2003: 102-9).

Beyond the concept of not belonging to a state, and thus not being afforded the rights of national citizenship in its various forms (Marshall, 1963), the social policy literature need not be searched long and wide to witness that the social and other rights of citizenship have been based mainly on and within the nation-state. Even when this is the case, the phenomenon of intranational migration, typically rural-to-urban and in the developing nation setting, presents significant complications to contemporary understandings of citizenship. The supranational aspects of migrant social rights are still in dire need of explication.

The purpose of this Focused Issue of GSP is to contribute to the analysis of social protection rights among both international and intra-national migrants in the context of global people-movement. In keeping with existing understandings of globalization, the phenomenon of globality of flows in capital and goods and services is assumed. In addition, however, the authors consider people-flows, placing a microscope on the common slippages in rights of individuals who relocate for whatever reason. Analysis also focuses on their communities and social networks. The articles in the issue respond to the dearth of research in the area, providing case studies that highlight the global, supranational and national policy and governance issues raised for global social policy analysts. Emergent problems with public policy regimes are explored, alongside discussions of the issues raised by these problems for the state, market and civil society sectors; and for coordination between them.

In the first article, Nyland and Nyland explore the movement of ideas in the policy and practice of early childhood education: from Italy, via the USA, into China. The authors utilize a case study of a mixed-funded, Chinese-US partnership project in child adoption based on the 'Reggio Emilia model', arguing that China is relying too much on non-governmental organizations (NGOs) to service the needs of its child citizens and that ideas can be 'lost in translation' as they are transported across regions and nations.

The movement of people within the nation is also strongly characteristic of economic and social development of countries like China. In the second article, however, Deumert et al. analyse rural-to-urban migration in South Africa, exploring in particular the ways in which migrants seek to have their needs met as they move into large cities. Survey data from migrants in four low-income areas in Cape Town is utilized, focusing on employment, life in the urban environment, the impact of language background and proficiency, and migrant access to formal and informal sources of protection against the market. The authors argue that language rights, particularly to English and Afrikaans, and access to informal but strong-tie social networks emerge as the most important variables, and that developing states need to design social policies for migrants with these factors in mind.

In the third article, Deumert et al. explore the rights of cross-border students in the context of the increasingly globalized market for higher education, with a focus on Australia, the third largest market in the world for international education. The authors find that the traditional institutions of social protection are largely ineffective in servicing student needs, given that cross-border students are treated as consumers and not human beings in their host country, and that legally and politically they are only temporary visa holders rather than citizens. It is argued that a regime embodying 'social and economic security' is superior to one based on social protection, calling for more integrated governance with streamlining between formal state and market institutions and civil society organizations at the national, supranational and global levels.

In some countries some migrants can have greater access to social rights than others. In the fourth and final article, Nielsen et al. move attention back to within-nation migration, focusing on China. Using data from a survey of internal migrants in the province of Jiangsu, the authors shed light on the characteristics of migrant workers who are able to access social insurance schemes, explaining why some are given insurance while some are not. They argue that, of the many factors which explain this phenomenon, the most significant are gender, the ownership structure of the enterprise in which workers are employed, and urban as opposed to rural residential registration status. Seen in this light, Nielsen and her collaborators argue, the optimism expressed by some regarding the diffusion of social rights under urbanization are not founded.

The four articles were first presented at a Workshop on 'Global People Movement and the Social Protection Needs of Migrants'. This was a Workshop of the Ninth International Metropolis Conference in Geneva, 27 September-1 October 2004. The theme of the conference was 'Co-operative Migration Management: International, National and Local Answers'.

