“IMPACT OF GLOBALISATION ON PUBLIC HEALTH SYSTEM OF

INDIA”

1.0 Problem statement and purpose of the study :

Globalisation with global transportation and communications revolution

enable rapid response to epidemics and catastrophes but at the same time
there is also a flip side due to the rapid mobility of the people across the
borders, the effect of infectious disease is a threat to everyone, particularly the
poor.

India is a very Young nation. After its independence in 1947, India did not
instantly started to Develop. The first 40 years of India was the struggling
period which can also be described as the “Restructuring Process” in which
steps were taken to cope up with the degraded conditions of the society after
the Post-colonialism. The Govt. Should have placed Health to an important
position in the Welfare Schemes but with the onset of the Liberalisation
Programme in 1991, there has been a sharp decline in the Government’s
commitment to public health.

For any country to progress, manpower is the primary thing and the foremost
requirement and only a healthy manpower can serve towards the
Development and Nation-Building. “Globalisation has boosted the Economic
Development of the Nations but all over the world it has turned the Welfare
State into Minimalist state and has reduced the state’s capacity of spending
the budget in the area of Basic requirement of Manpower and which is very
important to ensure equal Economic Development” as the Nobel Prize
Laureate Mr. Amartya Sen says that “you need an educated , healthy workforce
to sustain economic development.” For example, “improved primary
healthcare have made the China to produce enough manpower by making
positive use of its population. The people there can produce a lot and that’s
the reason that China have secured a good position in the HAQ ( Healthcare
Access and Quality ) Index ranking; 48 out of 195 countries. India can generate
a huge amount of workforce as it has the largest number of youth population
in the world. The need of the Hour is the Improved health policies.

“This research is motivated by the fact that The ultimate aim of every nation is
to develop in every aspect , the development of its society, different prospects
and most importantly The Development of Humans, and The development of
any nation and the humans residing within its borders is directly linked to the
health status of its people as we can see that Countries spending an ample
amount on health have the best Healthcare access and facilities, Healthy Life
expectancy, freedom to make life choices and are also the World’s most
developed nations and World’s happiest nations in spite of being the world’s
most globalised Countries with top KOF Index”.

2.0 RESEARCH QUESTIONS :

This research will therefore seek to explore and investigate the following
Questions :

 To examine the extent to which globalisation effects the public health

system in India along with other Third World Countries.
 Do communicable disease spread faster under globalisation?
 How These diseases have affected the Indian Population ?
 How Global Surveillance can be strengthened to prevent the
spread of Diseases through Globalisation ?
 How does globalisation affect the environment and our lifestyles
ultimately affecting our health ?
 The world politics In Globalisation which effects the Health ( WTO,
World Bank and IMF – The key players )
 AOA ( Agreement on Agriculture – Assault on food security ) – An
integral part of good health.
 WTO’s TRIPS ( TRADE RELATED INTELLECTUAL PROPERTY RIGHTS ) :
 Drugs should be for People, Not for Profit
 How was the health sector Reformed after 1991 ?
 To identify the problem caused to people, especially the poor.
  Why Govt is Rolling Back from it’s responsibilities ? – “From Welfare
state to the Minimalist State”.
 How did India’s neighbouring countries made the great escape from the
poor health conditions earlier than their much bigger neighbour ? The
comparison and evaluation of the health policies and to examine where
are we lagging behind.
 What can be the possible solutions, how long will it take and who all will
be the key players ?

3.0 LITERATURE REVIEW :

3.1 HOW HAS THE GLOBALISATION AFFECTED THE PUBLIC HEALTH
SYSTEM ?

With the advent of Neo-Liberalism, The world bank document titled “Financing
Health Services in developing Countries” made the following
recommendations :

 Increase amounts paid by patients.

 Develop private health insurance mechanism ( this requires dismantling
of state supported health services because if free or low cost health care
is available, there is little interest in private insurance. )
 Expand the participation of private sector.
 Decentralise Government health care services.

In almost every developing country where these prescriptions have been

followed, public health conditions have deteriorated. The health expenditure
fell in Philippines and Mexico. The component that degraded the Philippines’s
HAQ ( Healthcare access and quality ) Index was the degraded health services
and Health spending due to the onset of the private players to deal with severe
diseases like TB, Leukaemia, Cardiovascular disorders in which poor, especially
women suffered the most. Even In 2016, HAQ Index went as low as 18.6 in the
central African Republic, 19.0 in Somalia and 23.4 in Guinea-Bissau.
Even India ranked 145th among 195 countries. It lags behind its neighbours;
China(48th), Sri Lanka(71st), Bangladesh(133rd) and Bhutan(134th). Within India
itself there is a great disparity among the Healthcare access. Goa and Kerala
scores as high as 64.8 and 63.9 respectively on the HAQ Index whereas Uttar
Pradesh and Assam scores as low 34.9 and 34 respectively.

