INTRODUCTION: Globalization or (Globalisation) refers to the increasingly global relationships of culture, people and economic activity.

Most often, it refers to economics: the global distribution of the production of goods and services, through reduction of barriers to international trade such as tariffs, export fees, and import quotas. Globalization accompanied and allegedly contributed to economic growth in developed and developing countries through increased specialization and the principle of comparative advantage. The term can also refer to the transnational circulation of ideas, languages, and popular culture. Opponents of globalization alleged that globalization's benefits have been overstated and its costs underestimated. Among other points, they argued that it decreased inter-cultural contact while increasing the possibility of international and intra-national conflict.

MANAGING GLOBALIZATION IN HEALTH: The increasingly interdependent world poses severe challenges to communities around the world. The high density of the population leads diseases to spread much faster than ever before. While communities are physically separated by seas, roads, mountains or rivers, they have become too close and interdependent because of efficient transport, communication and trade systems that

allow pathogens to travel and infect people much more easily than ever before, thus allowing for globalization of infectious diseases. Globalization has also made it easier for the increase in non communicable diseases. Efforts are underway to manage these through the establishment of global goals, drawing of international health regulations, and negotiation of international agreements, financing of health services, and reducing determinants of health. Although globalization brings with it major challenges, it also permits the global community to manage its impact for the benefit of health. Only when global players work closely with member countries; can the negative effects of globalization be managed and the health of people improved.

GLOBALIZATION OF HEALTH SERVICES: Globally there has been tremendous growth in the health service sector, catalyzed by inadequate national public health services, the spiraling cost of health services and the availability of cheaper alternatives in developing economies. This has led to the globalization of health care worldwide, illustrated by growing cross-border delivery of health services that is estimated to be in excess of US$140 billion (World Trade Organization 2001). In India, health care is one of the largest sectors, in terms of revenue and employment, and this sector is expanding rapidly. During the 1990s, the Indian health care sector grew at a compound annual rate of 16%. Today the total value of the sector is more than US$34 billion. By 2012, India's health care sector is projected to grow to nearly US$40 billion (PricewaterhouseCoopers 2007). A major proportion of this growth is predicted to be attributable to the growth in the business of medical tourism. Medical tourism in India has gained momentum over the past few years. According to the Confederation of Indian Industries (CII), approximately 150 000 patients arrived in India in 2005 from across the globe for medical treatment, and this is expected to increase by 15% each year (Confederation of Indian Industries and McKinsey & Co. 2002). The medical tourism market in India was estimated at US$333 million in 2004 and has grown by about 25%. It is predicted to become a US$2 billion a year business opportunity by 2012 (Ernst & Young 2006).

Americans and Europeans Are Trekking to India for Surgery, According to Bloomberg Markets Magazine:

NEW YORK, Jan. 27 /PRNewswire/ -- Unwilling to accept long waits in Europe or high costs in the U.S., patients are traveling to India to have surgery, report Abhay Singh and Mrinalini Datta in the March edition of Bloomberg Markets. With "Medical Tourism" on the rise, more people from the U.S., Europe and the Middle East are seeking out Indian hospitals as a cheap and safe alternative, says the Bloomberg Markets story. According to Bloomberg Markets, Indian doctors are setting up what could be a medical renaissance in their country and the next great boom for the Indian economy. Many Indian hospitals are joining together to improve quality of care and boost first impressions. Indian hospitals are aiming for $2.3 billion in annual revenue by 2012. Instead of paying $200,000 for mitral valve surgery in the U.S. you could travel to India and receive the same treatment for $6,700, Bloomberg Markets reports. Instead of paying 15,000 pounds Sterling for hip

resurfacing in the U.K., the same procedure would cost 5,000 pounds in India, including surgery, airfare and hotel stay, according to the magazine. Would you do it? Has a Cheaper workforce enabled India to compete in a field many thought could never flourish in that country? These are the questions many people throughout the world have been asking themselves, and increasingly the answer is 'yes', says Bloomberg Markets. In the March issue, Bloomberg Markets takes a close look at this trend in health care, the people who have chosen to forgo surgery in their own countries and the potential impact worldwide. The March edition of Bloomberg Markets will be available for sale in mid-February. Bloomberg Markets articles are also available to Bloomberg terminal subscribers

INCREASED SHORTAGE OF SKILLED HEALTH PROFESSIONALS: An important reason for poor service delivery in the public sector is the shortage of trained and skilled health personnel. According to the recently released Planning Commission report, India is short of a phenomenal 600 000 doctors, 1 million nurses and 200 000 dental surgeons (Planning Commission, Government of India 2008).

