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Globalization and Health Sector in India
Globalization describes the process by which regional economies, societies, and cultures have become integrated through a global network of political ideas through communication, transportation, and trade. The term is most closely associated with the term economic globalization: the integration of national economies into the international economy through trade, foreign direct investment, capital flows, migration, the spread of technology, and military presence. However, globalization is usually recognized as being driven by a combination of economic, technological, sociocultural, political, and biological factors. The term can also refer to the transnational circulation of ideas, languages, or popular culture through acculturation. An aspect of the world which has gone through the process can be said to be globalized. The window of globalization was formally opened in India in July 1991, when the new central government introduced market-friendly structural adjustment programme of the IMF to formally integrate the Indian economy with the global economy. Lots of changes have been introduced since then and the worst sufferers have been the social sector in the country. There has been a sharp contraction of government spending on social sector infrastructure and greater reliance was placed on private initiatives and private sector expenditure on health and education- the two most important social sectors in the country covering the welfare of millions of our people. Health of the population is indicative of the ability of the people to participate in the labour process and leave a decent new nutritionally efficient, disease-free wealthy life, which contributes to human development and welfare. While the link between per capita SDP of the states and per capita health expenditure is found to be strongly co-related, the efficiency of health outcomes and the distribution of health facilities across regions and income groups have remained poor and the scenario has deteriorated since the introduction of economic reform measures in India.

The healthcare system in India was in a dismal state before the economic reforms of liberalization, privatization and globalization. First of all, there were very little facilities for healthcare and was limited to urban areas. Most healthcare facilities were run by the government and the conditions these facilities were in were pathetic. The biggest hindrance to the healthcare infrastructure was the presence of bureaucracy. Healthcare facilities were very few and were poor in quality. They were pathetic in terms of infrastructure, health facilities were poorly kept, no hygiene was maintained and it was inefficient, crude and primitive. Equipment was old and was incapable of providing quality healthcare. There were very few doctors. Most hospitals were completely understaffed. There were very few specialists. The worst part was the bureaucracy. The bureaucracy had an assurance of job security. They knew that they wouldn’t lose their jobs however badly they worked. This feeling made them more inefficient. They would work at their own pace and make things complicated. With the coming of globalization, it has become a different story. Globalization meant that there was now more private participation. This meant that all inefficiencies were to be corrected and rectified. They reduced the job security and made sure that only the people who performed had their job. Medical technology from all around the world was now present in India. Private health care centers help the burdened government healthcare centers and some even extend their reach to the rural areas. Advanced healthcare techniques have now come to India and it has been helping patients from all over India. Many multinational companies provide for their employees’ health, saving the government from providing healthcare to them. The coming of globalization has also benefited the healthcare industry monetarily. Globalization has also helped India to establish research and development facilities in the medical fields. This has led to a lot of new innovations in medical equipment, medical techniques and even medicine as a whole. Globalization has helped the pharmaceutical industry a lot too. Drugs from all over the world are available in India. Their standards are good compared to Indian drugs. India being one of the founder members of the WTO, is also an early signatory to the Articles of Agreement under the GATS, and after some years of grace period, has to open up its health sector to the forces of international trade.

Health scenario in India

Health care has been one of the most neglected aspects of development in India. Despite repeated statements in the successive plan documents on the centrality of health and healthcare, the field has suffered from persistent neglect in public policy in general and development planning in particular, with the consequence that the Indian population continues to be exposed to a high incidence of communicable diseases and readily preventable illnesses. Many basic illnesses had radically declined in large parts of the developing world in recent decades but they continue to be common in India and the burden of disease falls very unevenly on different sections of the population. The incidents of undernourishment and nutrition-related ailments in India are also very high by international standards. The emphasis in the context of structural adjustment policy of World Bank in placing the basic task to market mechanism and gradual withdrawal of state in the field of health services seems misplaced in view of the fact that the role of the state in this field has been pathetically low and market mechanisms continue to dominate in health care sectors in our mixed economy framework. In fact, international comparisons reveal the share of public expenditure in India in total health expenditure is only around 15%, compared with75% in Western Europe’s ‘market economies’, and 84% in Britain.

The following table shows the public health expenditures (1990-1998) of different countries using selected indicators.