In addition to the articles, the issue contains two short Forum pieces. The first, by Nicola Yeates, discusses the potential role of the World Trade Organization's (WTO's) General Agreement on Trade in Services (GATS) in extending social security for temporary migrant workers. The second reviews key social protection issues stemming from the global movement of labour, with a focus on the role of labour movements, the International Labour Organisation (ILO) and the Global Commission on International Migration (GCIM). The World Trade Organization's (WTO's) General Agreement on Trade in Services (GATS) has acquired certain notoriety within global social policy mainly because of its potentially far-reaching implications for the development of public health and welfare services. Most critical attention in this regard has focused on the restrictions the GATS places on governments in setting and pursuing public policy objectives specifically its potential to lever an enhanced role for commercial providers in the delivery of welfare services. There is, however, an alternative reading of GATS that emphasizes the possibilities it affords to lever improvements in temporary migrant workers' access to social security benefits.

One issue facing temporary migrant workers is that they are often required to pay social security contributions without a corresponding entitlement to receive benefits due to minimum contribution periods that exceed the period over which they pay contributions and/or the requirement that claimants be permanent residents of the country to receive benefits. In some cases migrant temporary workers will be 'taxed' twice, paying social security contributions at home as well as abroad. These and other social security 'losses' often are greatest for immigrants from developing countries which are less likely to be party to totalization agreements permitting their nationals to receive benefits based on their combined employment history whether at home or abroad (Desai et al., 2000).

It might seem somewhat improbable to contemplate the GATS as a significant feature of a global regime governing the social protection rights of migrant workers. Arguably though, GATS has the potential to become precisely that, subject to an expansive reading of current provisions.

Although GATS does not in principle apply to measures affecting access to the employment market of a Member or to measures regarding citizenship, residence or employment on a permanent basis (Annex on the Movement of Natural Persons), Grynberg (2001) points out that GATS applies to measures affecting 'natural persons' who are 'service suppliers of a Member' and to 'natural persons of a Member who are employed by a service supplier of a Member in respect of the supply of a service'. Thus, Grynburg argues, while it is clear that foreign nationals working as unattached (self-employed) service providers or employees of a foreign company are covered by the GATS, it is not clear that unattached foreign nationals offering their labour services to a domestic firm providing services domestically are excluded from the GATS (see also Winters et al., 2002). An expansive interpretation of GATS Mode 4 (Movement of Natural Persons) provisions would enable governments to schedule commitments relating to lower-and medium-skilled workers emigrating on a temporary basis to provide a commercial service as an employee (Mode 4 commitments are currently restricted to higher-level and skilled personnel, notably professionals and specialists, whose mobility is directly related to foreign direct investment).

Not only would this be consistent with the GATS' aim of progressing the liberalization of trade in (labour) services, it would solidify the intersection of the WTO/GATS with employment and social security regimes, increasing pressure to ensure that social security provisions for temporary migrant workers are GATS-consistent. This would entail addressing inequities in social security arrangements for temporary foreign workers, ensuring that they have access to and use of the same range of benefits as 'like' suppliers (in this case, nationals employed as temporary workers) (National Treatment principle) and eliminating social security measures that discriminate between 'like' foreign nationals (Most Favoured Nation principle).

'GATS-proofing' social security could be achieved by 'levelling up' (introducing new entitlements or making existing ones more generous) or by 'levelling down' (aligning entitlements to the level of the least generous provision). Either way, the application of these principles would have profound implications for national regimes not least because access to benefits so often depends on permanent residence. Assuming that residency rules remain fundamentally unchanged, a number of Policy options that effect these principles can be identified. One option is to distinguish between short-term and long-term social security programmes in order to permit temporary workers to access at least some coverage during their period in the host country, as suggested by Winters et al. (2002). Reducing 'excessive' labour taxes on foreign temporary workers could entail exempting them from paying social security contributions in the host country or allowing them to pay their home country rates to take account of the differences in labour costs between foreign and domestic labour (Winters et al., 2002). Alternatively, the contributions made by temporary workers in their host country could be 'repatriated' to their country of origin in the form of an intergovernmental social security transfer.