The availability of medical specialists in local Community Health Centres (CHCs), compared with the number of approved posts, is also worrying. The existing CHCs have a high shortfall of specialist manpower, such as obstetricians and gynaecologists (56%), paediatricians (67%), surgeons (56%) and medical specialists (59%) (Satpathy and Venkatesh 2006). While the public sector is encumbered with staff and resource shortages, it has been estimated that over 75% of the human resources and advanced medical technology, 68% of the estimated 15 097 hospitals and 37% of 623 819 total beds in the country are in the private sector (Ministry of Health and Family Welfare 2005). These figures suggest that the private sector is the prime employer of health personnel predominantly trained in public health institutes. Further growth in this sector due to medical tourism could aggravate the internal brain drain, as better-quality health care professionals flow from the public health care segment to the corporate segment, with its better pay and superior infrastructure (Chanda 2002).

UNREGULATED GROWTH OF THE PRIVATE SECTOR: The government is expected to play an important role in regulating the private sector. However, in India, state interventions have been minimal (Bhat 1999). There is no policy framework to have a common set of regulations for the private health care sector. The implementation and enforcement of the existing regulations has been weak, and many of these regulations have not been updated and hence have lost their relevance. There are no institutional mechanisms within the government to address private sector issues. Moreover, there has been considerable resistance from various constituents of the private health care sector to accept in principle the applicability of certain regulations to their profession (Bhat 1999).

In India, the private sector has already received considerable subsidies in the form of land, reduced import duties for medical equipment, etc. Medical tourism could further legitimize their demands and put pressure on the government to subsidize them even more. This is worrying because the scarce resources available for health will go into subsidizing the private sector.

INCREASED COST OF MEDICAL TREATMENT: In India, currently over 80% of health care expenditure is borne by patients through out-ofpocket expenditure. It has been predicted that one effect of the increase in medical tourists would be a rise in the overall cost of health care in the country (Ministry of Health and Family Welfare 2005). In recent years, several studies have indicated the rising nature of medical costs. According to NSSO survey estimates, between 19956 and 2004 medical costs increased by 55.67 and 77.28%, respectively, for government and private sources in rural India. In urban India, the corresponding increases were, respectively, 76.6 and 116.2% (NSSO 2006). In India, the private sector caters for 80% of the health needs of the population. The establishment of state of the art health facilities within this sector, combined with increased disparity in the quality of services provided in the two sectors, will further increase the dependence on the private sector and hence expenditure on medical treatment.

ACCESS TO QUALITY FOOD: Globalization can be beneficial in increasing access to food. Many countries export food to those countries which, for a variety of reasons such as poor economies and drought, are unable to produce sufficient quantities for domestic consumption or even for those who import foods to add variety. With the importation of food, local inhabitants inadvertently acquire new risks. The imported foods may be overly processed, contain processed sugars; be high in fat content, and their consumption might contribute to development of chronic diseases of life style. This has led to changes in dietary habits. Instead of children eating low fat food with high fiber, many are eating over processed foods. With a combination of access to television and programmers that advertise these foods (such as McDonalds), children in developing countries are now becoming as obese as those in developed countries. They eventually begin to suffer from the same life style-related diseases, such as diabetes, cancers, hypertension and heart diseases; this comes on top of diseases related to poverty, such as diarrhea, acute lower respiratory diseases, malaria, TB, HIV, and cholera. The double burden of communicable and non-communicable diseases is a threat to provision of public health services in developing countries, which barely afford to provide even basic care. But this is not limited to developing countries.

THE WAY AHEAD: The current demand for health and wellness services has generated a global market in health services. In India, the private sector has responded promptly to this demand, which is evident from the recent increase in the number of super-specialty centers offering services to medical tourists. Even the government has initiated measures to encourage the growth of medical tourism but these have mainly benefitted the private sector.

ADVANCES IN MEDICAL SCIENCES AND INFORMAITON TECHONOLOGY: Globalization has not only brought challenges, it has also created opportunities. Scientists are now able to work together in person or through telemedicine or email to find treatments or cures for diseases. The advent of internet has accelerated access to scientific information. Electronic journals are now available to scientists across the globe; they now are able to use evidence-based medicine to diagnose, treat and rehabilitate their patients. Globalization has also contributed to the discovery of medicines to treat diseases. The pharmaceutical industries produce drugs needed by the poor, but which the poor cannot afford to purchase. The Trade Related Aspects of Intellectual Property Rights gave the pharmaceutical companies the right to hold on to patents for 20 years to recoup their research and development investment before generics could be produced. Indeed the profits were quite substantial. A report produced by a consumer watchdog, the Public Citizen in the USA, showed that the ten most profitable drug companies increased their profits by $4.8 billion or 20% from 1998 to 1999. These profits exceeded the profits of other Fortune 500 industries such as auto, oil, securities and airlines. Despite the reduction in prices and donations made for poor people to access these drugs, they are still unaffordable to many. The cost of ARV treatment at reduced price is around $200 annually, which is beyond the means of many who live on $1 per day. It is no surprise that only 7% of the people who need ARV have been able to access it. With the globalization of infectious diseases such as HIV/AIDS, it is critical that people have access to medicines at affordable costs. The patents remain an obstacle that the World Trade Organizations TRIPS agreement imposes on developed and developing countries to produce generic copies of the branded products. With access to technology, developing countries and NGOs no longer leave the interpretation of such global agreements as TRIPS to highly industrialized countries. The 1998 debate on the Revised Drug Strategy resolution, centering on

