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Indian Budget 2018: development watershed or politics as usual?

26th March 2018 by newtjoh

In 2014, the Bharatiya Janata Party (BJP) became India’s governing party after winning an absolute majority of the seats in lower house of the Indian parliament, the Lok Sabha. Its nationalistic religious socio-cultural based (Hindutva) electoral platform has always been controversial. Its leader, Narendra Modi,  was prevented entry to the US  after his alleged complicity in the 2002 killing of 2,000 Muslims during communal riots. But, as Union prime minister, he has eagerly availed himself of opportunities to bestride the world stage, basking in his international superstar, rather than his past pariah, standing. In January 2018, for instance he addressed the annual economic gathering in Davos, Switzerland where he enjoyed the company of the western financial and political elite. He  began his life’s journey as a lower middle-class tea seller, then deserted his wife to become a monk, before working his way up the party apparatus by dint of sheer single-minded focus and ability to become chief minister in his home state of Gujarat, one of India’s most economically advanced states.

Indeed the BJP’s overarching Hinduvta platform is sometimes tempered,  more often  paralleled, by its development one.  In the Budget that the Union Finance Minister, Arun Jaitley, presented to the  Lok Sabha on the 1st February 2018, the latter development driver tended to  overshadow Hindutva, although as  it will be the last one covering a full year before the next Union election takes place in May 2019, preceded by a number of State Assembly elections, the electoral dimension also loomed large.  And, BJP  deployment of Hindutva still continued, with, for instance, the Union Home Minister waving off yet another BJP-promoted religious march or ‘Rath Yatra’ later in the same month: this time to collect water and soil from all four ‘holy’ corners of the nation.

The BJP’s 2014 platform included pushing up India’s real GDP growth performance back again to beyond  the 8% per annum achieved between 2003-11, when the  post-1992 liberalisation of the licence-quota-control Raj really began to bear fruit.  During earlier decades this had evolved into economic calling card of the hegemonic post-independence dynastic, but ostensibly secular and socialistic, Congress Party. But by  the eighties, the party began slowly to embrace market reform, responding to annual growth rates that in the 60’s and 70’s were sometimes barely above the rate of population increase. The watershed was the 1991 crisis, when India nearly ran out of foreign exchange, after which reform became a driving force, with both the BJP and Congress, as well as other parties aspiring to political power, competing to become holder of the development mantle.   Congress  remains the BJP’s main electoral rival under the fresh leadership of Rahul Gandhi, son and grandson of  former prime ministers, Rajiv and Indira Gandhi, respectively, and the great-grandson of Nehru, India’s first and renowned post-independence leader.

In practice, post-2014  economic performance under BJP stewardship has continued to be relatively sluggish. 6.5% growth was registered in 2016-17, amidst fears that the delayed result of the November 2016 demonetisation measure could continue to hinder growth into 2017-18. Investment levels remain stuck at levels below the near 35-40% of GDP that were recorded pre-Global Financial Crash (GFC).

Job creation  and rural incomes, especially in the rural areas, have also stagnated under the BJP watch. This has led some rural caste groups wielding vote banks significant at the local and state levels, such as the Patidars (one who owns a strip of land) in Modi’s home state, becoming politically unsettled, see, https://economictimes.indiatimes.com/news/politics-and-nation/the-day-of-the-patidars-why-their-votes-matter-in-gujarat-election/articleshow/61994403.cms. 

Against that backdrop, Jaitley’s budget measures were focused across three main inter-related areas, in agricultural and rural development, in extending access to universal healthcare, and in improving infrastructure.

Agriculture and rural development
Two thirds of the 1.3 billion Indian population still live in villages or rural areas, despite urbanisation proceeding steadily  and the urban population rising to 380 million.

Agriculture remains India’s largest economic sector in terms of the number of people who rely on it for income and employment,  in contrast to value-added. Most villagers still eke out a precarious and uncertain living from agriculture or related occupations. 50% of crops grown remain rain-based: a failed summer monsoon can mean no crops to sell; while a good one can lead to over-supply, which then pushes down prices and incomes. Rural incomes therefore are still highly dependent on the climate or ‘the gods’, and, unsurprisingly have lagged post-reform urban incomes.  in the early post-1991 reform period to the mid-2000’s rural incomes stagnated, as they done since 2014.  Such cold reality provides the sobering backdrop to the BJP’s promise to double rural incomes by 2022 from their 2017 level, while increasing rural employment.