India’s neighbours making great strides in the Health Development has puzzled
many. As we see Bangladesh, it has made the most improvement in South Asia,
of 29 points, improving its ranking from 180 in 1990 to 132 in 2016. How could
these countries make the great escape from the poor health conditions earlier
than their much bigger neighbour ? Because their Spending on Public Health
Systems is more than India and the concerned authorities have taken better
steps to deal with it. Srilanka is a very good example who has learnt from
Scandinavian Countries and framed excellent policies to deal with their Public
Health System. Similarly, Bhutan has a great GNH ( Gross National Happiness )
Index.

3.2 FROM WELFARE STATE TO MINIMALIST STATE – A SETBACK FROM

THE RESPONSIBILITIES.

After the arrival of private players and avenues, many private hospitals were
built in India with advanced medical facilities and good care but the question is
that how much of the population is able to access those facilities in a country
where 70.6 million people are still living in poverty and more than 50 % of the
population ( more than 1.3 billion ) are middle class with $2 to $10 per capita a
day (according to Asianstudies.org ) and within this population are the lower
middle class who are growing at the fastest pace who spend $4 - $6 per day
and who are not able to afford the high fees of private healthcare sectors.

India’s sluggish public health spending hovered around just 1% of the total GDP
in 2018 which accounted for less than 30% of the total health expenditure
whereas it is advised by the WHO to use at least 3%-4% of The GDP for
Healthcare. And besides low public spending, neither the central nor the state
governments undertook any significant policy intervention, Except the
“National Health Mission” to redress the issue of widening socio-economic
inequalities in health. But the NHM, with a budget of less than 0.2 %of GDP, is
far too less to make a major impact.

In India’s Public health sector, Ayushman Bharat and PMJAY ( Pradhan Mantri
Jan Aarogya Yojana was supposed to be the “Game Changer” but The death of
more than 100 Children in Bihar due to Encephalitis shows the complete failure
of the Mission. At a panel discussion on “Ayushman Bharat : Fact and fiction”,
organised by AIIMS Front for social consciousness in it’s campus, The Public
Health Experts including the Doctors at AIIMS said that the “Ayushman Bharat
is an eyewash to hide govt’s failure to provide effective healthcare”.

Dr. Vikas Vajpayee, professor at the centre of social medicine and community
health of Jawaharlal University stressed on the need to analyse the failure of
various publicly –funded health insurance schemes, including the RSBY (
Rashtriya Swasthaya Bima Yojana ). He added it was just another official
channel through which public money will go to private set-ups.

Even if we look at the current budget allocation of Ayushman Bharat-PMJAY, it

is Rs. 6400 Crores for 10 crore families which comes down to Rs. 640 per family
and Rs. 128 per person which is too low to expect good treatment from
hospitals. Also the budget has focused on Ayushman Bharat Yojana but there
has been a curtailment from reproductive and child health areas. Under
flexible pool including routine immunization program and pulse polio
immunization program, there has been a curtailment from Rs. 7,411.40 crores
in 2018-19 to Rs. 6,758.46 crore in 2019-20. The National Mental Health
Program saw a decline from Rs. 50 Crores to Rs. 40 Crores. Also diseases like
cancer, diabetes, cardio-vascular disease and stroke are very severe and
requires huge amount of money for treatment even with the support of NGO
and it is difficult for the poor and the middle class families to afford huge
amount of money for the treatment of such chronic diseases. The budget for
Prevention and control of such diseases reduced to Rs. 175 Crores from Rs. 295
crores. The total budgetary allocation for the tertiary care programmes saw a
Rs. 200 crore dip, from Rs. 750 crores in 2018-19 to Rs. 550 crores in this fiscal.

These problems of low union budget on public healthcare schemes have

occurred due to the Liberalisation of Economy with the fast pace of
Globalisation which resulted in the transformation of Welfare state into
Minimalist State, making the State to take a setback from it’s responsibilities.

