54 SOCIAL SCIENTIST progress that had been made in the health status of women in the eighties? As with other elements of the structural adjustment programme, the new health strategy envisioned by the World Bank is aimed at fundamentally restructuring the existing health system in India. The key elements of the new initiative are that: a) primary health care centres are to restrict their activities to prevention of communicable diseases and promotion of family welfare; b) curative care is to be restricted to the private sector; c) NGOs are to be encouraged in the health sector; d) user fees are to be introduced in public hospitals for greater efficiency of investment; and e) fees for medical education in government colleges are to be introduced. What are the implications of this new thrust? Firstly, with user costs introduced, the poor, and among them women especially, will delay medical care so as to minimize health costs. It will also mean that the gender differential in health care among children may widen even more. Through the eighties there had been a marked improvement in life expectancy of men and women with the gender differential narrowing down significantly. Despite the improvement in various indicators of health status, it was not reflected in the sex ratio which is the best summary indicator of female health status. The marginal improvement in the sex ratio between 1971 and 1981 was reversed in 1991. This decline and the continuing adverse sex ratio is a cause for grave concern as it reflects the fact that a) females are not surviving in the earlier age groups and b) females are possibly being denied life before birth or at birth before it is recorded. Evidence is mounting that female infanticide is still pervasive c^nd aminocentisis prevalent. In the absence of sufficient sensitiveness to gender issues in the development process, the structural adjustment programme can result in severe stress on women. Secondly, it would undermine the already declining role of the PHCs in the total health delivery system. The emphasis on vertical programmes has obstructed the integrated functioning of the PHCs which were to provide "comprehensive preventive and curative service for all problems of health."16 Thirdly, the emphasis on the private sector will imply that the type of curative services available will depend on the nature of demand generated. Our discussion on structural adjustment amply shows that the poor will face a situation of decreasing real incomes thereby limiting their demand for health services. An end result of this process will be that a dual system of curative services will emerge. For the rich who can demand curative services, the most modem of curative services will be supplied. On the other hand the poor will have to do with the limited government facilities available. The shift of middle class pressure groups to the commercial health care system will erode the social pressures for the upkeep of