Perhaps a more ambitious option is to use the GATS to extend more favourable treatment to nationals of Members not already party to totalization agreements. Traditionally, totalization agreements are negotiated on a bi-lateral basis and more rarely on a regional basis (as in the EU), but in theory social security measures could be made subject to the Most Favoured Nation (MFN) rule instituting the multilateral elimination of discrimination between foreign nationals by all WTO Members. While this could lead to the extension of social security coverage worldwide for this group of migrant workers, it would undoubtedly pose numerous difficulties.

Totalization agreements require a certain degree of compatibility between the social security systems of the countries concerned and the specific terms of agreements reflect the circumstances of the participating countries. It would also be difficult to determine which Member provides the most favourable treatment. Given the difficulties of multilateralizing totalization agreements, Members could table an MFN exemption for social security and promote the conclusion of more bi-lateral social security agreements between Members. Article VII provides for the negotiation of mutual recognition agreements between Members and permits others to negotiate accession to any agreement concluded. Extending worldwide mutual recognition in social security could provide the basis for reducing 'excessive' labour taxes on foreign temporary workers and extending coverage for this group.

Of course, this would do little in itself to address issues of inequity in access to, and use of, social security resulting from factors other than those relating to national origin (that is, gender, urban/rural, ethnicity; absence of or incomplete coverage nationally). Neither would it address the lack of social security coverage for migrants working in the informal economy. Nor would it necessarily prohibit the re-inscription of discrimination on grounds of national origin in social security. It would also probably face political objections by supporters and detractors of the present WTO/GATS regime either not wishing to complicate already complex and contentious trade liberalization negotiations, or detract from broader reforms to the WTO trade regime or from the need to abolish it entirely, or extend the 'encroachment' of the GATS in the public services field.

In addition it may be resisted by governments objecting to the development of supranational binding rules that materially affect national social security policy autonomy. After all, EU member governments, which, by worldwide standards, a relatively coherent political bloc, have fiercely resisted the European Commission's aspiration to make social security a supranational project. Finally, there may be more specific objections to extending social security entitlements to foreign nationals.

It is important to point out that any ensuing political divisions would not be reducible to a conflict between 'developed' and 'developing' countries, even though the Indian government has so far been the most vocal on the international trade implications of unequal access to social security by individual 'service suppliers' temporarily working in 'developed' countries.

Although some commentators (Desai et al., 2000) indicate that the losses of social security payments are greatest for immigrants from developing countries, long vesting periods are more often found in social security schemes in 'developing' and 'newly industrialized' countries themselves than in 'developed' countries. Thus, opposition to a GATS-induced policy to grant foreign temporary workers better social security entitlements may come from 'developing' and newly industrialized countries that employ many foreign workers. For example, Saudi Arabia, Oman, Bahrain and the United Arab Emirates, all of whom rely heavily on immigrant labour, only grant foreign workers employment injury protection and deny them public pensions (Gillion et al., 2000: 548). Opposition to the extension of the GATS rules into the social security area may also come from private financial services providers, which are otherwise major supporters of GATS because of the 'new' market opportunities they believe it would open to them. For example, private providers of mandatory pension insurance may voice objections if the extension of the GATS to social security means allowing foreign competition for pension fund capital. Migration is not a new phenomenon -indeed much of the globe as we know it has been shaped by the migration of peoples for centuries. Yet today we have greater interconnectedness than at any other time in our history. The Director General of the International Labour Organisation (ILO) has summed up the core issue presented by migration succinctly when he stated that the greatest structural deficit of globalization is the failure to create jobs where people live. This failure drives two realities, both key issues for the ILO:

1. The imperative to create and sustain decent work in all countries of the globe, and 2. To manage the movement of people in order to create greater prosperity for all.

I shall focus on the second of these.

In migration discussion there is an economic dimension, and a human rights imperative. Solutions that enable effective and just outcomes for government, employers and workers will be constructed on the foundations of the core mandate of the ILO -labour rights and standards.