Table 1.1 Health Expenditure: Selected Indicators

Public expenditures on health, 1990-98 In absolute terms (PPPs per capita)	As a share of total health expenditure (%)	As a share of GDP (%) India 	14	15	0.8 South Asia	16	18	0.9 Sub-Saharan Africa	36	40	1.7 East Asia and Pacific	60	40	1.7 Middle East and North Africa	114	50	2.3 Latin America and Carribbean	221	49	3.2 Europe and Central Asia	251	77	4.0 High-income countries Europe EMU	1485	75	6.7 All	1604	62	6.0 Source: Calculated from World Development Indicators, 2001, Table 2.15, reported as Table 6.1 in Dreze and Sen.

It is true that in social activities like health care for all, the incentive of private investment and initiatives are clearly low and concerted state action and the allocation of adequate public resources are badly needed in view of the fact that the incidents of basic communicable diseases and related illnesses is still extremely high in this country. But there are a few ‘model’ states like Kerala, Tamil Nadu or Himachal Pradesh, where the social or political context happened to be favorable. As for example, the installation of simple, well-designed public hand-pumps in most Indian villages have improved the access to safe drinking water and diminished the incidents of communicable diseases. The latest success story is the all-India polio immunization programme, which involved unprecedented feats such as the vaccination of about hundred million children in a single day. As far as the overall performance of health services is concerned, the picture is far from encouraging in most states. While the health services have steadily expanded in quantitative terms, there is much evidence that their quality has deteriorated. There is no denying the fact that under a globalized market-friendly regime, provisions of international supply would aggravate the deterioration in the supply of health care facilities in a developing economy like India. So, globalization in its present form needs to be controlled by the interventions and regulations by the state to weed out these adverse consequences.

A Case Study: Anemia, Worms and Preschool Participation in Delhi, India

This study evaluates the impact of an NGO (Pratham, Delhi) preschool nutrition and health project in poor communities in eastern Delhi which delivers a cheap package consisting of iron supplementation and deworming drugs to 2-6 year old children through their existing preschool network. Approximately 68% of sample children were anemic (Hb < 11 g/dL) and 24% suffered from intestinal helminth (worm) infections at baseline in mid-2001. Anemia is among the world’s most widespread nutritional problems, especially for children (Hall et al. 2001). The 200 preschool in the study were randomly divided into three groups, and the schools were gradually phased into the programme it expanded over the course of two years. In the first year of the programme, the group 1 preschool received the assistance package of iron supplementation (delivered to the schools by NGO field workers, and given to the children by teachers), deworming drugs (400 mg albendazole), and vitamin A, while the group 2 and 3 preschools received only vitamin A and served as comparison schools. In the second school year (2002-2003), group 1 and 2 preschools received the full package, while the group 3 schools served as the comparison group. Existing results are described in an unpublished working paper. During the first year of the project, we find large gains in child weight- over 0.5 kg on average- in the treatment schools relative to comparison schools; estimated weight gains remain positive, although smaller and statistically insignificant, in the second year of the project. Average preschool participation rates increased sharply by 6.3% points among assisted children over the two years, reducing preschool absenteeism by roughly one-fifth.

The following figure represents the time pattern of programme impacts, comparing group 1 to group 3 schools and group 2 to group 3 schools.

Figure 1.1

Figure 1.1: Preschool participation rate (November 2001 to February 2003) in Delhi. Difference between group 1 and 3 (blue line, diamonds), and difference between group 2 and 3 (red line, squares). The figure shows that the school participation rates increased substantially in the months after schools were phased into the programme: group 1 began receiving treatment in December 2001, and group 2 in November 2002. Given the low cost of the intervention- less than $2 (USD) per child per year, on average- these results suggest that the package of iron supplementation and deworming is a highly cost-effective means of improving child school participation in a poor urban setting where anemia and worm infections are widespread. The results thus largely confirm that child health gains translate into higher school participation. The demonstration that a nearly identical relationship holds in another geographic setting (urban India) with a younger age group and a different health intervention, provides additional confidence that there exists a robust relationship between child health, nutrition, and poor participation in poor countries. GATS and Health Services

