Rupa Chanda

Trade in health-related services

The supervision of a domestic health system in the context of the trade environment in the 21st century needs a sophisticated understanding of how trade in health services affects, and will affect, a countrys health system and policy. This notion places a premium on people engaged in the health sector understanding the importance of a comprehensive outlook on trade in health services. However, establishment of systematic comparative data for amounts of trade in health services is difficult to achieve, and most trade negotiations occur in isolation from health professionals. These difficulties compromise the ability of a health system to not just minimise the risks presented by trade in health services, but also to maximise the opportunities. We consider these issues by presenting the latest trends and developments in the worldwide delivery of health-care services, using the classification provided by the World Trade Organization for the General Agreement on Trade in Services. This classification covers four modes of service delivery: cross-border supply of services; consumption of services abroad; foreign direct investment, typically to establish a new hospital, clinic, or diagnostic facility; and the movement of health professionals. For every delivery mode we discuss the present magnitude and pattern of trade, main contributors to this trade, and key issues arising.

India-EU relations in health services: prospects and challenges

BackgroundIndia and the EU are currently negotiating a Trade and Investment Agreement which also covers services. This paper examines the opportunities for and constraints to India-EU relations in health services in the context of this agreement, focusing on the EU as a market for Indias health services exports and collaboration. The paper provides an overview of key features of health services in the EU and India and their bearing on bilateral relations in this sector.MethodsTwenty six semi-structured, in-person, and telephonic interviews were conducted in 2007-2008 in four Indian cities. The respondents included management and practitioners in a variety of healthcare establishments, health sector representatives in Indian industry associations, health sector officials in the Indian government, and official representatives of selected EU countries and the European Commission based in New Delhi. Secondary sources were used to supplement and corroborate these findings.ResultsThe interviews revealed that India-EU relations in health services are currently very limited. However, several opportunity segments exist, namely: (i) Telemedicine; (ii) Clinical trials and research in India for EU-based pharmaceutical companies; (iii) Medical transcriptions and back office support; (iv) Medical value travel; and (v) Collaborative ventures in medical education, research, training, staff deployment, and product development. However, various factors constrain Indias exports to the EU. These include data protection regulations; recognition requirements; insurance portability restrictions; discriminatory conditions; and cultural, social, and perception-related barriers. The interviews also revealed several constraints in the Indian health care sector, including disparity in domestic standards and training, absence of clear guidelines and procedures, and inadequate infrastructure.ConclusionsThe paper concludes that although there are several promising areas for India-EU relations in health services, it will be difficult to realize these opportunities given the pre-dominance of public healthcare delivery in the EU and sensitivities associated with commercializing healthcare. Hence, a gradual approach based on pilot initiatives and selective collaboration would be advisable initially, which could be expanded once there is demonstrated evidence on outcomes. Overall, the paper makes a contribution to the social science and health literature by adding to the limited primary evidence base on globalization and health, especially from a developing-developed country and regional perspective.

The Consequences of Globalisation: India's Software Industry and Cross-Border Labour Mobility

The Indian software industry is a prime example of globalisation. The industry has been characterised by large cross-border mobility of its skilled labour force. Using a unique survey of Indian software firms, our paper quantifies the extent and impact of mobility on firm behaviour and performance. Cross-border labour mobility in the paper refers to both temporary and permanent labour flows by Indian software professionals. The picture that emerges is of a highly mobile world in which temporary mobility has been an important characteristic of the industry. A significant number of workers have work experience abroad in a developed country. Moreover, the share of skilled workers with such experience has been positively associated with the incidence of skilled migration from the firm. This suggests network effects are at work. In terms of the impact on performance as measured by the change in turnover per worker and the change in the employment size of the firm the paper finds little evidence of a robust adverse effect. Further, the evidence suggests that there have been important external effects at work, as through changes in the willingness of workers to acquire skills, as well as through increased provision of educational services. These have further abated the risk of a brain drain. However, the software industry may be rather different from other industries. Our results need to be interpreted as the outcome of a particular case of skilled migration and not one necessarily representative of all types of skilled migration and source sectors.

Movement of Natural Persons and the GATS

Trade in services has expanded considerably in recent years, However, numerous regulatory barriers constrain such trade, especially when it involves the temporary cross-border movement of labour, also termed, movement of natural persons. Many developing countries have the potential to export services through cross-border movement of professional, semi-skilled and unskilled labour. The General Agreement on Trade in Services (GATS) seeks to progressively liberalise trade in services via different modes of supply, including the movement of natural persons. Under the first round of GATS negotiations, member countries have made sectoral and cross-sectoral commitments to promote trade in services for these different modes of supply. This paper discusses the significance of and various constraints to the movement of natural persons in service trade. It also assesses the nature of liberalisation that has occurred in this mode of supply under GATS and notes the limited progress made in this regard. In view of the ongoing round of GATS negotiations, it suggests ways to stregthen the overall GATS framework through greater transparency and specificity in the commitments on movement of natural persons and through the introduction of various multilateral disciplines. Copyright Blackwell Publishers Ltd 2001.