“As Imrana Qadeer, faculty at council for social development said that the
Government should have strong regulatory mechanisms over Such aspects.
Neglect of basic healthcare infrastructures under the NRHM ( National Rural
Health Mission ) by drastically curtailing investments, increases the load on
secondary and tertiary care institutions and rationalises partnerships with
Private sectors and Foreign Firms, which are waiting to enhance its profits
through schemes like RSBY and PMJAY”.

3.3 DO COMMUNICABLE DISEASE SPREAD FASTER UNDER

GLOBALISATION ?

Every phase of human civilization that has seen a rapid expansion in exchange
of population across national borders has been characterised by the spread of
communicable diseases.

( DATA BY CENTRE FOR DISEASES CONTROL AND PREVENTION )

Affiliation : WHO, Geneva, Switzerland

 The early settlers in America, who came from Europe, carried with them
small pox and measles that affected the Indigenous population of Native
Americans.
 Plague travelled to Europe from orient in the middle ages, often killing
more than quarter of the population of the European cities.
 During 1996, fatal yellow fever infections were imported into the United
States and Switzerland by the tourists who travelled to yellow fever
endemic areas without yellow fever vaccination.
 In 1996, 10,000 cases of Malaria were imported into the European
Community.
 Among the pilgrims for the Haj in 1987, 7.7 per 100000 returned to their
country of origin with meningitis.
 Cholera, often associated with religious pilgrimage and movement of
refugees, resulted in 70,000 cases and a 2% fatality rate in 1995 among
recently arrived Rwandese refugees in Goma, Democratic Republic Of
Congo.
 Rickettsial diseases such as louse-borne typhus have also recently
caused illness and death among refugees and prison population of
Burundi and Rwanda.
 During 1991, cholera entered Peru, it spread through the existing
sanitation and water systems, causing more than 3000 deaths.
 Spread of Dengue and Chikungunya : The first epidemic of dengue
hemorrhagic fever (DHF) was described in Southeast Asia, Manila in
1953 and by the late 1990s, there were around 40 million cases of
dengue fever. It spread in other countries like China, India, Taiwan,
Malaysia, Pakistan, Indonesia, Thailand, Nepal, Vietnam. In India,
according to figures of the National Vector Borne Disease Control
Programme (NVBDCP) under the Indian Health Ministry, the disease has
claimed the lives of 83 people till September 2018, while 40,868 persons
were affected by it and according to a collaborative studies conducted
by the CNRS and The National Institute of malaria research, 40% of the
population of New Delhi have been infected by the Dengue Virus at least
once in a lifetime.
 Similarly “Nipah Virus” which was first recognized in 1999 in Malaysia
which also affected Singapore and spread due to globalisation in
Bangladesh in 2001 and later in India and then in Cambodia, Ghana,
Indonesia, Madagascar Island, Philippines and Thailand. In India, the
disease has claimed 67 lives till now.
 Similarly TB and AIDS spread far and wide across the world and the
condition was much severe in South Asia. According to a bulletin of the
 “World Health Organisation” on “communicable diseases in the South-
East Asia Region”, 253 in 100000 adults in India is infected by HIV and in
2007 India and Indonesia were among the top 5 countries in terms of
total number of TB Cases. In India, each year, approximately 2,20,000
deaths are reported due to TB and the between 2006 and 2014, the
disease cost Indian economy USD 340 billion.

Strong Global Surveillance is the need of the hour.

3.4 WTO ( WORLD TRADE ORGANIZATION )– THE KEY PLAYER

“TRIPS ( TRADE RELATED INTELLECTUAL PROPERTY RIGHTS ) – NO
MEDICINES FOR THE POOR”

TRIPS protects the interest of big biotechnology, pharmaceuticals, computer

software and other businesses. The trips agreement required countries like
India to change over to a “strong patent protection regime”. A regime that
would no longer allow countries to continue with domestic laws that enabled
domestic companies to manufacture new drugs invented elsewhere, at prices
that were anything between one twentieth and one hundredth of global
prices.

It may be recalled that it was the Patent Act, which by encouraging Indian
Companies to develop new processes for patented drugs, also facilitated the
development of the world class manufacturing facilities in a developing
country like India. The TRIPS Agreement has placed enormous power in the
hands of MNCs, by virtue of the monopoly that they have knowledge. “They
have generated super profits through the patenting of top selling drugs but
drugs which sell in the market may have little to do with the actual health
needs of the global population”.

We have large number of “Orphan” drugs – drugs that can cure life threatening
diseases in Asia and Africa, but are not produced because the poor can’t pay
for them. Today’s medical research is highly skewed in favour of heart diseases
and cancer as compared to other diseases like Malaria, Cholera, Dengue fever
and AIDS which kill many more people especially in developing countries. Just
4% of drug research money is devoted to developing new pharmaceuticals
specifically for diseases prevalent in the developing countries. “Drugs should
be for people, Not for profit”.