Globalization of health services involves various modes of transaction. It involves cross-border electronic delivery, such as telediagnosis, teleconsulatations and transmission of medical images. It also involves cross border movement of consumers to avail health care services in another country, often because such treatment is not available or is too expensive in the patience home country. These may also be combined with tour packages, giving rise to the term ‘medical tourism’, and focusing attention on countries like Thailand, aggressively marketing it. Globalization of health sector is also evident from the growing foreign equity participation and establishment of joint ventures, alliances and management tie-ups among care establishments, resulting in the transfer of technology, skills and practices. Finally there is the global movement of doctors, nurses, technicians and the resulting networks of health care professionals that are sources of investment and know how. Commercial presence involves the establishment of hospitals, clinics, diagnostic and treatment centers, and nursing homes. Countries such as India, Indonesia, Nepal, Sri Lanka and Thailand have become increasingly open to foreign investment. When GATS was adopted in 1994, few countries were aware of the challenges it would bring. Very few government departments other than trade and finance ministries were involved in the negotiations and several countries committed all or part of their health services to GATS liberalization without the knowledge of their health ministries. Health services are also included under the GATS heading of ‘professional services’, which covers medical and dental services as well as the category of ‘services provided by midwives, nurses, physiotherapists and paramedical personnel’. Already 52 countries have made liberalization commitments in the formal category, and 28 in the latter. GATS also covers insurance services, including health insurance, and 78 countries have already committed those services to liberalization under GATS. This has caused particular concern in those countries, which base their health systems on social insurance programmes, since few health ministries were informed and their trade negotiators had committed their health insurance sectors to GATS.

Health in Post-Independence Era

At the time of independence, the health situation in India was extremely dismal. There have indeed, been large gains in health status since independence, reflected in the improvement in some health indicators presented in table 2.1. Overall mortality (infant mortality) has declined dramatically and life expectancy at birth has increased.

Table 2.1 Selected Health Indicators: India, 1947 and Current Indicators	At the time of independence, 1947	Current level (2002) Birth rate	40.8	25.0 (SRS, 2002) Death rate	27.4	8.1 (SRS, 2002) Infant mortality rate	146	63 (SRS, 2002) Life expectancy at birth	32.7	62 Source: SRS (Sample Registration System)

One of the major reasons for these gains has been the development of an impressively vast, three-tiered system of rural health infrastructure, namely, Sub-centers, Primary Health Centers (PHCs) and Community Health Centers (CHCs). The successful eradication of smallpox and elimination of guinea worm diseases are indisputably major public health achievements in India. Plague has remained in control since 1969. Yaws is near eradication and leprosy, near elimination. Cholera epidemics and deaths are comparatively infrequent and fewer. The incidence of measles, polio, whooping cough and tetanus in children has been significantly lowered. Immunization has made a major contribution to these gains. Diagnostic laboratory services have developed considerably, and communication and transportation have improved immensely. Improvements in water supply and sanitation have also helped achieve these outcomes. Despite these gains and achievements, there was a sharp decline in the quality of health services in the country. Large disparities across sections of the population are worrisome. In terms of health and from the view point of the framework of the epidemiological transition, different sections of the Indian society seem to belong to different phases of the transition: the poor and the vulnerable sections of the population suffer from diseases of poverty and under-nutrition, largely infectious and gastro-enterical diseases, among the rising urban middle class, the diseases of affluence such as heart and non-communicable chronic degenerative diseases are more prevalent. A recent World Bank study (2001) in India has also shown the poorest quintile to be having almost double the exposure to lifestyle risk factors like tobacco and smoking as compared to the richest 20% of the population. The poor are often concentrated in backward and remote areas having vey week infrastructure, degraded environment, poor sanitation, lack of access to safe drinking water which combined with under-nutrition and poor hygiene makes them highly vulnerable to ill-health. Acute anemia among women and children is a serious health problem. Bihar is the state with highest prevalence rate of anemia among women and children and Rajasthan and Punjab are just behind it. The lowest anemia affected state is Kerala. Now India has the highest number of people living with HIV/AIDS and 70% of HIV infections in Asia. But only 7% of people infected with the virus have access to treatment, according to the 2006 AIDS Epidemic Update by UNAIDS/WHO. According to the report, 5.2 million people in (15-49) age group in India are affected, and among the affected 38% are women. The most distressing data is that only 7 in 100 patients have access to treatment. We analyze the health status outcomes in India by comparing India’s disease burden with that of the world, and then examine India’s trends in mortality, fertility, malnutrition, and illness. As table 2.2 below demonstrates, India accounts for a fifth of the global disease burden, with a 17% share of the world’s population. Although India’s share of the world’s deaths is equal to its share of the world’ population (17%), the country’s contribution to pre-health transition diseases affecting younger people is disproportionately high. Compared with its share of the world’s population, India has high levels of deaths due to childhood infectious diseases such as acute lower respiratory infections (28.1%), and diarrhea (32.1%), measles (21.4%), and tetanus (40.3%). These conditions, as well as tuberculosis (28.1%), another disease with high death rate in India are common to low-income countries at an early stage of the epidemiological transition.