It provides the political context to Jaitley’s budget announcement to increase the minimum price support (MSP) for Kharif crops (those largely sown in the summer monsoon, such as rice) to a level of 150% of their production cost, mirroring the support levels already prevailing on other Rani crops. He also unveiled measures to support the development of employment-generating food processing industries, the further rolling-out of institutional credit and marketing infrastructure, and of the lifting of restrictions on agricultural exports.

In addition, his  budget included a commitment to build one crore (10m) new homes, under the banner of “a home for all ‘poor and homeless’ households”, along with an additional 4 crore electricity connections. And, in a country where only c30% of the rural population is estimated to have access to an in-situ toilet,  an additional 20m toilet connections were also announced.

These proposed measures reflect the electoral significance of rural voters, as well as the lobbying strength of organised farmer lobbies. With respect to the latter, the BJP continues to face pressure from organised farming lobbies to maintain not only price support for agricultural goods, but also untargeted subsidies on inputs, such as on fertiliser, on farm machinery, on irrigation, as well as on electrical power.

On the debit side,  farm price MSP support can  encourage corrupt rent-seeking activity by agents best placed to exploit the system for their own, rather than officially defined, ends. Setting administrative, rather than market-based, prices apart from pushing up food prices and hence inflation, can incentivise farmers to grow supported crops, leading to over-dependence and an ‘eggs in one basket’ exposure that risks future loss of livelihood.

Its distributional impact  is unclear, although it can be expected that the more productive framers cultivating intensively larger landholdings for market distribution will benefit most through higher profits, with some gains trickling down to increased wages. A stated aim of the government is to encourage consolidation and higher productivity agriculture. That, however, implies the exit of more marginal smallholders, the further capitalisation of the agricultural sector,  with the pace of migration of the rural poor to the urban centres, consequently, quickening.

Infrastructure
Although about one-third of India’s population is urban,  two-thirds of gross value-added (GVA) within the economy is urban-based. Construction is India’s second largest economic sector in terms of its contribution to GDP. It also is employment-intensive, employing around 52m people in 2017.

Smart investment in productive infrastructure that improves connectivity by reducing the costs imposed on capital and labour by congested city streets, by inadequate and antiquated railway, road, and aviation links, and by patchy and unreliable digital services, should  help to push-up the growth rate, as is desired by the government.

The official national education aim is to ensure inclusive and quality education for all and to promote life-long learning. In that light education is slated to receive an additional one lakh crore rupees until 2022 with up to 13 lakh new teachers trained with blackboard and digital skills, referenced to a wider aim to extend the duration and improve the quality of education received by the growing number of school-age children. The National Apprenticeship Scheme is also to be expanded .

The Budget also announced higher investment outlays on railway rolling-stock, line-doubling, and wi-fi availability along with expanded aviation capacity in regional and sub-regional hubs, and of broadband access in the rural areas.

Rolling out universal health-care (UHC)
70 years after independence, less than 20% of Indians are covered by health insurance or have access to affordable health care, despite the 1947 Constitution promising universal access to affordable health care. Most households today risk incurring health costs that can be financially catastrophic, with seven per cent of low-income households – around 63m people- pushed into poverty by such costs each year.  Many others, of course, die or suffer life-changing disabilities because of their lack of access to quality health care or because of poor sanitation, in particular within the rural areas. The impact of mortality and morbidity rates, of poor sanitation of inadequate, and of inaccessible primary and secondary health services, and their associated economic costs are unquantifiable, but are likely to be huge.

As way of background, an official report (the Srinath report, https://www.slideshare.net/anupsoans/universal-healthcare-dr-srinath-reddy-report-to-planning-commision ) in 2011 recommended to the previous Congress government that annual public spending on health care should be raised from 1.2% to 2.5% of GDP by 2017, and to 3% in 2022,  in order to eliminate the need for user charges. The report noted that  per capita government spending on health in India (at purchasing power parity:PPP)  at $43 was significantly lower than was the case in Sri Lanka (PPP$87), in China (PPP$155), and in Thailand (PPP$261), as well as across most other low to middle-income countries.