the primacy of public health over commercial interests, was led by southern African countries, which with the support of NGOs were able to educate the member countries and the world about the importance of the TRIPS agreement in accessing medicines. It was no surprise that at the following World Health Assembly member countries unanimously supported the Revised Drug Strategy. However, because the TRIPS agreement is negotiated at the WTO and not WHO, the health concerns do not take priority over commercial interest. But countries are still not taking advantage of the flexibility of the TRIPS agreement. Governments are allowed to authorize a third party to use the patent without the permission of the owner of the patent or without a license as long as the patent owner is paid adequate compensation. The TRIPS agreement does permit countries to establish administrative means to allow for production or importation of generic products from the competitive sector (Love, 2001).

HEALTH INSURANCE: Over the last 50 years India has achieved a lot in terms of health improvement. But still India is way behind many fast developing countries such as China, Vietnam and Sri Lanka in health indicators (Satia et al 1999). In case of government funded health care system, the quality and access of services has always remained major concern. A very rapidly growing private health market has developed in India. This private sector bridges most of the gaps between what government offers and what people need. However, with proliferation of various health care technologies and general price rise, the cost of care has also become very expensive and unaffordable to large segment of population. The government and people have started exploring various health financing options to manage problems arising out of growing set of complexities of private sector growth, increasing cost of care and changing epidemiological pattern of diseases. The new economic policy and liberalization process followed by the Government of India since 1991 paved the way for privatization of insurance sector in the country. Health insurance, which remained highly underdeveloped and a less significant segment of the product portfolios of the nationalized insurance companies in India, is now poised for a fundamental change in its approach and management. The Insurance Regulatory and Development Authority (IRDA) Bill,

recently passed in the Indian Parliament, is important beginning of changes having significant implications for the health sector. The privatization of insurance and constitution IRDA envisage improving the performance of the state insurance sector in the country by increasing benefits from competition in terms of lowered costs and increased level of consumer satisfaction. However, the implications of the entry of private insurance companies in health sector are not very clear. The recent policy changes will have been far reaching and would have major implications for the growth and development of the health sector. There are several contentious issues pertaining to development in this sector and these need critical examination. These also highlight the critical need for policy formulation and assessment. Unless privatization and development of health insurance is managed well it may have negative impact of health care especially to a large segment of population in the country. If it is well managed then it can improve access to care and health status in the country very rapidly. Pakistanis rely more on Indian doctors New Delhi, April 19 (IANS) Pakistanis looking for a liver transplant rely more on Indian doctors as they are more efficient, said a Pakistan-based neurologist whose daughter recently underwent an organ transplant in Delhi.

If I hadnt travelled from Pakistan to India (for the transplant), my daughter would be in the grave by now, Sajjad Hussain told IANS Monday.

My daughter was almost dead but the Indian doctors have given her a new life, he said. His daughter Sara Hussain, a medical practitioner herself, needed a transplant for her diseased liver.

Hussain said when it comes to health related issues, 90 percent of Pakistanis prefer travelling to India as there is no language barrier, and the similar eating and living habits make it easy for them to adapt to the circumstances, Hussain said.

Earlier most Pakistanis used to come for kidney transplants but with this procedure now

available in their country also, most of them now come to India for liver transplant as Pakistani doctors have less expertise or are not trained in it, said Subhash Gupta, a senior consultant, liver transplant at the Apollo hospital here.

Meanwhile, Hussain said that hepatitis C, an infectious liver disease caused by the hepatitis C virus (HCV) affecting the liver and spread by blood to blood contact, has more or less assumed epidemic-like proportions in Pakistan and people from Islamabad and Lahore particularly are mostly affected by liver related disease.

The main reason for such issues is that the drinking water in Lahore and Islamabad is contaminated and used syringes are reused in hospitals, he said.

An Apollo hospital official said that the hospital had carried out around 70 liver transplants on Pakistani nationals alone in the past two years. Science has no borders, particularly when it comes to health issues, said Anupam Sibal, group medical director.

Compared to other nationals, its easy to treat Pakistanis because their genetics and disease patterns are almost the same as ours, he added.

CONCLUSION: New and emerging diseases are spreading globally at alarming rates. Although globalization brings with it major challenges, it also permits the global community to manage its impact for the benefit of health. Only when global players work closely with member countries can the negative effects of globalization be managed. It is crucial that the member countries that are to implement these agreements be thoroughly informed of the implications of the policy guidelines or agreements that are to be taken so that they can be partners, more so- equal partners. Further, affected member states have to be involved from the beginning and partake in all discussions and brainstorming meetings that generate these global policies and agreements.