Table 2.2 India’s Share of the World’s Health Problems Percentage of World Population	17 People living in poverty (less than US$ 1 per day)	36 Total deaths	17 Under five mortality (death per 1000 live births)	23 Maternal deaths	20 DALYs lost	20 Deaths preventable with childhood vaccinations	26 HIV cases	14 Tuberculosis cases	30 Leprosy cases	68

A fuller measure of the burden of diseases counts not only deaths but also years of healthy life lost due to disability. A consolidates measure of losses from death and disability is disability-adjusted life years (DALYs) lost. Indis’s share of world’s total burden of DALYs lost was 19.5%, moderately larger than its 16.7% share of the world’s population. However, other conditions like injuries from falls, road traffic acidents, and fires; each account for relatively large portions of DALYs lost in India and in comparison to the rest of the world. At the same time, India continues to have a high burden of readily preventable and treatable conditions due to childhood communicable diseases, tuberculosis, malnutrition, and maternal illness. These illness are concentrated in the poorer states and among the poor. There is no denying that health indicators have continued to improve over time in India. Infant mortality rates have shown a steady and secular decline in India and life expectancy too has continued its upward climb. Yet the state of affairs is far from satisfactory: health indicators in India are inferior not only compared to the rich countries of the West but also compared to the achievements of other developing countries like China and Brazil. For example, despite greater sources, life expectancy in some states of India is similar to those in some of the poorest sub-Saharan African countries. Only the state of Kerala records achievements in health that is better than not only the rest of India but also the rest of the developing world and often at par with the Western developed countries. Infant mortality is a good indicator at ho well antions are doing in protecting their most vulnerable members. Both infant and child mortality have continued their declined trend but remain at high levels in India. The diversity in health status outcomes across the states of India is really enormous. Among the demographic and health indicators of 16 major states, Kerala compares favourably with most midle-income countries and even some high-income countries in West Asia. But Madhya Pradesh, Orissa, Rajasthan, and Uttar Pradesh are well below the average of low-income countries, and just above the levels of sub-Saharan Africa. Together the different states represent the whole range of health outcomes within these two extremes. The indicators conceal the wide disparities existing within the states- between urban and rural areas and between relatively developed areas, and remote areas inhabitated by tribal and other marginalized groups. While metropolitan cities have what could be onsidered modern tertiary care facilities by international standards, people in many remote rural areas do not have access to even basic primary care. Fertility rates also vary widely among the states. The differences among the states stem largely from poverty, illiteracy, and inadequate access to halth and family welfare services.

Characteristics of India’s Health Sector

India’s health sector is characterized by: •	A government sector that provides publicly financed and managed curative and preventive health services from primary to tertiary level, throughout the country and free of cost to the consumer (these account for about 18% of the overall health spending and 9% of the GDP).

•	A free levying private sector that plays a dominant role in the provision of individual curative care through ambulatory services accounts for about 82% of the overall health expenditure and 4.2% of the GDP. Nationwide health care utilization rates show that private health services are directed mainly at providing primary health care and financed from private resources, which could place a disproportionate burden on the poor.

As the public health infrastructure in the country is very small and grossly inadequate to meet the health care demands, the private health care sector has taken a dominant position. Private general practice is the most commonly used health care service in both rural and urban areas. It may be noted that the dominance of the private health sector is not something that has emerged recently or out of specific policies favoring privatization under the new economic regime of liberalization and globalization. It has always been there, including the states’ support for it to grow and flourish. While some policies of the state governments have actively promoted the private health sector’s growth, others have done this through sheer inaction and lack of concern. In today’s liberalized scenario and with World Bank’s advice of limiting state’s role to selective health care for a selective population, the private health sector is ready for another leap in its growth. And this will mean further appreciation in the rates of people’s treatment and a worsening health care scenario for the majority of our population. Private health care and essential drugs are becoming increasingly unaffordable to the majority of poor families suffering from illness. A growing proportion of Indians cannot afford health care when they fall ill. National sample surveys on morbidity show that the number of people who could not seek medical care because of lack of money increased significantly. The dominance of the private sector not only denies access to poorer sections of society, but also skews the balance towards urban biased, tertiary level health services with profitability overriding equity, and rationality of care often taking a backseat.