Srinath urged  that the existing national – Rashtriya Swasthya Bima Yojana (RSBY) – and similar state publicly-financed health schemes should be merged and their scope considerably expanded in order to create a viable UHC model in India, funded from general tax revenues,  rather than ‘unsteady streams of contributory health insurance which offer incomplete coverage and restricted services’. Instead all citizens should be guaranteed access to essential primary, secondary and tertiary health care services. This UHC  model, it proposed, should be provided by a mix of public and contracted-in private providers, with 70% of the increased funding devoted to primary care, reversing by 2022 the current mix of public and private funding to one instead two-thirds publicly-financed.

In 2017 total combined public and private spending on health care totaled 4.5% of Indian GDP (well below international averages). Publicly financed health expenditure remained at the particularly low-level of 1.3%. Private spending was more than double that. User-payments for hospitalisation, for drugs and for other medical expenses and  private insurance premiums continue to constitute the main sources of national total health financing, although with central and state governments reimburse insurance funds for costs they incur on eligible publicly-covered insured persons. Only 23% of total government spending on health is actually directed at the provision of public health care facilities.

The main proposal made in the Budget was for 10 crore poor households, or an assumed 50 crore people living in such households (one crore = 10 million, so 10 crore is 100 million, 50 crore is 500 million), to be provided with up to around five lakh rupee  hospitalisation insurance cost cover per household. This compares to  to the three lakh cover currently provided by the main RSBY and its state-level current equivalents. (One lakh is 100,000, so  five lakh is 500,000 rupees: at prevailing rupee-sterling exchange rate (85-90 rupees = £1), the proposed NHPS  will offer each eligible household broadly between 5,500 and 6,000 pounds insurance cover for hospital-related costs).

If, and when, it is implemented, this National Health Protection Scheme (NHPS) – the Ayushman Bharat in Hindi – will become the world’s largest health insurance scheme, administered by a dedicated and new National Health Authority of India. Its second plank is to expand and improve the currently chronically under-resourced public primary health sector. Currently each village should have  a sub-centre provided with one multipurpose health worker covering an average 5,000 people. The next tier is the primary health centre equipped with basic operating, lab, and lest one doctor and other supporting staff, with the community health centres and district hospitals providing in-patient and some specialist  care. However many supposed sub-centres do not exist; while those that do, inevitably, vary in quality and effectiveness. Many villagers have to travel some miles to find a working one. It is proposed that the sub-centres are converted into wellness centres, equipped and resourced to diagnose and treat illnesses, such as diabetes and hypertension, with 150,000 to be rolled out by 2023.

Central and state governments (with a 60% central, 40% state  apportionment) are expected to pay the insurance premiums of the additional 100m households covered by the NHPS, or to otherwise set up an alternative institution or fund to defray claims. As discussed above,  the future actual cost of NHPS premiums, and whether the government will, or can, meet them, remains to be seen. As way of  comparison, premiums charged for a household of five in a private scheme vary on average between 12,000 and 24,000 rupees annually. Assuming a 12,000 rupee annual cost would imply a Rs. 1.2 lakh crore public budgetary cost. This compares to the actual budget of Rs. 2,000  allocated in 2018-19, the initial rolling-out year.

The low distribution costs and economies of scale that large-scale bulk purchasing of insurance cover could potentially offer,  has led some insurers to project that the premiums could fall to Rs 5,000 annually, reducing the public budgetary requirement to 50,000 crore, of which the national share at 60% would be Rs.30,000: that sum is still, however, fifteen times the 2018-19 allocated amount. Government officials project that the premium cost could drop to as low as  Rs 1,000 to 1,200, but that appears very optimistic.  In order to demonstrate commitment to the effective execution and implementation of the NHPS in line with stated aims, rather than lip-service to another aspirational policy designed with more of an eye on short-term electoral impact, the government needs to show the colour of its money in terms of future year budgetary allocations .

Another issue relates to the selection and  targeting of  scheme beneficiaries. It is proposed that they will be identified from the 2011 Social and Economic Caste Census.  Such a form of election, however, is subject to definitional and recording error, as well as to corruption and fraud.