3.5 AGREEMENT ON AGRICULTURE (AOA) – ASSAULT ON FOOD

SECURITY :

The present phase of globalization also have grave consequences for food
security, which is an integral part of good health. The lifting of restrictions on
imports, as required by the AOA has resulted in the widespread disruption of
the rural economy. The AOA ensured that the subsidies provided to domestic
agriculture by developing countries would be phased out while those being
provided by developed countries would be retained. This has resulted in
exports of primary commodities by developing countries becoming
uncompetitive while their domestic markets are being flooded by subsidized
imports from developed countries. As a result vast tracts in India now grow
cash crops like cotton, tobacco, sunflower.

Also due to such policies, thousands of farmers have committed suicide ! Who
will take responsibility of their death ?

In all these conditions, one thing can be noted that Countries spending an
ample amount on health have the best Health care access and facilities,
Healthy Life expectancy, freedom to make life choices and are also the World’s
most developed nations and World’s happiest nations. For example as Norway,
Netherlands, Switzerland, Denmark, Iceland, Belgium, Finland provides very
good Health access facilities and also secures a good position in the HAQ Index
with Iceland, Norway and Netherlands in the Top Three with a score of 97.1,
96.6 and 96.1 respectively. These countries are also the World’s most
developed nations with Norway and Switzerland at the top with 0.953 and
0.944 points and they are also the World’s Happiest Nations in which Finland,
Norway, Iceland, Switzerland, Netherlands top the list with The GNH ( Gross
National Happiness ) Score of 7.632, 7.594,7.495, 7.487, 7.441 points
respectively and they also have Healthy Life Expectancy.

 METHODOLOGY :

1. DATA COLLECTION :

For the purpose of this research, and in order to achieve the objectives, both
primary and secondary data will be collected. Primary data will be collected in
two ways. Firstly, a questionnaire survey will be conducted with the poor,
middle class and lower middle class families including patients at hospitals and
clinics. Secondly, interviews will be also carried out with Experts of Public
Health, Doctors and Authorities.

2. THE QUESTIONNAIRE SURVEY :

Close-ended questions will be designed in order to call for responses, which

narrow down the field of enquiry, since the respondents chooses among fixed
responses. It will also help the researcher to easily analyse the data since the
response can be directly compared and easily aggravated. But since close
ended-questions offer limited alternative replies, so there will be open
questions too in which the respondents can give some new opinion and ideas.
Surveys will be employed among people of all ages.

3. THE INTERVIEW SURVEY :

Personal interview will be taken in order to reach the objectives since it is the
most versatile and productive method of communication. Target group will be
the patients, Public health Expert, Doctors and Local Authorities. The Choice
will be based on researcher’s knowledge as well as the knowledge of the
Target Groups.

4. ANALYSIS OF INITIALLY DONE RESEARCHES :

An analysis of initially done researches help to better understand the situation,

to compare the now and then factors and to write the results. It also helps us
in knowing that how far we have achieved from the initial policies, where are
we lagging behind and what changes and new developments can be added.

It also helps in framing a new policy by assimilating now and then policies. We
also come to know about the new needs of the society according to changing
times and deal with it accordingly.

 CONTRIBUTION OF THE RESEARCH :

It is intended that the findings of this research project will be used to access
and evaluate the Health Conditions of the people and the factors related to
it, the actual conditions of the poor, middle classes and lower middle
classes and how far they are able to make use of the limited Public Health
care Initiatives in India. Research Will analyse that who are the major
beneficiaries and who are the sufferers in terms of Health and Poor Living
conditions and economic conditions due to Globalisation and Setback Of
Government’s responsibility. It will also evaluate the Effects of
Globalisation on the Health Conditions of the other third world nations.

These findings could be used for analysing and understanding the root
cause and to correct it by taking into it’s ambit The Key Players. It will make
the concerned authorities and the Citizens more aware about the
 importance of Good Health and The authorities and Public Health Care
Experts will start working on policies which will adjust into the framework
of Globalisation as earlier done by the Scandinavian Countries and some
European Countries.

“The Data of the research can be kept in mind while framing such Health
Policies, which will improve the health conditions of the mankind and The
Mankind with a good health can prove to be the most powerful resource on
the planet”.

-- MUKESH KUMAR