The magnitude of migration is significant and increasing. Some 86m migrant workers are estimated to be economically active globally, with 34m in developing regions. The ILO estimates that in total there are some 175m people residing outside their countries of birth or citizenship. Indeed as the Director General of the ILO reminded us recently, together they would constitute the fifth most populous nation on the globe. This is not a north-south issue. About 40% of all migration occurs between one developing country and another, and through large cross-border movements of workers among neighbouring countries in the developing regions.

Yet despite the urgency of the challenges we face, it is salutary to remember that there is sometimes a tendency to overestimate the magnitude of migration in the receiving countries. By the late 1990s migration still represented no more than 4.2% of the industrialized countries' total workforce. Foreign born persons now account for about 10% of the total population in the USA, 17% in Canada and 24% in Australia. By comparison foreign born persons comprise only about 5% of the population in Europe and 1% in Japan.

The most vulnerable situations of migrant workers are those with irregular status because of the kind of work they do and the absence of national law protecting them. The ILO estimates that about 15% of all migrants are in irregular situations and the bald economic fact is that many communities would cease to function if their labour was withdrawn -many employers would go out of business.

An increasing proportion of migration for employment is temporary. As Yeates makes clear in her Forum piece in this issue, the General Agreement on Trade in Services (GATS) Mode 4 negotiations in the World Trade Organization (WTO) are expected to accelerate this trend. Many developing countries have made the rapid expansion of GATS Mode 4 to cover semiskilled and unskilled workers a major priority. This will continue to cause tension for national governments as employers increasingly call for temporary workers to cover labour shortages and trade unions oppose these proposals in the face of just concern that the WTO rules provide no protection of worker rights and hence the body has no tools to resolve the need for equal treatment of temporary migrant workers.

Beyond the historic factors driving migration, including oppression, conflict, famine and dire poverty, there is the reality of demographic changes and ageing populations in industrialized countries. I note that because of ageing populations the number of employed people in the EU, for example, will decline by 20m workers between 2010 and 2030. This will place continued economic growth at risk and increase the pressures on the financing of the welfare system in industrialized countries. Migration can help alleviate these pressures.

In Australia the business community and the unions have begun to act in partnership to resolve the impending threat of a shrinking labour force. Increased migration is certainly part of the answer. When the economic benefits for both sending and receiving countries are considered, increased migration through regular and well-managed procedures is critical.

In addition to the challenge of ageing populations the main benefits to receiving countries come through increased aggregate demand and the increased size of the domestic market, which enables employers to benefit from economies of scale without having to focus excessively on export markets. Larger domestic markets -established through migration -make the economic arguments for excessive trade liberalization and open capital markets less compelling. My own country, Australia, would not be the rich nation it is today without immigration. Indeed we are a land of immigrants. The intake of migrant workers this year will result in a small net gain to our GDP but by the end of a decade, increased migration will add a staggering 3-4% to GDP growth in Australia.

The economic impact on sending countries is increasingly dramatic. Reduced labour supply in countries where the jobs do not exist can reduce labour market pressure and put upward pressure on wages and working conditions offering greater security and dignity for working families. Remittances from family members working in other countries are another important way in which migration promotes growth and reduces poverty in developing countries. The positive impact of remittances on consumption and investment expenditure in many developing countries is obvious. In 2001 workers' remittances to developing countries totalled 72bn dollars, exceeding Official Development Assistance (ODA) flows to developing countries and constituting over 40% of total Foreign Direct Investment (FDI) flows. Remittances are particularly important for the very poorest countries and, unlike FDI, are a relatively stable source of hard currency. This is not to deny that there are some social consequences that concern both Government and unions.

Remittances are private financial flows from workers to their families or other private beneficiaries. They can have a significant impact on the distribution of income in developing countries. They are used by some worker families to buy basic goods in local markets, send kids to school and pay for health care. Often remittances are used by middle income families to construct or renovate homes. These construction activities have significant multiplier effects on the domestic economy. Remittances also provide finance to poor families that would not otherwise have access to credit, to establish their own micro business. Remittances thus provide an important means of helping transform and mainstream the informal economy.

