#  **Reforming the institutional framework to promote trade**

The above example of Cuba shows that a successful export promotion strategy in the health sector is fully compatible with a large state involvement and the preservation of a predominant public health sector. Indeed, experience shows that governments have played an important role in the success of the leading health services exporting countries. Public involvement could be crucial at all stages, from the design to the implementation of export promotion strategies.

A common problem is the absence of statistics on trade in health services that could translate, at the government level, into the absence of coherent sectoral development strategies. For example, with a view to elaborate an export strategy for medical tourism, it would be useful to know the number of medical tourists, the type of procedures offered, the type and level of expenses of patients, etc. Only rough approximations exist in most countries. Some countries have made efforts to remedying this situation and improve their national statistics on trade in health services by, for instance in Morocco, introducing a count of foreign patients treated in local hospitals. The _Manual on Statistics of International Trade in Services_ (United Nations, 2002) provides a useful set of guidelines for governments willing to tackle this problem.<sup>5</sup> Another related common problem is the absence of cooperation among ministries (e.g. health, trade, and tourism) and dialogue among actors. Practically, too many actors are involved in trade in health services that do not necessarily communicate among each other. These include: tour operators, private practitioners, clinics, hospitals, research institutes, ministries, professional bodies or associations, real estate developers, and (foreign/local) investors. Experience shows that the best performing countries on the international trade in health services scene, such as Thailand, have created horizontal administrative structures to coordinate domestic positions and strategies on health tourism (sometime called “medical tourism observatories”). By contrast, the dispersion of actors remains a technical challenge for lagging countries, for example in Maghreb, where export success stories appear to result from individual and uncoordinated initiatives rather than real strategies.

A number of countries have set up trade promotion agencies, primarily to encourage and facilitate exports of domestic goods and services. It is often the case, however, that these agencies focus on exports of traditional goods rather than services – and hence neglect the health services sector. In the case of Cuba (case-study n°10), the creation of a dedicated agency in charge of promoting and marketing Cuban health tourism has proven successful. Such function could be assumed by an already existing trade promotion agency or part of the mandate of the administrative coordination structure – depending on the country’s specifics. In any case, marketing and promotion are essential to boost trade in health services, in particular due to the absence of transparent worldwide data on the quality of healthcare and the important role of reputation in consumers’ destination choice.

Finally, it should be noted that public (often university) hospitals have played an important role in the development of many countries’ reputation in the health sector, and often continue to showcase knowhow and attract foreign patients or health professionals.

> 5 The _Manual on Statistics of International Trade in Services_ has been developed and published jointly by six organizations (UN, EC, IMF, OECD, UNCTAD, and WTO), managed through the mechanism of an inter-agency task force. The Manual sets out an internationally agreed framework for the compilation and reporting of statistics of international trade in services in a broad sense.

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