'''Health Status in India ''' Health status in Indian states are as diverse as the states are, and available statistics shows very uneven levels of attainment of health across the rural-urban divide as also across the geographical divide between the better performing and the poorly-performing (BIMARU) states (table 3.1). It cannot be a matter of pure coincidence that all the better-performing states (Kerala, Maharashtra, Tamil Nadu) are known to have better preserved public health systems as opposed to the poorly performing ones, where even the physical infrastructure and the manpower resources are grossly inadequate and frequently non-existent. In states like Uttar Pradesh, the State Health Service is basically engaged in administering the Pulse Polio Programme, whereas in states like Bihar and Jharkhand, the doctor or the compounder/pharmacist posted with the designated rural health centers, usually visit the village market weekly or fortnightly and run some sort of an out-patients’ department service. This is because either the physical infrastructure is non-existent or is too dilapidated or has been acquired for some other purpose. In still more remote areas, even such service is unheard of. In fact, the State Health Service simply does not exist for large parts of the population of many of these states, and the poor health service seeking population virtually remains at the mercy of private operators in the market.

Table 3.1 Differentials in Health Status Across Indian States

Sector	Populations BPL (%)	IMR/1000 Live Births (1999-SRS)	<5 Mortality 1000 (NFHS-II)	Wt. forage % of children <3 yrs (<2SD)	MMR/lakh (Annual Report 2000)	Leprosy Cases/10000 Population	Malaria +ve cases in year 2000 (in ‘000s) India	26.1	70	94.9	47	408	3.7	2200 Better Performing States Kerala	12.72	14	18.8	27	87	0.9	5.1 Maharashtra	25.02	48	58.1	50	135	3.1	138 TN	21.12	52	63.3	37	79	4.7	56 Low Performing States Orissa	47.15	97	104.4	54	498	7.05	483 Bihar	42.60	63	105.1	54	707	11.83	132 Rajasthan	15.28	81	114.9	51	607	0.8	53 UP	31.15	84	122.5	52	707	4.3	99 MP	37.43	90	137.6	55	498	3.88	528 Note: BPL- Below Poverty Line; IMR- Infant Mortality Rate; NFHS-II - 2nd National Family Health Survey; SD- Standard Deviation; MMR- Maternal Mortality Rate; TN- Tamil Nadu; UP- Uttar Pradesh; MP- Madhya Pradesh. Source: NFHS-II

Undernourishment and Government Interventions

The question of food security or rather of food insecurity should necessarily engage one and all intrinsically, as it is the most fundamental violation of all human rights. Yet, in this country, as grain stocks pile up, millions migrate, undergo conditions akin to slavery, and suffer untold misery due to lack of food. Over the years, as the Government projects figures of increasing food production, and urges farming communities to shift from subsistence to cash crops, we find that malnutrition levels are increasing, and the most vulnerable sections of the population, the women and children are undernourished. Undernourishment of children in millions implies that one generation of people are not being allowed to reach their full active potential. On the other hand, the centralized systems of welfare including PDS, and other programmes of food nutrition safety nets that the government has set-up have hardly worked, as people in the rural and tribal areas, where much of the underdevelopment still occurs, have little control over the management and running of these systems. Thus enormous subsidies given to run these systems in terms of Government of India finances, international finances and direct food resources are rendered to naught, as misappropriation, and poor management result in distress and hunger and hunger conditions continuing the same as ever before. The poorest communities in this country do not derive any benefit from these institutions for all the good that they do to these communities through their supports for nutrition and feeding. Government of India has approved the implementation of the scheme Nutritional Programme for Adolescent Girls (NPAG) in the year 2005-2006 on a pilot basis, through the department of Women and Child Development, Ministry of Human Resource Development. Funds for implementation of this scheme would be released as Additional Central Assistance (ACA) on a 100% grant basis to the states. The scheme would be implemented in the same 51 districts as were identified by the planning commission earlier. The scheme was to be implemented as per the Guidelines issued by the Planning Commission earlier, with two major modifications as under: •	The scheme was to be restricted only to adolescent girls.

•	 The list of the beneficiaries was to be approved in the Gram Sabha. The revised Guidelines were circulated to all states with a request to ensure that steps for implementation of the scheme be taken immediately. Steps for implementation of this scheme must be taken up by the State Governments/UT Administrations by coordinating with the Food and Civil Supplies Department of the state to ensure the availability of food grains under this scheme. State Governments may apprise of the position on the implementation of the scheme.