Hard currency is required if a developing country is to purchase the inputs and technology that are necessary for establishing a larger manufacturing and service based industry structure. Remittances are therefore an important element in reducing poverty and promoting a diversified development strategy for the poorest countries. In the absence of remittances, developing countries would be required to attract hard currency through other mechanisms. Either relying on further international loans or further pursuit of the undesirable polices currently used to attract private FDI: labour market deregulation; low domestic wages; fiscal restraint; and privatization -these are strategies largely opposed by trade unions because of their disastrous impact on the lives of workers and their families and policies increasingly recognized as unsustainable.

I note that the economic benefits of remittances are currently reduced through high transaction costs, with up to 20% of remittance values being lost in transactions costs imposed by banks. This is profiteering and an ugly side of globalization that must be exposed and eradicated.

What of the economic benefits to sending countries through return migration and the diaspora effect? Apart from trade links and the circular transfer of skills and technology, expatriates are increasingly a significant source of FDI. In China alone some $60bn (US dollars) of FDI came from Chinese people living abroad. This is not to deny that there are some social consequences that concern both government and unions. The main economic cost of migration for sending countries is brain drain. The migration of well-educated and high skilled workers from developing countries to industrialized countries has been increasing since the early 1990s. Health care and education in a number of countries has been strongly affected by the departure of trained doctors and nurses.

To offset the economic impact of brain drain international cooperation is required to compensate developing countries for the cost of educating skilled workers who migrate. This could be financed by returning a proportion of taxes paid by migrant workers to their home countries.

But just as the international labour movement may take the lead in advocating the positive economic case, we would implore the employers to join with us and support the need to eliminate worker rights abuses that are too often associated with the employment of migrant labour. Without decent work and equal treatment of migrant workers the profits of employers are at best short term and the potential costs of social disharmony will only serve to threaten the sustainability of their enterprises. For governments, the economic case for migration is hollow without the protection of people. The political consequences of failing to address the human rights dimension of migration are clear.

Therefore we cannot overlook human rights abuses, or the often significant social costs for families that decide to send one member abroad to work. Clearly, this involves major sacrifices and hardships. The impacts of the feminization of migration are dramatic, given that women now account for half of all migrant workers. Women migrants face particular risks of sexual abuse and violence as well as family dislocation; and they are primarily the victims of the evil underbelly of inadequate management systems for the movement of people -trafficking.

I will not labour the question of human rights but let me state emphatically that for trade unions human rights and labour rights go hand in hand, and I would like to be assured that this is also a given for employers and governments as we map a better future. In this context we must not walk away from the responsibility we share to determine a way forward.

In closing, can I first alleviate the fears I have heard from a few governments regarding state sovereignty; and second provide a 2005 postscript on civil society and intergovernmental activities in the management of international migration and in particular labour migration.

To the first point: labour movements do not seek to interfere in the sovereign rights of states. While as citizens of our individual countries we may well seek to influence government, the public policy decisions about who comes to live and work in a nation and in what numbers is the responsibility of governments. However, to the extent that migrant workers are invited into a nation or to the extent that migrants live and/or work in a nation due to cross-border flows of people, then we seek to build on the tools of the ILO and work with our social partner to identify pressing issues, map best practice guidelines and build a multilateral framework. The framework, while not binding, should carry the authority of workable solutions to strengthen our economies, build social cohesion and eliminate the corruption enabled by the gaps in the contemporary framework of global regulation.

To the second: the work of the Governing Body of the ILO on developing a non-binding rights-based framework of best practice for managing labour migration is to be considered further through an Experts Meeting in December 2005. In a separate but related forum, the Global Commission on International Migration (GCIM), mandated by UN Secretary General Kofi Annan, is to report, also in 2005. This will follow current consultations in all regions of the world, which consider issues for national, regional and global governance.

Migration divides governments and people otherwise committed to progressive social and economic policies; and yet it is at the very heart of the challenge of a just globalization. Working towards meeting this challenge is imperative for governments, employers and workers.