Even if fully implemented, the NHPS  will cover only around 40% of the population, leaving many  households with low to moderate incomes, as well as poor people, uncovered and exposed to an associated higher risk of morbidity and/or of catastrophic health costs. It  has attracted the epithet ‘ModiCare’, derivative of the US insurance support MediAid scheme for the poor and uninsured. It will need to overcome  similar problems to those that beset the US system, related to its reliance on a predominately privately provided hospital sector to provide secondary and tertiary health care to the population in general. Such a reliance is questionable in terms of both effectiveness and equity outcomes, touched on in https://www.asocialdemocraticfuture.org/personal-experience-indian-private-health-sector/ .

Certainly it is not clear that entrenching an insurance-based system is the best strategic route to  a viable and sustainable Indian UHC system, to the more universalist  approach recommended  by the Srinrath report and other  health and development experts.

Conclusion

The overarching issue concerning India’s post-1991 development is whether and to what extent that the substantial leap in GDP has benefited or percolated down to the majority of the population, the poor and those with low and moderate incomes. The rise in per capita average GDP achieved indicate that household per capita income should have more doubled since 1991, and if continued should double further every 12-15 years. Although the proportion of the population defined as living in poverty, as measured by a very low consumption strict subsistence-related standard,  has fallen, it remains highly doubtful that the actual household and per capita incomes  of the majority of the population have risen anywhere near that implied rate, with the incomes of the rural poor and some of the urban poor remaining stagnant. Most of the GDP gain has been secured by higher income and educated groups  employed in buoyant  market  sector, such as IT, and by those in a position to extract or colonise economic rents linked to rising land values. That  increased numbers of individuals belonging to disadvantaged caste and other groups have been able to make good financially, perhaps, perhaps serves to cloud dramatically increasing inequality and that, according to National Sample Survey data, per capita expenditure only rose on average by 0.1% per year between 1993  and 2010.

Related and ancillary to that is that social welfare outcomes as measured by nutrition, educational and health indicators have not improved significantly, and in some cases have actually regressed, resulting in India falling behind countries with lower levels of GDP per capita, such as Bangladesh, in child mortality and immunisation  rates per 1,000 population, for example. Impressive economic growth has not gone  hand-in hand with social welfare advancement in post-reform India.

Given India’s robust and effective democracy, one would expect rising and strong pressures for improved social outcomes and compressed income inequality. These pressures, however, are mediated by and on cross-cutting caste, communal, and regional lines within India’s gigantic, awe-inspiring, and complex democracy. In order to secure and maintain power, parties at both central and sate level must succeed in building up electoral coalitions of support across such lines, rather than rely on broad development programmes.

The 2018 Budget  evidenced that in relation to its MSP measures, while also responding to competitive populist pressures to improve access to health care through the NHPS in a grandstanding and bold manner, clearly designed to attract attention during a year preceding the 2019 general election.

That said,  the focus on rural development, connectivity infrastructure, and on health, which despite massive under-provision relative to need and latent demand, health is still India’s third-largest economic sector, makes sense, in GDP value-added, employment, as well as in social welfare terms. As ever, the acid test of progress will be their focused and effective implementation and measured outcomes.

 

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Filed Under: India Tagged With: health services, India, public finance and budgets

A personal experience of the Indian private health sector

13th March 2018 by newtjoh

I stayed in Kolkata, the erstwhile colonial capital of imperial British India, for three months this year, at my wife’s home in New Alipore.

Halfway through my stay, a family crisis erupted when my sister-in-law aged 69, was taken dangerously ill. A doctor summoned to her home advised that she needed urgently to be admitted to a specialist hospital  due to complications connected to severe abdominal pains. Otherwise she would likely die.

That day she was admitted to the intensive care unit (ICU)  of the Charnock Hospital – a well-equipped private facility, with facilities akin to UK and American standards, located on the Eastern By-pass. It is a super-speciality hospital providing in coronary, stroke, critical care, as well as gastroenteritis services: http://www.charnockhospital.com/charnock-hospital-aboutus.html.

Fortunately she was covered by comprehensive health insurance, by dint of her husband’s former and her son’s current employment by the local Airports Authority.

The next day family members, including myself, went to the hospital in order to  find out her diagnosis and prognosis.  We arrived at around 11am and waited in the modern, almost sleek, waiting area to await information on her condition.

Whilst we did, occasional raised voices could be heard from the payments desk, the most active reception booth, which was shrouded by information boards setting out the price list for different types of treatments. These concerned the need for patient families to pay in advance for continuing treatment, and  about the precise amount demanded. Wads of notes were paid over by family members of patients or ‘customers’ without applicable insurance cover – the majority –  who were required to pay in cash up-front for treatment.