A healthy and well-balanced diet is essential for good health. When there is not enough food, or if the diet does not contain the right balance of foodstuffs, people become more prone to illness and may become undernourished or malnourished. Children, in particular, are vulnerable to poor nutrition. Undernourishment and malnourishment can lower their resistance and make them more likely to suffer from infectious diseases. Often, children will eat only small amounts of food if it is spicy, even if it is nutritious, and it is important to make children’s food less spicy than adult food. It is also important that children are fed not just foods high in starch or carbohydrate. •	A well-balanced diet usually has a mixture of food. •	Proteins (for example beans, peas, meat, fish or eggs). •	Carbohydrates (such as maize, potatoes, cassava, rice and many other staple foods).

Conclusion

Economics of health or health economics and growth emphasizes the relevance of devoting time, financial resources, and effort to the improvement of health and social welfare. These requires not only and investment in health care but also in public health policies, sanitation, nutrition and other sectors that interact with health. Health investment also involves devoting attention to a wider range of strategies that are mid and long-term in their outlook that aim to improve the population’s human and social capital. Such strategies may require a greater focus on medical research in the developed world. It will also require striving towards innovation, changing practices and improving human capital in the clinical management arena in an attempt to augment its effectiveness and efficiency in the real world. The findings of the impact of health on economic growth and the analysis of different dimensions of their connections will contribute to a deeper understanding of the benefits of investing in health. This understanding is highly significant for economic policy making and should help to contribute to human and socio economic development. Good health is a crucial component of overall well-being. However, improvements in health status may be justified on purely economic grounds. Good health raises levels of human capital, and this has a positive effect on individual productivity and on economic growth rates. Further, good health helps to forge improved levels of education by increasing levels of schooling and scholastic performance. Privatization of health care system has received accelerated emphasis in the new policy era of globalization, and instead of solving the problems created by shrinkage of states’ patronage and participation, it has aggravated ‘poor health at high cost’, which has made the poor absolutely vulnerable to face the risk of illness and related morbidity, and put a break on supply of healthy labour force in the coming years to cope with the requirements of accelerated growth syndrome. Table 4.1 below summarizes the snapshot view of how India is placed vis-a-vis some other countries in the world in respect of public sector spending on health.

Table 4.1 Public Health Spending in Selected Countries

Indicator		% Population with income of < $ 1 day	Infant Mortality Rate/1000	% Health Expenditure to GDP	% Public Expenditure on health to Total health Expenditure India 	44.2	70	5.2	17.3 China	18.5	31	1.7	24.9 Sri Lanka	6.6	16	3	45.4 UK	-	6	5.8	96.9 USA	-	7	13.7	44.1 Source: National Health Policy, 2002.

With globalization of health services being permissible under the GATS, India could take the advantage of Telehealth services and export the services of medical personnels like doctors and nurses and Indian market would expand for medical tourism, because, the relative cost of treatment of advanced and critical diseases are cheaper in India compared to many countries in the world, but the benefits of such international exposure are likely to remain confined to only 5% of our population, and would not be inclusive in nature. In recent years, interest has been expressed by national health services overseas for Indian nurses, to meet domestic shortages. And there are growing numbers of joint ventures and tie-ups, such as Apollo Gleneagles, Max India and Fortis Healthcare. India is also emerging as a source of foreign direct investment (FDI) in health services, as shown by the regional expansion plans of major players, such as Apollo group. This study of health care system in India during the period of globalization clearly brings out appalling nature of health and nutritional deprivation for the country’s poor and the vulnerable, including women and children, which are reflected in low human development indices of Indian states. With declining trend of public expenditure in most states as a proportion of net state domestic product in real terms and rise in private expenditure on health care and disease prevention, but poor public and private health infrastructures, particularly in rural areas, fiscal contraction in the states as a result of economic reforms has worsened the scenario and actuated the trend for morbidity of the population. The emphasis on pro-poor inclusive growth in the XIth five year plan notwithstanding, the health status of the population and the associated deprivations are likely to be aggravated in the face of globalization of health services as per the dictates of the GATS agreement because the government has not been able to formulate a comprehensive health policy and reform the health care organization and infrastructure. As a result, we do not expect a turn-around in the country’s health conditions in the near future and the benefits of globalization in the form of better treatment options and better technology being available through trade channels are unlikely to be repeated in India, because bulk of our ailing population would be unable to afford them and the medicines are likely to be costlier than before. The integration of trade policy and health policy reforms in our country are therefore necessary to face the challenges thrown open by the new open regimes.

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