  Castles, S. and Miller, M.J. (2003) The Age of Migration, 3rd edn. New York and London: Guilford Press. Deacon, B. (ed.) (2000) 'Civil Society, NGOs and Global Governance', GASPP Occasional Papers No. 7/2000. Helsinki: STAKES. Deacon, B. with Hulse, M. and Stubbs, P. (1997) Global Social Policy: International Organizations and the Future of Welfare. London: Sage. Farnsworth, K. (2004) Corporate Power and Social Policy in a Global Economy. Bristol: Policy Press. Graham, D.T. and Poku, N.K. (eds) (2000) Migration, Globalisation and Human Security. London: Routledge. Holden, C. (2003) 'The Global Healthcare Complex: Extent and Regulatory Issues', paper presented at Policy and Politics in a Globalizing World Conference, Bristol, 24-6 July. Marshall, T.H. (1963) 'Citizenship and Social Class', in T.H. Marshall (ed.) Sociology at the Crossroads, and Other Essays (pp. 67-127). London: Heinemann. Ramia, G. (2003) 'Global Social Policy, INGOs and Strategic Management: An Emerging Research Agenda', 3(1): 79-101. Stubbs, P. (2003) 'International Non-State Actors and Social Development Policy', Global Social Policy 3(3): 319-48. Weiner, M. (1995) The Global Migration Crisis: Challenges to States and to Human Rights. New York: Harper Collins. Yeates, N. (2001) Globalization and Social Policy. London: Sage. Gaby Ramia Monash University, Australia N I C O L A Y E AT E S Open University, UK Extending Social Security for Temporary Migrant Workers: What Role for the General Agreement on Trade in Services (GATS)? (nicola yeates is Senior Lecturer in the faculty of Social Sciences, Open University, Milton Keynes, UK)

acknowledgement

  This Forum contribution is derived from Yeates(2005).references Desai, M.A.,Kapur, D. and McHale, J. (2000) 'Sharing the Spoils: Taxing International Human Capital Flows', mimeo, Harvard University. Gillion, C., Turner, J., Bailey, C. and Latulippe, D. (eds) (2000) Social Security Pensions: Development and Reform. Geneva: ILO. Grynberg, R. (2001) 'Liberalising Global Labour Markets: Recent Developments at the WTO', mimeo, Commonwealth Secretariat, London. Winters, A., Walmsley, T., Wang, Z.W. and Grynberg, R. (2002) Liberalising Labour Mobility under the GATS. London: Commonwealth Secretariat. Yeates, N. (2005) 'The General Agreement on Trade in Services (GATS): What's In It For Social Security?', International Social Security Review 58(1): 3-22. S H A R A N B U R R O W International Confederation of Free Trade Unions Belgium The Economic Case for Migration and the Protection of Mobile Workers: Challenges for the International Labour Movement (SHARAN BURROW is President, International Confederation of Free Trade Unions Belgium. Member, Governing Body of the International Labour Organisation Commissioner, Global Commission on International Migration) AN ABRIDGED AND UPDATED VERSION OF A PLENARY SPEECH DELIVERED TO THE INTERNATIONAL LABOUR CONFERENCE, 2004

  to record my appreciation for the willing collaboration with GSP and GASPP of a large number of international civil servants who have given of their time either as board members or as referees or in other ways over the past few years. Those in the International Labour Organisation (ILO), United Nations Development Programme (UNDP), United Nations Educational, Scientific and Cultural Organization (UNESCO), United Nations International Children's Emergency Fund (UNICEF), World Health Organization (WHO), World Trade Organization (WTO) and World Bank know who they are. I am aware that progressive global social policies emerge out of the struggles of global social movements but their supporters in international agencies play an often unsung part in this process.

	context I want	gsp
		Global Social Policy Copyright © 2005 1468-0181 vol. 5(3): 267-279; 057408
		SAGE Publications (London, Thousand Oaks, ca and New Delhi)
		DOI: 10.1177/1468018105057408

Global Social Policy 5(3)