Their alternative,  if they could not or were not willing pay the prescribed charges, was to take their relative to an overcrowded general public hospital, where facilities would be much more limited, much more chaotic, with much less prospect of the delivery of suitable and timely specialised care. Indeed during that same week, a number of cases were reported in the local press where seriously injured or ill patients  were unable to access the care they needed from public hospitals that resulted in their death or were forced to seek private care instead. Another motorcyclist, for instance, who had suffered a  head injury in rural West Bengal was  unable to a obtain treatment due to a lack of neurological resources, was forced to travel first from  his  district hospital to the regional Medical College nearly two hundred miles away, before being referred to a specialist neurological unit  at one of  Kolkata main public hospitals, another three hundred miles, where he had to wait over 14 hours to receive treatment on a corridor bench, before direct representations by his relatives to the hospital superintendent secured his admission.

Back at Charnock, at around lunchtime her son and daughter–in law were summoned to the ICU, where they were advised  that their mother’s most pressing problem was  a ‘leaking’ gall bladder with some element of typhoid fever also apparently present. Medicine had been ministered in an attempt to resolve or manage the problems, but the medical representative advised that in the event of  a full X-ray denoting that surgery was required, the urgency of the situation meant that it may be needed to be undertaken as early as tomorrow morning,  and would involve an element of potential risk to the patient.

Asked to come back early next morning, they went home in order to complete a forest of forms connected to their mother’s insurance cover to be submitted as required to the hospital in lieu of up-front-payment.

They returned to Charnock next day at 5AM. It turned out to be a very long and stressful day for them. They were told that the specialist surgeon whom would have operated could not do so as he himself had to  support a sick relative, and that, accordingly, they should transfer the patient to another private super-speciality hospital  – the largest such one in Kolkata – nearby: the  Apollo Gleneagles.

Their next tasks were fourfold; first, to arrange transport for their mother; second, to complete the forms connected to that transfer; third, to collect the MRI scan and other test results  conducted on their mother;  and third, to fourthly her  admission at the Apollo. This was on top, of course, the continuing uncertainty and the increasing criticality concerning their mother’s treatment plan: in short, was surgery required and what risks would it entail? After all, if the gall bladder was actually leaking,  surgical intervention was needed without any further delay; on the other hand, if the problem was one of infection and fever, drug therapy might be  safer and less risky  compared to intrusive surgery on an elderly patient with heart problems, which could lead to the infection spreading through the blood and ultimately to sepsis: https://en.wikipedia.org/wiki/Sepsis.

Meanwhile the patient’s brother, whom I was staying with in New Alipore,  had a contacted his own diabetes specialist who an Apollo consultant, to expedite the emergency  admission. He  promised to  contact a colleague who he felt was best suited to conduct any needed surgery.

The hospital transfer to the Apollo Accident and Emergency department had only just been effected when we arrived at around 5PM.   I was surprised that visitors such as ourselves were allowed  to mill around the beds of this busy 20-bed emergency department, while doctors and nurses scurried around in order to respond to monitor warning bleeps or to conduct examinations, without challenge.  There appeared to be a rapid through-put of patents as some were transferred to wards to be replaced by new arrivals. This churn, however, was not always quick enough, with one case reported that morning of a 54 year-old man dying in an ambulance parked outside the ward due to a bed not being immediately available.

Bad news about our family member was received that the Charnock Hospital apparently had lost the MRI results of the patient or some reason could not provide it to  her son and daughter-in-law, who understandably were becoming increasingly stressed.  Another problem that was communicated to me by my wife was that the resident on-call staff at the Apollo conducting the initial examination appeared to resent the fact that the family contact consultant had assigned the case to a particular  surgeon.  They made the case-owner consultant was a diabetes, not a gastroenterology, specialist, but my wife expressed concern that the real problem was that this meant that they would not have a claim on the insurance monies linked to the case. Apparently there was competition between doctors to ‘control’ cases for that reason, sometimes to a point where it became an organised scam.

The good news was that my sister-in-law was surprisingly lucid given her condition suggesting that the medication was working, and that the assigned surgeon arrived soon afterwards to conduct his own examination, which he proceeded to do carefully and professionally.