Inter-modal Linkages in Services Trade

According to the GATS, services can be traded through four different modes of supply, namely, cross border supply, consumption abroad, commercial presence, and movement of natural persons, termed modes 1, 2, 3, and 4, respectively. There is much evidence to indicate interdependence across these four modes in services trade. There are essentially two types of linkages, namely, positive and negative linkages, across the various modes of supply. Positive linkages take the form of (i) complementarities across modes, where one or more mode is simultaneously used for providing the service across borders; and (ii) facilitation across modes, where trade through one mode creates conditions that are conducive for trading through other modes. Negative linkages take the form of (i) substitution across modes, where trade through one mode is substituted by another; (ii) restrictions on one mode which affect trade through other modes of supply and distort the way in which a service is trade; and (iii) restrictions which apply across multiple modes and constrain several modes simultaneously. In addition to these first order linkages, there are also extended spillover effects across the modes that arise indirectly over the medium and long run. This paper discusses the various kinds of linkages that are found in service sector trade, using evidence from companies, countries, and surveys and from a wide range of services. The objective is to provide an integrated perspective on service sector trade and related multilateral negotiations under the GATS so that countries can better leverage cross modal and cross-subsectoral trade opportunities, address constraints in a holistic manner, and maximize the overall gains from services trade.

India and Services Outsourcing in Asia

This paper examines Indias role in services outsourcing within Asia. It provides a brief overview of the global as well as Indian services outsourcing industry. The core section examines Indias relationship with other Asian countries such as China, the Philippines, Vietnam, and Malaysia in service outsourcing. It examines the extent to which these countries pose a competitive challenge to India and concludes that at this time, India is far ahead although it is likely to face growing competition as its costs rise. The paper highlights the need to move beyond this comparative paradigm and to examine the complementary and collaborative opportunities that exist between India and other Asian countries in services outsourcing. It concludes that there is considerable scope for such synergies and that India and other Asian countries can form different parts of a larger regional or global delivery model. Regional and bilateral agreements within Asia can also facilitate this process.

CONSTRAINTS TO FOREIGN DIRECT INVESTMENT IN INDIAN HOSPITALS

This paper examines the impact of a liberalised foreign direct investment (FDI) regime in Indian hospitals on FDI inflows. The paper shows that there is hardly any FDI in Indian hospitals due to domestic constraints such as high initial establishment costs, low health insurance penetration, manpower shortages, high cost of medical equipment, and regulatory deficiencies. These constraints also impede domestic investment in hospitals. The paper concludes that a liberal foreign investment regime may not result in increased FDI inflows if regulatory and structural impediments continue to constrain investment in the host economy. Investment liberalisation must thus be supplemented by domestic regulatory reforms to create an environment that is conducive to all investors.

The Punjabi Diaspora in the UK: An Overview of Characteristics and Contributions to India

The recognition of diaspora contributions towards their home country through remittances, investments and networks has facilitated a shift in attitude and thinking regarding migration, from brain drain to “brain bank”, “brain gain”, “brain trust” and “brain circulation”. This shift in thinking is also evident in India in recognition of the manifold contributions being made by the Indian diaspora to the home country. This paper examines the historical and socio-economic characteristics of one important Indian diaspora community, the Punjabis in the UK and discusses the latter’s contributions to India and to its home state of Punjab. The evidence reveals that the NRI Punjabi diaspora in the UK is quite old, dating back to the colonial period. It is a heterogeneous community, divided by castes and sub-castes which influence the institutions through which its subgroups engage with the homeland. The secondary and primary evidence collected for this study indicate a wide variety of contributions - economic, social, philanthropic, cultural and political. Some of the main sectors of contribution are health, education and rural infrastructure. However, the evidence also reveals that there is much greater potential for diaspora engagement and that large scale investments by the diaspora are deterred by corruption, an inefficient bureaucracy, lack of streamlined procedures and lack of supportive diaspora policies at the state and central levels. The study thus concludes that greater thrust is needed, especially at the state level to facilitate the Punjabi diaspora’s engagement with India and with its home regions and state.

Mapping the Universe of Services Disciplines in Asian PTAs

This paper analyses the relationship and dynamics between multilateral and regional or preferential trade rules and commitments in services in a sample of eight PTAs involving Asian countries. It examines the evolving universe of rules and negotiating architectures in services and the extent to which PTAs have gone beyond the GATS. (S–S) agreements. The analysis reveals that although countries tend to commit more sectors and subsectors under PTAs than under the GATS, these commitments are not deeper within subsectors or modes and that they tend to be less liberal than the existing policies. Where PTAs improve upon the GATS is in terms of their overall architecture as they include additional chapters and annexes which go into considerable detail on a variety of cross-cutting, sector specific, and emerging issues. The analysis suggests that North–North agreements tend to cover some of the more difficult issues such as government procurement, while North–South agreements have a focus on issues such as recognition of qualifications which relate to the importance of mode 4 in North–South services trade. South–South agreements tend to focus on institutional cooperation and establishment of mechanisms, reflecting the need for strengthening capacity and institution building in these countries. However, overall, there is considerable diversity among PTAs, which do not follow a uniform pattern, indicating that the negotiating dynamics vary by partner countries and across PTAs.

Integrating services in South Asia : trade, investment, and mobility

List of Tables List of Figures Foreword Acknowledgements List of Abbreviations Introduction 1. Regional Integration Efforts and Outcomes in South Asia 2. Why Services Integration? 3. Regional Integration Prospects in Telecommunication Services 4. Regional Prospects in Energy Services 5. Prospects for Tourism Trade in South Asia 6. Regional Prospects in Health Services 7. Regional Prospects in Education Services 8. South Asias Multilateral and Regional Commitments in Services 9. Way Forward for Services Integration in South Asia Epilogue: Political Economy Challenges Index