We went outside in the corridor to receive his feedback, which he gave in  a measured and respectful manner. In essence, he advised that if the cause was a diseased or leaking gall bladder, which was the most likely cause on the evidence available, its source could be missed by limited micro-surgery; accordingly, that the safest course of action was to conduct the next day a full surgical examination and to proceed to the removal of the organ as found necessary,  as the gall bladder itself was not a vital organ, but such surgery would be high risk.

This seemed to make sense to us, and we went home relieved that at least a course of action had been mapped out and would be undertaken by a by a dedicated professional who looked and acted the part.

The operation, indeed, took place next day. We attended in a dedicated waiting room provided to relatives of those having surgery, where electronic screens reported on the progress of each operation: all mod-cons, like much of the activity of the hospital. After about two hours, the surgeon called us to the theatre entrance, where he showed us  gall bladder he had successfully removed from my sister-in-law and in particular  its diseased ‘mouth’, which was black,decayed, and horrible. He was hopeful that the cause of infection had been removed, but cautioned that post-surgical bleeding could follow and that she was not yet out of danger,  and needed to be transferred to the high dependency unit.

Fortunately she did continue to recover slowly and was able to return home after a fortnight.

That was not the end of my unplanned brush with the Indian private medical sector insofar that a friend of the family was reaching a tipping point in the treatment of his son’s kidney failure. He needed a transplant but his father’s  employment-related insurance cover no longer covered his son, as had attained 25 years of age.  Because the cost of kidneys to be used for such purposes was extremely high – Indian culture is not supportive of deceased family members donating their organs after death, while a public donor bank suffers from public administrative and other failures related to a lack of a national health service. Organs needed to be purchased often from living donors, which could push the costs beyond the means of a retired – albeit high-ranking – policeman, such as in this case. He thereby  enlisted the support of family members  to draft  a letter to his insurance company requesting that he donate the needed kidney to his son conditional on compatibility checks.

What lessons were drawn from these events?

First, of course, class, money, and location counts: unless you possess the benefit of employment-related, or were able to purchase  private health insurance at an annual premium cost reported cost between 12,000 to 24,000 Indian rupees per annum for a family of five (roughly £150 to £300), or had enough savings to pay for treatment as needed, if you suffered a  serious accident or illness you would need to rely on the grossly under-resourced  public hospital sector and take your not too bright chances accordingly. In fact 86% of rural, and 82% of urban, Indians are reported not to have any such access to insurance, explaining why 63 million of them are pushed into debt by unplanned healthcare spending each year.

Whilst not seeking to minimise the current crisis of the NHS (which also suffers from rationing, distributional, and informational issues) universal and accountable provision by the State does offers clear equity and efficiency advantages, as well a value-base or footing geared to individual need, even though that value-base can be perverted for provider and political ends as well.

Second, there is no guarantee of excellent or good treatment within the private hospital sector. Treatment is still often reliant on personal contact and power and the ability to navigate an often rigged and corrupt system where corporate and personal profit, rather than patent need, can prove paramount. Patients must rely on family members to either activate insurance policies or to negotiate payment at a time of high stress and uncertainty. The hospitals secure super-profits from the charged use of drugs and sundries in treatment, sometimes as much as 1000%.  Hospitalisation costs are outstripping premium incomes.

Third, the problem of asymmetric information between provider and patient and their family members comes into particular play within such a private system: you must rely on medical advice that particular treatments are appropriate and needed given the particular circumstances of the case; the suspicion is that sometimes the treatment follows the payment schedule  based on inputs rather than customised to individual need and circumstances, and best outcomes.

Fourth, and related to the third, while overall the health services are massively underfunded in India, with public health expenditure accounting  at less than 1.5% of GDP, adversely impacting on both preventative and curative care outcomes, private health expenditure reimbursable from insurance and user charges continues to escalate. private providers prioritise screening consultations – with pictures of young ”yuppie- families, captioned, for example, that is never too early to prevent cancer, that inevitably result in unnecessary or over-prescribed treatments that yield additional income to the associated tests and examinations involved, which themselves often represent a diversion of scarce medical resources from alternative and more effective preventative ends. See, for example, http://apollogleneagles.in

 

 

 

 

 

 

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Filed Under: India Tagged With: health services, India, private health insurance

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